When she was in her early 20s, Nicole Veum says she made a lot of mistakes.
“I was really sad and I didn’t want to feel my feelings,” she said. “I turned to the most natural way I could find to cover that all up, and I started using drugs: prescription pills, heroin for a little bit of time.”
Her family got her into treatment. She’d been sober for nine years when she and her husband decided to have a baby. This was something she wanted to feel.
She told her doctor if she needed an epidural, she didn’t want any fentanyl in it. She didn’t want to feel high.
“'Cause I remembered seeing other friends, they’d used it, and they were feeling good and stuff,” she said. “I didn’t want that to be a part of my story.”
Epidurals are usually a mix of two types of medications: a numbing agent, usually from the lidocaine family, and a painkiller, usually fentanyl. The amount of fentanyl is limited, and little passes into the bloodstream, experts say, but if a woman doesn’t want the fentanyl, it’s easy to formulate an epidural solution without it. Doctors either use a substitute medication or up the concentration of the numbing agent.
“There’s no medical reason why someone should be forced to be exposed to opioids if they don’t want to,” said Kelly Pfeifer, a family doctor and addiction expert who now works as director of high-value care at the California Health Care Foundation.
Especially for women who are in active treatment for opioid addiction and taking methadone or Suboxone, Pfeifer said there’s another issue to be wary of: Some other narcotics commonly used for pain during labor can immediately reverse the effects of those treatments.
“Suddenly, you’re in the middle of labor, which is already painful, and now you’re in the middle of the worst withdrawal of your life,” she said.
For Nicole Veum, it was the worst wildfire in California history that interrupted her birth plan. She was in active labor when the October 2017 wildfires broke out. Those blazes swept through the North Bay and parts of Northern California, burning more than 5,000 homes and killing 44 people.
“There was a ton of smoke in the hospital, like, you could visibly see it outside and smell it,” she said.
Nurses said everybody had to evacuate. Veum was transferred to another hospital five miles away. And the special instructions for her epidural got lost in the chaos.
“Then when they went to change the drug, I saw the tube said fentanyl on it, and by that point I was starting to feel, feel the itchies,” she said, referring to one of the signs that she could feel the opioid in her body.
Most women without a history of addiction wouldn’t experience this, said Jennifer Lucero, chief of obstetric anesthesiology at the UCSF Medical Center. Anytime a woman who is not in recovery asks for an epidural without fentanyl, usually out of concern for the baby, Lucero explains why it’s there.
The fentanyl allows the anesthesiologist to balance out the numbing agent in the solution, she says, so women don’t have as much pain from the contractions, but they can still feel the pressure, and move their legs a bit or shift in bed during labor. When she explains the trade off, and assures women that the opioid will have no effect on their fetus, most of them opt to keep it in the epidural solution.
But there are other ways doctors have been trying to cut down on opioids in labor and delivery, namely what they prescribe for after the birth. For years, women who had a normal, vaginal birth were sent home with a 30-day supply of Norco, Percocet or other opioid.
“And they would not use it and it’d just be sitting in the bathroom cabinet,” Lucero said. “Some people would think they’re supposed to take them all.”
Studies show that even after five days of opioid use, the chance of long-term dependence rises steeply; every week of opioid use increases the risk of misuse by 20 percent. While most people who get a bottle of pills when leaving the hospital won’t develop an addiction, some will – about 0.6 percent.
Now, doctors are trying to prescribe limited amounts of opioids only to women who have had a cesarean section.
Women like Nicole Veum. After another 12 hours of labor at the new hospital with little progress, Veum agreed to a C-section. And doctors sent her home with a bottle of Percocet. They told her, if she was worried, to have her husband or a friend hold on to the bottle and control the dosage.
Addiction expert Dr. Kelly Pfeifer said, in a situation like this, just a few pills, or even ibuprofen, would’ve been fine.
“Any parent will tell you there’s nothing more stressful than the first week of being a parent and having a baby and being in sleep deprivation,” Pfeifer said. “And here you have a little bottle of Vicodin that you used to turn to to make you feel better when you’re stressed.”
First the fires. Then the fentanyl in her epidural, then the Percocet. It was Veum’s first test seeing how her sobriety and motherhood would line up.
She called a friend who’s also in recovery and talked it all through. She said the Percocet could have sent her down a rabbit hole, but it didn’t. She was fine leaving that behind.
“I was OK. I was OK with it. It was just something that happened,” she says as her baby, now 1, played with a new toy. “A lot of people metaphorically felt it as a baby coming out of the ash, the life coming from the ashes. And I feel that. I feel like it was a big time for our community and me personally to be reborn in some way."