The number of drug shortages in the last year reached an all-time high, with many medications used for the management of pain in short supply. In the past, drug shortages of concentrated oral morphine drops and immediate-release oxycodone have affected the outpatient world, but now pain-related medication shortages are taking a toll on the management of patients in the inpatient setting.
“In recent months, it has been difficult for us to acquire [I.V.] fentanyl and various I.V. benzodiazepines, and these shortages have forced us to restrict use of these agents and switch to alternative products,” Lee Kral, PharmD, BCPS, Clinical Pharmacy Specialist, at the University of Iowa (UI) Hospitals and Clinics Center for Pain Medicine, told Pharmacy Today. For example, the operating room (OR) has been affected, with shortages of various anesthetics, I.V. benzodiazepines, and pain medications, “leaving physicians wondering what they will use for their OR cases that day,” Kral said. “We literally have a whiteboard up in the OR with how many vials we have remaining of certain medications so physicians can appropriately plan ahead as to which agents they will select for their patients.”
Shortages of agents such as parenteral butorphanol and nalbuphine for peripartum pain control and injectable ketorolac, a mainstay for pain control in the emergency department, affect hospitals’ ability to manage pain in patients outside the OR.
At the UI Hospitals and Clinics, drug shortage lists are continuously updated by the pharmacy department and communicated to hospital staff. Within these lists, specific inventory counts are listed at the time of the update. A large multidisciplinary group, which includes pharmacy, determines the best way to restrict and prioritize the use of the specific medications. To address the fentanyl shortage, the labor and delivery unit at the UI Hospitals and Clinics agreed to change the epidural infusions from fentanyl to hydromorphone. Within the policy, specific direction was given as to what the new infusion should consist of, and information related to the stability of the alternative infusion was also included to guide pharmacy personnel.
The UI Hospitals and Clinics also restricts agents to specific patient populations during times of critical shortages. With the current shortage of I.V. lorazepam, a restriction was placed on this agent for use only in patients with seizure activity, those suffering from alcohol withdrawal who cannot tolerate oral medications, agitated patients unable to take oral medications and for whom parenteral antipsychotics are contraindicated, and for neonatal ICU patients requiring sedation, noted Kral. For clinicians who want to use a lorazepam drip for other patient populations, the order must be converted to either propofol or dexmedetomidine (Precedex—Hospira).
Drug shortages may also cause additional problems with patient care. “Sometimes suitable alternatives are not available and clinicians are forced to use medications they are not familiar with,” Kral said. “This opens up the door to the potential for serious medication errors to occur.”
For example, dosage recommendations for analgesics vary significantly, so clinicians need to be aware of correct equianalgesic dosing recommendations if available. Look-alike, sound-alike medication errors can also occur. Remifentanil (Ultiva—Mylan), alfentanil, or sufentanil can all be easily mistaken for fentanyl. In addition, if medications from different distributors with different concentrations or vial sizes are stocked in the OR or in automated medication dispensing units, clinicians may reach for these vials without carefully reading the labels, potentially resulting in incorrect dosages.
A number of government agencies are working on the current drug shortage crisis, with FDA taking the lead on endeavors to minimize these events. In the meantime, clinicians should be well versed on which agents are in short supply, especially those that will impact pain management. Preparing in advance by identifying suitable alternative options and educating clinicians on their appropriate use should help to minimize the impact these shortages are having on patient care.
Numerous resources are available to help pharmacists manage these shortages at their institutions. Some of the more common resources include the American Society of Health-System Pharmacists (ASHP) Drug Shortages Resource Center and FDA’s Current Drug Shortage List. A beneficial feature of ASHP’s site is that information on the implications for patient care, safety, alternative agents, and management are listed for select shortages. Both sites also contain information on resolved shortages and discontinued drugs.