Editor's note: The illicit drug trade is undergoing a seismic shift, with Utah in the middle of the deadly impact of opioids. But opioid use is having an impact even when the use is as prescribed, as this latest story in an ongoing series of stories about the opioid epidemic reveals.
SALT LAKE CITY — Three days after having his tonsils removed, 21-year-old Parker Stewart's recovery was going well and he was in good spirits.
He visited his family's house, where he good naturedly teased his little sister, who had had a tonsillectomy on the same day, for "still laying there on the couch feeling miserable," recalls his mother, Yvonne Gardner.
"Wow, I'm feeling pretty good," Gardner remembers her son saying.
After returning home, Stewart, a newlywed of three months, wrapped presents for his wife and put them under their Christmas tree in their Vernal home. He called it an early night, going to bed about 8 p.m., saying he felt tired.
But morning came and Stewart never woke up.
"We got that horrible phone call," Gardner remembers, while sitting in church on Dec. 4, 2016. "My daughter-in-law called and said he wasn't breathing. … He had already been gone for a few hours and there was nothing we could do."
Stewart, a towering young man at 6 feet 4 inches tall and 220 pounds, was the picture of health before he died, says his family. They were blindsided by his death.
Gardner was baffled by the official autopsy explanation months later that her son had died from pneumonia. Seeking more answers, she began to question whether the oft-prescribed painkiller her son had been taking after his tonsillectomy was to blame, despite the fact that he was taking just half of his prescribed dose.
"(He had) no coughing, no congestion — how could he die overnight of pneumonia?" she wondered in an interview with the Deseret News. "How could any person die of pneumonia overnight?"
While Gardner was searching out answers, so was someone else — someone who quickly became an unlikely ally in publicly singling out a combination substance of oxycodone, hydrochloride and acetaminophen as Stewart's likely fatal culprit: The very physician who prescribed him the drug, Dr. Michael Catten.
"That should never have happened. This was a 21-year-old kid who was not sick. He was totally healthy. He was fine," said Catten, an ear, nose and throat surgeon who works at Uintah Basin Medical Center in Roosevelt, and at Ashley Regional Medical Center in Vernal. "I would say that the reason he had fluid in his lungs … was because he wasn't breathing well because he was taking narcotics."
Gardner said of Catten, "I didn't realize until after the funeral that he had tried to contact me."
"He had contacted me and told me how sorry he was," she said. "When he got the information back, the surgery was fine. There wasn't anything done incorrectly about the surgery. We started working to try and find some answers. Emotionally it had wiped him out."
Catten was especially alarmed at Stewart's death because another man for whom he had performed a tonsillectomy about six months earlier had also unexpectedly died within a week of the procedure. With that patient, he said, "I thought, 'Well, maybe it's something else,'" especially considering the man's prior medical history.
"Parker really was the one that was like — 'OK, there's something seriously wrong. This was a 21-year-old kid,'" Catten told the Deseret News.
Since Stewart died, the doctor has been sending patients home with a pulse oximeter — a device that tracks a person's oxygen intake levels — whenever he prescribes them opioids. Of about 50 patients who have taken those devices home in that time, the doctor said, "10 or so of them" have revisited their hospital for oxygen levels that were recorded as hazardously low, a return rate that has him on edge.
"(We) always address the 'war on narcotics,' so we all think of, 'OK, we need to get rid of our drugs and we need to be careful because the addicts are coming in and taking them and abusing,'" Catten said.
"But what you also need to realize is we are killing innocent people with our narcotics."
Attempts to reach the makers of Percocet were unsuccessful on Friday. Catten said Percocet is just one of several different kinds of opioids that have caused him to worry about what could happen to unsuspecting patients who are simply following the directions for their prescriptions.
Catten had another stunning experience less than a month after Stewart died when he equipped one of his tonsillectomy patients, a 15-year-old girl, with a pulse oximeter. Her parents, wanting to be cautious, had her sleep between them. However, in the middle of the night, her oxygen intake began to fade while all three were momentarily asleep.
"For five minutes … she's basically, like, out. They call the ambulance, the (paramedic) gives her Narcan," he said.
That emergency measure successfully revived her.
"(They) watched it happen. I was like — this is a real problem."
In the small community of Vernal, Gardner soon found out who the 15-year-old girl was and learned of her story.
"The mother said she woke up at 4 a.m. and noticed her daughter gray, not breathing, no heartbeat. At night, they had been checking on her because they heard Parker's story," she said.
Catten is far from being the only medical professional who is concerned about what he is seeing. Intermountain Healthcare recently completed one patient trial, is in the middle of another, and will soon begin a third in an effort to examine the feasibility and effectiveness of various kinds of at-home breathing monitoring for those who have been given opioids after surgery, saying more needs to be done to address patient safety.
Dr. David Hasleton, associate chief medical officer at Intermountain Healthcare, said the recently completed trial and the one already underway are in partnership with Uintah Basin Medical Center, though that hospital is not an Intermountain facility.
Patients considered to have high risk factors were "sent home with a monitor that helps the clinicians understand their real risk" in the recently completed trial, Hasleton said, and that protocol is the same with the other studies. Patients found to have unsatisfactory breathing during the night are told to return to the hospital, just as Catten is doing.
While Intermountain has been in touch with Catten about his experiences with patients, the health system's studies are "running parallel" to his observations as separate research that was initiated before hearing his concerns, Hasleton said.
Early next year, a third study at The Orthopedic Specialty Hospital in Murray will equip patients with a pulse oximeter that clasps onto a person's finger, which Hasleton called "a good but not a great measure" of the adequacy of their breathing while they sleep, and compare it to two additional tools they will use.
One such tool is a carbon dioxide exhalation monitoring device that uses tubing under the nostril, believed to result in less false positives and less false negatives than an oximeter, Hasleton explained. The third device, he said, is what researchers hope will prove to be the most effective of them all: a tiny acoustic microphone that rests on a person's neck, intricately tuned to measure a person's breathing via audio input.
"We're pretty sure that (the acoustic microphone) is going to have some effect. What we're after is how much effect," Hasleton said.
He added that the small microphone would also enable two-way audio communication between the individual and a provider at a remote location if needed.
He said part of what Intermountain is examining is how economically feasible it is to send home any of the devices on a large scale — a hospital practice that he, Catten and others have all said is virtually unheard of around the country.
Patient data from Intermountain's recently finished trial is still being finalized. But Hasleton said a growing body of knowledge has made clear to Intermountain Healthcare over the last several years that patients with certain risk factors can in fact die while taking painkillers as prescribed after surgery.
Hasleton said awareness of the risks of taking opioids, even as prescribed, is quite low among patients.
"By and large the general public has no idea. If you ask people, they say … when it comes down to them, they believe if they are prescribed something, that prescription is safe for them. But the reality is, a prescription does not fit everybody the same way," Hasleton said.
Specifically, a person who suffers from sleep apnea — a condition in which a person's breathing is shallow or undergoes abnormally long pauses while sleeping — is known to have a greater chance for a dangerous reaction to even a prescribed dose of painkillers, he explained.
That is why Intermountain patients being prescribed pain medication undergo a screening assessment looking for signs of that condition, he said.
Measured risk factors are whether a person is known to snore loudly, frequently feels tired during the day even after good sleep, has any observed pauses in breathing at night, has high blood pressure, has a body mass index of more than 35, are over 50 years old, have a large neck size (more than 17 inches around for a man or more than 16 for a woman), or are male.
A person is considered to be at greater threat of post-surgery complications with painkillers if they can answer yes to three or more of those factors.
In hindsight, Gardner said, she believes her son "had possible sleep apnea." Even when he was a young boy, she said, Stewart snored loudly.
"Ever since he was young, he could rock the house," she said. "We could hear it through the walls because he was so loud."
Stewart had also been snoring the morning he died, his mother said.
Dr. Jonathan Boltax, who works as a clinical pulmonary care instructor with the Department of Pulmonary and Critical Care Medicine at University of Utah Health, said the respiratory risks of opioids are considered common knowledge among doctors and researchers.
"There is absolutely no question that opiates suppress respiratory drive and lead to deaths from respiratory failure," Boltax told the Deseret News.
But there is also a strengthening intellectual body of knowledge about the drugs' risks even to some people who are carefully following their doctor's orders, Boltax said.
"There's definitely concern (for those) who have surgeries and have underlying sleep disorder like sleep apnea and then get pain medications," he said. "That's being recognized as a problem."
Catten, along with Gardner and her family, have also brought Stewart's story to state Sen. Kevin Van Tassell, R-Vernal, who confirmed that he will be sponsoring a concurrent resolution urging the Utah Department of Health, health systems and academic researchers to further study "opioid-induced postoperative respiratory depression" and what can be done to avoid deaths associated with it.
Van Tassell said the nonbinding measure is important in that it puts on the record that the state officially recognizes postoperative deaths as a problem.
"We're identifying it, making people aware of it and we're still going to continue to gather information for it," Van Tassell told the Deseret News. "Frankly, a year ago I had no idea that this was even a problem."
The text of the drafted resolution proclaims that "deaths from opioid-induced postoperative respiratory depression are often misdiagnosed as pneumonia and are therefore underreported."
It also says that "the use of a low-cost, in-home monitoring device to alert a caregiver of low oxygen saturation would have prevented many of these needless deaths" and urges physicians to get patients to use them.
However, the measure, since it isn't a bill, wouldn't be binding on providers or the other parties it addresses.
The state senator believes a nonbinding resolution is more realistic than a bill, considering the issue's lack of prior discussion at the Capitol and what he said could be the unpredictably prohibitive cost to health providers incurred by moving all at once to officially requiring all at-risk patients be given oximeters.
Rep. Michael Kennedy, R-Alpine, who introduced a bill that was passed this year requiring a two-year state study into deaths caused by anesthesia complications, said he likes "the symbolism" of the resolution and how it could encourage patients to be as cautious as possible.
"What's that do to a patient? Immediately it tells them, well maybe, I'm going to take half," Kennedy said.
But the representative, who is a family doctor, also advised tempered expectations about how much a resolution can actually move the needle in the medical field in Utah since it wouldn't be binding.
Speaking on Intermountain Healthcare's position on the drafted resolution, Hastleton said, "We support that wholeheartedly and are working toward that."
Catten never planned to become a disciple of the risks inherent in taking painkillers following surgery. He only became one when lightning proverbially struck twice with his patients, he says.
"Until you're seeing a cluster of tragic events that bring your attention to it, you don't necessarily see it," he said.
He deeply questioned himself in light of the unexpected deaths of Stewart and his other patient.
"I've gone down that road and I've actually had (my surgeries) looked at," Catten admitted.
He is careful to note that nothing has been found wrong with the surgeries themselves. And still, "I almost quit over this stuff," he said.
He believes most doctors aren't eager to discuss their patients' unexpected deaths for fear of both lawsuits and aspersions cast on their professional reputations.
"You don't want to talk about your failures just because of your own ego, and it's too painful to talk about," Catten said. "That's part of the problem (and) why these problems keep happening."
Catten knows "it's happening too much, it's happening a lot." But beyond that, he's frustrated at the lack of more coherent data about precisely how much it is happening, in Utah and elsewhere.
Asked about what proportion of opioid-related deaths stem from using the painkillers as prescribed, according to the latest data either kept or used by Intermountain Healthcare, Hasleton conceded, "I can't give you a percentage."
He said that, likely, "it's a pretty small amount. We're probably talking fractions of a percent, but certainly for a family, that's a big deal to them."
A study published in the Journal of the American Society of Anesthesiologists in March 2015, examining 20 years' worth of malpractice legal claims related to respiratory depression, warned that "the recommended intervention(s) to reduce (respiratory depression) and prevent poor outcomes are based largely on consensus opinion because data regarding their efficacy are lacking due to the rarity of serious complications."
The research, with authors from Vanderbilt University, University of Michigan, University of Washington and Virginia Mason Hospital in Seattle, attempted to address that lack of data. Researchers identified 92 cases found in a legal claims database in which prescribed opioids were believed to have caused respiratory depression, and concluded that "97 percent were … preventable with better monitoring and response."
"On the basis of these findings, preventive strategies may require continuous monitoring, rather than intermittent checks, and a focus on effective response capacity, as well as event detection," the study states.
Gardner subscribes to Catten's belief that actual deaths from opioids are few and far between enough that "they're brushed under the rug as a weird coincidence or that it's unexplainable."
"These are all preventable deaths, (for) people not seeking out a high or anything else. They're just trying to recover from surgery and they're dying," she said. "I hope we can find some solid answers."
What should never be lost in any of the problem-solving, Gardner implored, is the crushing weight borne by each and every family who loses a loved one the way hers lost Stewart. His wife, parents and seven siblings will never be the same, Gardner said.
"(He and his wife) had their life planned out and she has to … find him not breathing," she said. "All of the plans they made for their life are done, they're over."
"As parents, we (shouldn't) ever have to bury our child, deal with a funeral and having to pick out a headstone," she went on to say. "What I want other parents to understand — it's not a simple thing to give your child a painkiller. … It can cause pain because of burying your child, because of things you did not know were risks."