What Parenteral Opioids to Use in Face of Shortages of Morphine, Hydromorphone, and Fentanyl

Davis, Mellar P.; McPherson, Mary Lynn; Mehta, Zankhana; Behm, Bertrand; Fernandez, Carlos

doi:10.1177/1049909118771374

Cited by 20 publications

(14 citation statements)

References 71 publications

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“…Use in that year was deemed low in 21 countries and very low in more than 100.” Patients in Latin American often have limited access to opioids for pain control (used for both analgesia and anesthesia). Yet even in the U.S.A., there are currently shortages of pharmaceutical medical opioid analgesics needed for acute pain control during medical procedures (Davis et al, 2018). And because of a large increase in opioid related overdose deaths unrelated to burn patients (Chen et al, 2019), there is growing political and legal pressure to further reduce reliance on opioids for pain control in the U.S.A.…”

Section: Introductionmentioning

confidence: 99%

Immersive Virtual Reality as an Adjunctive Non-opioid Analgesic for Pre-dominantly Latin American Children With Large Severe Burn Wounds During Burn Wound Cleaning in the Intensive Care Unit: A Pilot Study

Hoffman

Rodriguez

González

et al. 2019

Front. Hum. Neurosci.

106

144

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Background/Aim: Using a within-subjects, within-wound care design, this pilot study tested for the first time, whether immersive virtual reality (VR) can serve as an adjunctive non-opioid analgesic for children with large severe burn wounds during burn wound cleaning in the ICU, in a regional burn center in the United States, between 2014–2016. Methods: Participants included 48 children from 6 years old to 17 years of age with >10% TBSA burn injuries reporting moderate or higher worst pain during no VR on Day 1. Forty-four of the 48 children were from developing Latin American countries. Patients played adjunctive SnowWorld, an interactive 3D snowy canyon in virtual reality during some portions of wound care, vs. No VR during comparable portions of the same wound care session (initial treatment condition randomized). Using Graphic Rating scales, children's worst pain ratings during “No VR” (treatment as usual pain medications) vs. their worst pain during “Yes VR” was measured during at least 1 day of wound care, and was measured for up to 10 study days the patient used VR. Results: VR significantly reduced children's “worst pain” ratings during burn wound cleaning procedures in the ICU on Day 1. Worst pain during No VR = 8.52 (SD = 1.75) vs. during Yes VR = 5.10 (SD = 3.27), t (47) = 7.11, p < 0.001, SD = 3.33, CI = 2.45–4.38, Cohen's d = 1.03 (indicating large effect size). Patients continued to report the predicted pattern of lower pain and more fun during VR, during multiple sessions. Conclusion: Immersive virtual reality can help reduce the pain of children with large severe burn wounds during burn wound cleaning in the Intensive Care Unit. Additional research and development is recommended.

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Section: Introductionmentioning

confidence: 99%

Immersive Virtual Reality as an Adjunctive Non-opioid Analgesic for Pre-dominantly Latin American Children With Large Severe Burn Wounds During Burn Wound Cleaning in the Intensive Care Unit: A Pilot Study

Hoffman

Rodriguez

González

et al. 2019

Front. Hum. Neurosci.

106

144

View full text Add to dashboard Cite

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“…Interestingly, this reduction in the overall production quotas of opioids is concurrent with the rise in the production of marijuana (14,17). Indeed, another factor contributing to the decline in morphine prescriptions may be the nationwide shortage of parenteral opioids (notably morphine, hydromorphone, and fentanyl) that has resulted in a transition to alternative opioids such as nalbuphine and buprenorphine (18).…”

Section: Discussionmentioning

confidence: 99%

Reductions and pronounced regional differences in morphine distribution in the United States

Dowd

Tang

Yan

et al. 2022

Preprint

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BackgroundMorphine is one of the oldest, most commonly prescribed, and widely used opioids in the United States (US). Morphine’s potent analgesic properties have also been associated with the increase in misuse, addiction and opioid-related deaths in the US since the 1990s. Despite federal regulations, population-adjusted prescription opioid distribution varies markedly between states. The objective of this study was to describe the temporal pattern of morphine distribution nationally and between states.MethodsDrug weight and population data were obtained from Report 5 of the US Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System (ARCOS) to characterize patterns in the distribution of morphine from 2012 to 2020.Morphine distribution amounts were separated by state and business type and corrected for population. States outside a 95% confidence interval relative to the national average were considered statistically significant.ResultsPharmacies and hospitals distributed 24,200 kilograms of morphine in 2012. Tennessee (180.2 mg/person) was 4.7-fold higher than Texas (39.4 mg/person).National distribution decreased 56.4% to 10,723 kilograms in 2020. Tennessee (56.4 mg/person) was 3.8-fold higher than the District of Columbia (15.0 mg/person). The decline in Illinois (−40.9%) was significantly less than the national average (−56.8%) while that of Oregon (−71.1%) and Arizona (−70.4%) were significantly higher. Hospital decrease (−72.7%) from 2012-2020 was larger than that of pharmacies (−56.12%).ConclusionsThe national 56% decline in the distribution of morphine in the last decade may be attributable to prioritization of the opioid crisis as a public concern, including subsequent growth of opioid misuse and treatment programs and decreased production quotas for opioids, including morphine. This decline also coincides with the national shortage of parenteral opioids resulting in greater prescriptions of alternative opioids such as nalbuphine and buprenorphine. Further research is necessary to understand the persistent four-fold regional difference between states.

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“…5 For those patients with severe pain, the parenteral route has been proven to be a fast, reliable, and safe mode for opioid dose titration. [24][25][26] After the POS, the primary oncology teams prescribed significantly higher MEDDs, which suggests that even higher doses of nonparenteral opioids were not sufficient to treat severe pain. Oral opioid formulations may have highly variable bioavailability in patients with cancer who have persistent nausea and vomiting or those with certain gastrointestinal issues such as bowel obstruction, malabsorption syndrome, or cachexia.…”

Section: Discussionmentioning

confidence: 99%

Implications of the Parenteral Opioid Shortage for Prescription Patterns and Pain Control Among Hospitalized Patients With Cancer Referred to Palliative Care

Haider

et al. 2019

JAMA Oncol

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IMPORTANCE The recent parenteral opioid shortage (POS) has potential implications for cancer-related pain management in hospitalized patients. OBJECTIVE This study compared changes in opioid prescriptions and clinically improved pain (CIP) among patients treated by an inpatient palliative care (PC) team before and after our institution first reported the POS. DESIGN, SETTING, AND PARTICIPANTS A cohort study of 386 eligible patients with cancer treated at a comprehensive cancer center 1 month before and after the announcement of the POS. We reviewed data from electronic health records, including patient demographics, opioid type, route of administration, and dose. Board-certified palliative care specialists assessed CIP at follow-up day 1. EXPOSURES The announcement of the POS by the institution's pharmacy and therapeutics committee on February 8, 2018. MAIN OUTCOMES AND MEASURES The primary outcome was to measure the change in opioid prescription patterns of physicians, and the secondary outcome was to measure the proportion of patients who achieved CIP before and after announcement of the POS. RESULTS Of 386 eligible patients, 196 were men (51%), 270 were white (70%), and the median age was 58 years (interquartile range, 46-67 years). Parenteral opioids were prescribed less frequently by the referring oncology teams after the POS (56 of 314 [18%]) vs before the POS (109 of 311 [35%]) (P < .001). The PC team also prescribed fewer parenteral opioids after the POS (96 of 336 [29%]) vs before the POS (159 of 338 [47%]) (P < .001). After the POS (vs before the POS), significantly fewer patients achieved CIP on follow-up day 1 (119 [62%] vs 144 [75%] of 193; P = .01). Multivariate analysis showed that before the POS, patients had an 89% higher chance of achieving CIP on follow-up day 1 (odds ratio, 1.89; 95% CI, 1.22-2.94; P = .005). CONCLUSIONS AND RELEVANCE There was a significant change in opioid prescription patterns associated with the POS. Furthermore, after the POS, fewer patients achieved CIP. These factors have potential implications for patient satisfaction and hospital length of stay.

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What Parenteral Opioids to Use in Face of Shortages of Morphine, Hydromorphone, and Fentanyl

Cited by 20 publications

References 71 publications

Immersive Virtual Reality as an Adjunctive Non-opioid Analgesic for Pre-dominantly Latin American Children With Large Severe Burn Wounds During Burn Wound Cleaning in the Intensive Care Unit: A Pilot Study

Immersive Virtual Reality as an Adjunctive Non-opioid Analgesic for Pre-dominantly Latin American Children With Large Severe Burn Wounds During Burn Wound Cleaning in the Intensive Care Unit: A Pilot Study

Reductions and pronounced regional differences in morphine distribution in the United States

Implications of the Parenteral Opioid Shortage for Prescription Patterns and Pain Control Among Hospitalized Patients With Cancer Referred to Palliative Care

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