Use Multiple Strategies to Manage Pain During Injectable Opioid Shortages

Hospitals are feeling pain from the shortage of injectable opioids...including IV fentanyl, hydromorphone, and morphine.

The shortage is due to manufacturing delays and DEA quotas preventing other companies from increasing production. Now DEA is loosening restrictions, but shortages are still a problem.

Continue to maximize non-opioids. Use this as an opportunity to reduce opioid prescribing. Start with scheduled doses of NSAIDs and acetaminophen. These can work as well as opioids in many patients

Don't automatically reach for IV acetaminophen (Ofirmev). It doesn't work better than oral or rectal...but costs MUCH more.

When opioids are needed, use them as part of a multimodal regimen...and not just for surgery. Check ED and ICU order sets too.

Think about other non-opioid options...such as IV lidocaine or ketamine. But verify that protocols are in place to ensure safe use.

Adjust med use if needed to manage shortages with injectable non-opioids...such as ketorolac, bupivacaine, ketamine, and lidocaine.

Use oral instead of IV opioids. Consider automatic IV to PO switches for PRN opioids in patients able to take PO. Allow a limited number of IV doses to acutely control severe pain...since the faster onset allows for quicker titration.

Be creative with available IV opioids. For example, if you have PCAs in stock, consider using them in patients unable to take PO...or in place of standard continuous infusions in ICU patients.

Try to save fentanyl for procedures since it has a fast onset and short duration...or for patients with anaphylaxis to morphine or hydromorphone.

Ensure safe opioid use. Create standardized dosing conversions for switching between opioids...or converting from IV to PO.

Continue trying to avoid meperidine due to its seizure risk.

Don't use a partial agonist/antagonist (nalbuphine, etc) in chronic opioid users...because of withdrawal risk.

If less commonly used IV opioids are needed during a shortage, ask about adding EHR reminders...to highlight safe practices.

Use our chart, Analgesics for Acute Pain, for more differences between IV opioids, non-opioid strategies, etc.

Key References

  • www.ashp.org/-/media/assets/drug-shortages/docs/drug-shortages-iv-opioids-faq-march2018.ashx
  • J Hosp Med 2018;13(4):263-71
  • J Pain 2016;17(2):131-57
  • Medication pricing by Elsevier, accessed Apr 2018
Hospital Pharmacist's Letter. May 2018, No. 340520



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