Prevent opioid dependence and addiction following surgery

season 2 Episode 2: Treating acute pain to prevent opioid dependence and addiction

SOLUTION:

The more opioids you get after surgery, the more likely you are to be dependent on them down the road. And it doesn't take very long to become dependent on opioids – days to weeks. The solution Washington State and others have enacted are tighter guidelines advising doctors how many pills can be dispensed following surgery, getting them to counsel patients on the risks of the medication, and encouraging them to recommend alternatives for pain relief.

STORY:

How changes in Washington State law around opioid prescribing played out through two major surgeries. Reporter Eilís O’Neill follows a couple, Megan and Ben, through the birth of her second child. Two and a half years earlier, when her first child was on his way, Megan had a totally different experience.

LINKS TO MORE INFORMATION AND RESOURCES:

If you want help finding local drug treatment, support groups, or organizations in your community for yourself or someone else, you can call 1-800-662-HELP (4357) and speak with someone at the national helpline run by SAMHSA, the Substance Abuse and Mental Health Services Administration. It’s free, confidential, and open 24 hours a day/365 days a year, available in English and Spanish. More information here.

TRANSCRIPT

Anna Boiko-Weyrauch: This is Finding Fixes, Season Two, Episode Two. I’m Anna Boiko-Weyrauch. 

In this episode we’re looking at preventing opioid addiction—this time following surgery. That’s the way many people first get introduced to, and hooked on the drugs.

We’re staying with an analogy we introduced earlier this season. Looking at the opioid epidemic like it was a swimming pool. Go back to Episode One for more on that.

Remember, people start off in the shallow end of the opioid swimming pool—that’s where they first get introduced to pills or heroin. 

For some patients it’s all too easy to slip into the deep end. 

For example, one woman named Linda Hargrove. In 1995, she had to have major surgery.

Linda Hargrove: I was in the hospital maybe about three weeks maybe. And I grew dependent.

Boiko-Weyrauch: Back home, Hargrove couldn't get off them. She started coming up with ways to keep getting opioids.

Hargrove: Going to the doctor, making up excuses for why I needed some more: or I lost them, or they fell into my sink or whatever the excuse.

Boiko-Weyrauch: Hargrove’s husband intervened and got her into treatment. Otherwise, says she doesn’t know what would have happened.

Others end up on opioids for decades following surgery.

Habeeb Al-kanaani came to Seattle as a refugee from Iraq, where he was tortured and his back badly damaged. In the US, he got surgery, and ended up on Oxycodone.

Habeeb Al-kanaani: They take the pain away, yes, but they make you high more than they take the pain. Really high, and then you not think about anything. You just sit at home and not do nothing.

Boiko-Weyrauch: He became addicted, and now, decades later, he’s in treatment.

Dr. Gary Franklin researches public health at the University of Washington—he was one of the first people to identify the opioid epidemic in this state.

Dr. Franklin says it’s easy for any one of us to end up like Hargrove or Al-kanaani.

Gary Franklin: It doesn't take very long to even become dependent. We're talking days to weeks. 

Boiko-Weyrauch: The more opioids you get after surgery, the more likely you are to become dependent on  them. 

For example, if you get over a month’s supply of pills you have close to a fifty-fifty chance—almost a coin toss—of being physically dependent on the opioids a year later. 

Even shorter prescriptions carry a sizable risk. 

And, Dr. Franklin says it’s not just the patients he’s worried about.

Franklin: We know that most of these acute prescriptions the vast majority are not taken. They're left in the medicine cabinet for someone else to use or misuse.

Boiko-Weyrauch: As a result, many states, including Washington, have rewritten the rules on how to prescribe opioids. The new rules are trying to keep people from getting in too deep. This episode, we look at how those changes played out for one family and a few major surgeries. 

In Seattle, reporter Eilís O’Neill follows one patient who got one of the most common surgeries in the US: a c-section.

Here’s her story. 

(Baby crying, people talking quietly about the baby)

Eilís O’Neill: August 20th, 2019, Scarlett Swarner was born. A healthy seven-pound, ten-ounce baby girl. 

Two and a half years earlier, when her older brother was on his way, their mother, Megan, had a totally different experience. In the short period between the birthdays of this little sister and her big brother, the place where they were born, Washington state, had changed their rules on opioid prescribing.

I'll get to what that meant for their mother in a minute, but first, here's the big brother's story. 

A few years ago, in 2017, Megan and Ben Swarner were pregnant with their first child. They were at their twenty-four-week checkup when they found out something was wrong: their baby’s femur was extremely short. That could mean a lot of things—none of them good—so they were referred to a high-risk specialist, who gave them a second ultrasound and some bad news about their baby boy.

Ben Swarner: Basically, they told us that he probably wouldn't survive.

O’Neill:  The placenta hadn’t developed properly, so the baby wasn’t getting enough nutrients or oxygen.

The first person who met with Megan and Ben was a genetic counselor.

Megan Swarner: What she was telling me was that my baby was gone. And it’s like, “He’s not gone. I just saw him and heard him. I just heard his heartbeat, and I know I’m past viability.”

O’Neill: Megan and Ben thought about it and a few days later Megan checked into the hospital so the doctors could monitor the situation and deliver the baby at the first sign of trouble.

M. Swarner: I would be on the monitor for four to six hours a day at different points—

B. Swarner: —at least—

M. Swarner: —sometimes longer, yeah. With him. And so basically the monitor would just track his heart rate.

O’Neill: Four weeks passed. Then, the baby’s heart rate started dropping and then taking more and more time to return to normal. That meant he wasn’t getting enough oxygen.

M. Swarner: And, at that point, they said, “You're probably going to deliver tomorrow.”

O’Neill: Megan says, then things seemed to move really quickly. The nurses prepped her for surgery and brought her into the operating room for a c-section.

Her baby was tiny: just one and a half pounds.

O’Neill: How soon did he cry?

M. & B. Swarner: Right away.

M. Swarner: Probably the best thing I've ever heard. Just the unknowns of having a premature baby, and he was so tiny—and to hear him cry in the anxiety of all of it was just so cool.

O’Neill: They named the baby Nathaniel.

B. Swarner: Because it means gift from god, or gift of god.  

O’Neill: Megan says, when Nathaniel was born, a whole team was waiting for him.

M. Swarner: I think we had two neonatologists in the room when he was born and tons of nurses and Ben got to stand with them and he peed on the nurse and was crying.

B. Swarner: I didn't pee on the nurse—the baby—

M. Swarner: (laughing) Nathaniel peed on the nurse.

O’Neill: Nathaniel had to go to the neonatal intensive care unit. And Megan went into her own recovery. She says nurses gave her a lot of opioids.

She told me about it in the hospital, with a fan whirring in the background.

M. Swarner: Right after the surgery, I was on it religiously—like on the hour, on the schedule. 

O’Neill: Megan’s a stiff-upper-lip kind of person, but Ben says he could tell that, despite the opioids, she was in a lot of pain.

B. Swarner: All I remember from the pain perspective is that the drive home from the hospital on the city of Seattle roads was awful. I was trying to avoid all the potholes but managed to still hit a lot of 'em and just every time she—I could tell she was in a lot of pain.

O’Neill: Megan went home from the hospital with a big bottle of pills.

That was standard operating procedure after a c-section. But, for a lot of people, that bottle of pills becomes a problem.

Dr. Joseph Breuner is a family physician at Swedish Hospital. Addiction medicine is one of his specialties.

Dr. Joseph Breuner: Having a big bottle of pills—having a bottle of 100 pills—makes it seem like taking more might be better, and the way opioid receptors work in your body: if you take two pills one day and four pills the next and six pills the next day you'll probably do fine and you'll feel a good pain-relieving effect each time and you might even feel a little euphoria. And then if you stay at six pills thereafter you'll feel a little flat after two or three days and you start—after a week—to not even get the same pain relief. So your body kind of quickly gets used to the dose you're on and encourages you to seek more.

O’Neill: About two percent of women who get an opioid prescription after a cesarean section are still taking opioids more than three months after delivery. 

Women are more likely to develop this persistent opioid use if the prescription is bigger—if they get more pills.

Dr. Breuner says not everyone’s at risk of becoming addicted to opioids—but, for those who are, having access to more pills can be dangerous.

Breuner: If you take 100 people, 10 or 15 of them are gonna have susceptibility to addiction, and probably an additional 10 or 15 are gonna have unstable life situations right now—where they're constantly wanting relief from things and wanting to check out. And so, of the hundred people, there might be 20 or 30 that really like the feeling of taking the narcotic that we're prescribing for their leg fracture that they just got fixed. So those people get in trouble—and you can get in trouble pretty fast.

O’Neill: And the patient isn’t the only person Dr. Breuner is  worried about. Those pills can fall into the hands of other people in the household—teens, even children.

Fortunately, none of that happened in Megan’s case. Here she is in the hospital again.

M. Swarner: I remember after about a week or so starting to taper off a little bit and using it as needed and then I didn't finish the bottle. We ended up taking them to the pharmacy, so I didn't finish the full course that I was given.

O’Neill: Megan says she thinks everything went smoothly, despite the emotional stress and the large number of pills she received, because of two things: her faith and church community, and her history as a serious athlete.

M. Swarner: I think being athletic in high school and training really hard to be good at sports and to be fit and healthy—I think a lot of that is listening to your body and knowing that often it takes some discomfort and pain to build muscle and to push through and—but also listening to your body and not overdoing it.

O’Neill: Eventually, Megan got better, and Nathaniel got big enough to come home from the hospital—a healthy, if tiny, baby boy.

Megan and Ben waited almost two years, and, then, this December, they got pregnant again.

M. Swarner: We were super excited when we found out we were pregnant.

O’Neill: Were you just excited, or were you also a little bit nervous, because you knew that you had complications the first time? How was that?

B. Swarner: I think this is an area where our faith really comes into play, because we believe god cares, and so we can trust that he was going to take care of us through this birth.

O’Neill: This time, the pregnancy progressed without complications, but, because of the kind of C-section Megan had had before, the risk of uterine rupture was just too high if she tried to deliver vaginally. So she and Ben scheduled another C-section.

And the doctors delivered a healthy baby girl.

(Sounds of the newly born baby from their birth video)

O’Neill: Scarlett, Nathaniel’s new little sister. 

Scarlett wasn’t premature, and Megan’s pregnancy with her was easier. But Megan says it was a different experience in another way as well: She didn’t get so many pills.

By the time Megan had her second c-section, Washington state had changed opioid prescribing guidelines. The new laws encourage alternatives to opioids to manage pain, and cap prescriptions at a fourteen-day supply, unless the doctor can show a need for more. 

I talked to Megan while big brother Nathaniel, now a toddler, was playing in the background.When he was born,

M. Swarner: When it was time to take medicine they came in and gave it to me, and I remember taking the Oxycodone with the Tylenol every six hours in the hospital. And that's kind of how I was instructed to do it going home for the first, you know, next week or so. Whereas, this time, it was—even in the hospital, it was like, “If you need—if you're in more pain, let us know.” But it wasn’t just on the clock, “ok, time to take more narcotics.” So it was more patient-guided.

O’Neill: Also, this time, just two years after her first baby, when Megan was ready to go home, she got coaching about how to limit her opioid use and manage her pain. That conversation is also part of the state’s new guidelines. 

M. Swarner: Before discharge this time, one of the doctors came in and we had a conversation about how my pain was and what I thought I would need and what I'd been taking in the hospital. So I don't think I came home with as many pills as I did after I had Nathaniel.

O’Neill: Megan went home with only fifteen pills. She mostly took them preventatively—like when she needed to drive in to the clinic for Scarlett’s four-day check-up.

Joe Breuner, the family physician at Swedish, says that reflects how prescribing opioids is changing across the board.

Breuner: I started doing family medicine in 1990 and all through the late 90s and early 2000s we were prescribing more and more narcotics. Pain was being introduced as the fifth vital sign that we had to check pain when people came so that we could get them more medications. And then around 2010 colleagues of mine here at the residency and elsewhere just felt like we're really overdoing it and started to pull back on the reins.

O’Neill: Breuner says he’s started teaching residents how to prescribe few or no narcotics. In some situations, like vaginal births, he prescribes no opioids at all.

Breuner: We just don't do it anymore. And they take Tylenol or they take ibuprofen and they will use other alternate pain relieving methods.

O’Neill: Methods for ALL pain sufferers, like distracting themselves by drinking a glass of water, taking a walk around the block, or making sure they’re not hungry. He also coaches patients to give themselves massages with their hand, a tennis ball, or a shower.

In other cases, he does still prescribe some opioids—but many, many fewer.

Breuner: And we tell the patients, “We want you to come back and see us if you're having more pain than these take care of, because you really shouldn't.” You know, we set up for the patient the expectation, “This is going to be plenty to control your pain and you might not even need these. So if you do I want to see you cause something's wrong”—pretty different than getting a prescription of 40 pain pills with three refills on it which kind of, “Well, the doctor wants me to take all these; I should just take them all.”

O’Neill: Breuner says changing cultural expectations around pain could be part of the solution as well—teaching people that a little pain is okay, and how much pain is too much.

He says doctors have a long way to go when it comes to changing how they work with patients who are in pain.

Breuner: We're not necessarily very good yet at doing the non-narcotic methods because health care providers have also been able to just prescribe medications and not have to learn how to teach somebody exercises that's going to help a cramping muscle or stretch something out or think of other ways, think of non-narcotic ways to treat their pain so we’re—we're starting a learning process too.

O’Neill: Remember Gary Franklin, the public health professor at the University of Washington? He says that learning process is part of the key to solving the opioid epidemic.

Franklin: You know, if you want to reverse this epidemic you've got to start reversing it before each person gets into trouble.

O’Neill: A week after Megan’s surgery, I called her up to ask how she and the baby were doing.

(phone ringing)

M. Swarner: Hello?

O’Neill: Megan told me Scarlett was doing well and already showing signs of a personality.

M. Swarner: She is definitely my child: when she decides she wants to eat, she needs to eat right away. (laughing)

O’Neill: And Megan said she was doing well too.

M. Swarner: We’ve left the house twice—once for her pediatrician appointment, but that still counts, and then we also were able to go to church, and I was able to like walk in and be there and stand up.  

O’Neill: Megan had worried if fifteen pills would be enough, but she ended up only taking half of them.

M. Swarner: I don’t imagine I’ll use much of what I have left, just because using Tylenol and ibuprofen at this point is totally managing my pain. 

O’Neill: When Scarlett was almost two weeks old, I swung by the Swarners’ house to meet her in person.

(baby sounds, family talking)

O’Neill: Nathaniel’s two and a half years old now, and he’s doing well too.

M. Swarner: He loves music so he's all about playing the drums and the guitar and he sings songs. But he always gets stuck on one line. So we just get to hear one line of a song.

M. & B. Swarner: Over and over and over.

M. Swarner: His song lately—He just says, “no mountain” over and over and over. So we've been trying to work on him to get that whole little bit rather than just “no mountain.” So now he says “no mountain, no valley”—but we'll get there.

O’Neill: Public health officials are hopeful that, with new prescribing guidelines, they’ll get there too—ending opioid addiction before it can start, one patient at a time.

Boiko-Weyrauch: That story came to us from reporter Eilís O’Neill.

Next time on Finding Fixes:

David Tauben: The Marines have an expression—pain is weakness leaving the body. That is not what pain is.

Boiko-Weyrauch: We look at the complicated condition of chronic pain. 

Michele De Camp: I think it's accepting the fear, accepting the pain and then seeing where that leads you changed my perception of it a lot.

Boiko-Weyrauch: On the next episode, treating chronic pain with a whole new set of tools. 

Finding Fixes is a project of Investigate West, a nonprofit journalism organization working in the public interest. Financial support comes from the Philadelphia Foundation, Moccasin Lake Foundation, and listeners like you. If you’d like to support this podcast, make a tax-deductible donation at findingfixes.com. 

While you’re there, you can drop us a note or you can send us an email at fixes@findingfixes.com.

This episode was reported and produced by Eilís O’Neill, and edited by Alisa Barba and me, Anna Boiko-Weyrauch. Music by Jake Weholt. 

Thank you to everyone we talked to in this episode. And thank you so much for listening.