Parenteral-Opioid Shortage Linked to Worse Pain Control in Palliative-Care Patients

By Reuters Staff

NEW YORK (Reuters Health) - Patterns of opioid prescribing in palliative care changed significantly after the parenteral-opioid shortage was announced, and patients were less likely to achieve clinically improved pain, according to new findings.

"These factors have potential implications for patient satisfaction and hospital length of stay," Dr. Eduardo Bruera of The University of Texas MD Anderson Cancer Center in Houston and colleagues conclude in JAMA Oncology, online March 21.

Several factors have contributed to the parenteral-opioid shortage, Dr. Bruera and his team note: high demand, delays in production and reductions in production quotas of schedule 1 and 2 drugs, and shortages of sterile injectable products.

"Drug shortages, especially of sterile injectable products, will likely persist; therefore, knowledge obtained from this study will help health care professionals and hospital facilities to create timely, safe, and effective countermeasures," they write.

The authors looked at 386 cancer patients referred for palliative care before and after their institution announced the shortage on February 8, 2018.

Referring oncology teams prescribed parenteral opioids to 35% of these patients before the announcement, and 18% of patients afterwards (P<0.001). Prescribing by palliative care teams also fell, from 47% of patients before the shortage to 29% afterwards (P<0.001).

Before the shortage, 75% of patients achieved clinically improved pain by follow-up day 1, versus 62% after the shortage (P=0.01). Patients were almost twice as likely to achieve clinically improved pain before the shortage than afterwards (odds ratio, 1.89; P=0.005).

After the shortage began, oncology teams were less likely to prescribe morphine and hydromorphone and more likely to prescribe oxycodone and hydrocodone. Morphine equivalent doses prescribed per patient increased after the shortage, from 45 mg/d to 60 mg/d.

"Our findings suggest that more aggressive titration with nonparenteral opioids and more frequent assessment of pain intensity, especially during the first few days of hospitalization might result in better pain control," the authors write. "More studies should be conducted on the techniques to achieve this in a way that is logistically feasible."

They add: "Certain alternative drugs, such as nonopioid analgesics (cannabinoids, gabapentin, and ketamine) and less common parenteral opioids (nalbuphine and buprenorphine), might be used to treat cancer pain during the parenteral-opioid shortage. However, their use is limited owing to lack of evidence in cancer pain, complex opioid rotations, and risk of toxic effects. The main priority is to ensure the availability of parenteral opioids for hospitalized patients with cancer."

SOURCE: https://bit.ly/2UhKV0R

JAMA Oncol 2019.

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