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Parenteral Opioids Shortage: What Options Exist for US Health Centers and Hospitals?

While less-effective alternatives exist, both patients and practitioners remain at risk

A recent perspective1 by Eduardo Bruera, MD digs into the recent severe shortage of the three most commonly used parenteral opioids: morphine, hydromorphone, and fentanyl in his cancer center’s pharmacy, as well as the similar shortages impacting cancer centers and hospitals across the United States. Dr. Bruera is the medical director at the department of Supportive Care Center, Division of Cancer Medicine, at the University of Texas MD Anderson Cancer Center in Houston.

The shortage, largely the result of tightened government controls over opioids, has had serious repercussions for both patients and physicians alike. Just a few examples of heightened regulations: In August 2017, the US Drug Enforcement Administration proposed reducing opioid manufacturing by 20% in 2018,2 and in 2014, hydrocodone had been reclassified from a Schedule III substance to a Schedule II substance, making it more difficult to prescribe or use.3 What’s more, noted Dr. Bruera in his review, “The opioid shortage is not expected to be resolved in the near future, so hospitals will need to implement mitigation strategies.” Cancer patients, almost all of which require opioids, are most at risk, he wrote.

With this deficit in mind, Dr. Bruera explained that medication errors may become more prevalent as clinicians change patients’ regimens to use less familiar drugs or opioid-sparing drug combinations. In addition, there is an increased risk of delayed time to achieve analgesia and for different side effects to occur. “Physicians’ burden and stress increase when they are forced to make sudden changes in practice,” he added. Current pharmaceutical notifications for opioid shortages are stressful, time-consuming, and further discourage opioid prescribing.

Several proposed methods to combat the shortage are only partially effective and may lead to more complexity in treatment plans. “The electronic health record (EHR) might help by notifying physicians immediately when the opioid is in shortage and providing information on alternative available opioids and the recommended dose ratio,” Dr. Bruera said. He suggested an opioid reserve be established in all hospital pharmacies and health networks to “mitigate the impact of similar episodes in the future.” Taking a note from Canadian pharmacies, healthcare facilities could also successfully prepare parenteral opioids from powder for cost-effective measures. It should be noted that, due to the current limitations on dosing, many doctors have opted to use nonopioid agents or Schedule IV opioids, or refer patients to palliative care or pain specialists (many of which cannot meet the opioid demand, according to Dr. Bruera).

While pharmacologic (CGRPs) and nonpharmacologic therapies (chiropractic care) in the pipeline as alternatives to opioids, approval and market availability can take years. Dr. Bruera urged leaders to “make it a clinical and ethical priority to secure the availability of parenteral opioids for US patients who are in pain.”

Last updated on: August 27, 2018
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