Should Hospitals Be Punished For Post-Surgical Patients' Opioid Addiction?

By: Guest Author | Posted on: Dec 11, 2017

This article was originally published on npr.org by MARTHA BEBINGER View the original article by clicking here.

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After two weeks of recovery from an addiction to opioids prescribed by her surgeon, Katie Herzog takes a walk with her dog, Pippen.      - Jesse Costa/WBUR

In April this year, Katie Herzog checked into a Boston teaching hospital for what turned out to be a nine-hour-long back surgery.

The 68-year-old consulting firm president left the hospital with a prescription for Dilaudid, an opioid used to treat severe pain, and instructions to take two pills every four hours as needed. Herzog took close to the full dose for about two weeks.

Then, worried about addiction, she began asking questions. "I said, 'How do I taper off this? I don't want to stay on this drug forever, you know? What do I do?' " Herzog says, recalling conversations with her various providers.

She never got a clear answer.

When none of her providers explained to Herzog how to wean herself off the Dilaudid, she turned to Google. She eventually found a Canadian Medical Association guide to tapering opioids.

"So I started tapering from 28 [milligrams], to 24 to 16," Herzog says, scrolling through a pocket diary with red cardinals on the cover that she used to keep track.

About a month after surgery, she had a follow-up visit with her surgeon. She had reached the end of her self-imposed tapering path the day before and at the doctor's, she recalls feeling quite sick.

"I was teary, I had diarrhea, I was vomiting a lot, I had muscle pains, headache, I had a low-grade fever," Herzog says.

The surgeon thought she had a virus and told her to see her internist. Her internist came to the same conclusion.

She went home and suffered through five days of what she came to realize was acute withdrawal, and two more weeks of fatigue, nausea and diarrhea.

"I had every single symptom in the book," Herzog says. "And there was no recognition by these really professional, senior, seasoned doctors at Boston's finest hospitals that I was going through withdrawal."

Herzog did not name any of the providers who had something to do with her pain management or missed signs of withdrawal. She said she sees this as a system-wide problem. Herzog did share medical records that support her story. After the withdrawal, she did not crave Dilaudid and she manages any lingering pain with Tylenol. She has since returned to her providers, who've acknowledged that she was in withdrawal.

Not an isolated incident

Herzog's story is one doctors are hearing more and more. "We have many clinicians prescribing opioids without any understanding of opioid withdrawal symptoms," says Dr. Andrew Kolodny, director of Physicians for Responsible Opioid Prescribing and co-director of the Opioid Policy Research Collaborative at Brandeis University's Heller School. One reason, Kolodny says, is that doctors don't realize how quickly a patient can become dependent on drugs like Dilaudid.

Sometimes that dependence leads to full-blown addiction. The majority of street drug users say they switched to heroin after prescribed painkillers became too expensive.

Now, a handful of doctors and hospital administrators are asking, if an opioid addiction starts with a prescription after surgery or some other hospital-based care, should the hospital be penalized? As in: Is addiction a medical error along the lines of some hospital-acquired infections?

Writing for the blog and journal Health Affairs, three physician-executives with the Hospital Corporation of America argue for calling it just that.

"It arises during a hospitalization, is a high-cost and high-volume condition, and could reasonably have been prevented through the application of evidence-based guidelines," write Drs. Michael Schlosser, Ravi Chari and Jonathan Perlin.

The authors admit it would be hard for hospitals to monitor all patients given an opioid prescription in the weeks and months after surgery, but they say hospitals need to try.

"Addressing long-term opioid use as a hospital-acquired condition will draw a clear line between appropriate and inappropriate use, and will empower hospitals to develop evidenced-based standards of care for managing post-operative pain adequately while also helping protect the patient from future harm," said Schlosser in an emailed response to questions.

Kolodny said it's an idea worth considering.

"We're in the midst of a severe opioid epidemic, caused by the over-prescribing of opioids," Kolodny says. "Putting hospitals on the hook for the consequences of aggressive opioid prescribing makes sense to me."

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