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November 26, 2018 Focus on health care

Opioid shortage: While addiction issues loom, hospitals run short on necessary painkillers

Photo/Matt Wright Neil Gilchrist, the manager of pharmacy operations at UMass Memorial Medical Center, is among those working to make sure the hospital has enough opioid painkillers on hand.

Most headlines or struggles relating to opioids in recent years deal with opioid abuse and the often deadly consequences. But hospitals are facing another opioid challenge: They have barely enough injectable opioid painkillers to give patients prescribed the drugs.

“We've never seen anything like the last couple of years, even close to that,” said Roland Bercume, the senior director of pharmacy for UMass Memorial Medical Center in Worcester.

“It's real, and we've lived it and felt it; and we feel like right now we're getting a handle on it,” Bercume said. “It's important to let the public know that we've managed this, and it hasn't affected patient care.”

Still, those who oversee the use of opioid painkillers – commonly used drugs including oxycodone, codeine and morphine – say hospitals are barely getting by, thanks to planning in advance for which drugs may be nearing depletion.

The American Medical Association calls the shortage a result of damage to critical drug production facilities in Puerto Rico from a hurricane last year. Those storms came just months after the U.S. Food and Drug Administration found sterility problems at a Pfizer lab in Kansas causing a major opioid producer to stop operations.

The drop in production was so severe the American Medical Association in June said drug shortages had become an urgent public health crisis. The shortages extended even to everyday patient care products, including sterile intravenous saline or other fluids, the AMA said.

“The fact that drug shortages worsened when major hurricanes struck drug production facilities on Puerto Rico highlights the need to evaluate and plan for hazards that pose a threat to critical infrastructure for manufacturing pharmaceutical and medical products,” AMA board member William Kobler said in the association's announcement in June.

Despite concern about opioid addiction, they remain the most effective way to treat significant pain, especially compared to painkillers obtained over the counter. Injectable opioids begin working more quickly than opioids taken orally.

A national shortage

The shortage has been widespread, hitting hospitals across the country.

In April, the American Society of Health-System Pharmacists surveyed more than 300 hospital pharmacists and found 98 percent had been affected by shortages of morphine, hydromorphone and fentanyl. In three out of four cases, doctors instead gave patients oral opioid medications, which can take longer to begin working effectively, or in nearly half of cases, they instead gave patients non-opioid injectable medications.

Just over half of pharmacists in the survey said they prioritized patients based on clinical need because of the shortage. Three out of four respondents reported increased costs due to switching medications to something like intravenous acetaminophen or intravenous ibuprofen.

Managing a shortage & an addiction crisis

At the same time, doctors are prescribing opioids less often, a result at least in part of an effort to curb rising opioid abuse cases.

In 2012, doctors prescribed 81 opioids per 100 patients, according to the Centers for Disease Control and Prevention. By 2017, that rate had fallen to 59 out of 100 patients. Still, that rate is three times higher than it was in 1999.

Neil Gilchrist, the manager of pharmacy operations at UMass Memorial, said there's at least a slight correlation between the opioid abuse crisis and a lower production of prescription opioids, as health officials call for reducing how often doctors turn to opioids to manage pain.

Milford Regional Medical Center is similarly trying to move away from opioids when it can, said Susan Otocki, the hospital's pharmacy director.

“We're doing that on purpose to avoid the use of opioids, not because of the shortage but because it's better for the patient,” Otocki said.

Overdose deaths involving prescription opioids were five times higher in 2016 than in 1999, according to a study published in March in the American Journal of Public Health. While the state Department of Public Health doesn't break out prescription opioid overdoses, more than 1,500 total fatal opioid overdoses this year were recorded through the end of September.

Those figures are consistent with opioid death totals in recent years, leaving the public health issue as a major source of fatalities despite so much attention to the issue in Massachusetts.

Not every hospital is still feeling the pinch as much. Heywood Hospital in Gardner experienced a shortage from the summer of 2017 through early 2018, said Martin Goldberg, Heywood's director of pharmacy.

“However, the crisis level started to abate in March/April of this year,” Goldberg said, “and while there are still some pockets of shortages, the supply that we have now is sufficient to meet our patients' needs."

Avoiding dire problems

Central Massachusetts hospitals are responding to the broader drug shortage by planning well in advance.

At MetroWest Medical Center, the staff has been turning, when it can, to non-opioids like ibuprofen or topical creams, or using opioids in pill form instead of through injections. The supply has gotten better since the beginning of the year, said Daisy Burroughs, the hospital's public relations manager.

At Milford Regional Medical Center, drug inventory issues are mentioned in each shift's unit meeting, Otocki said. Common drug shortages like IV fluids are broadcast to the whole medical staff by email, and specific departments are alerted to shortages in drugs they're more likely to use.

“It's a chronic problem,” Otocki said. “You kind of almost have to take it day-by-day because you're not sure what you're going to be able to obtain.”

Like other hospitals, Milford works to find other drugs to fit a patient, such as oral opioids instead of injectable ones, or Tylenol, Motrin or Advil when the pain isn't too severe. In certain cases, opioids will be used occasionally to supplement those more common drugs instead of being taken, say, every six or eight hours.

In most cases with patients, Bercume said, UMass can find an alternative medication as effective as what might initially be prescribed. The hospital issues a notice to providers each week to update them on which supplies are running low so they can give medications accordingly.

“Talking to other organizations, we're all managing on a week-to-week basis,” Bercume said. “It gets pretty dire at some points.”

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