In one of our country’s most unfortunate contemporary ironies, while opioids are destroying people’s lives and the lives of their family members throughout all strata of society — rich, poor, urban, suburban, rural — they are in short supply in hospitals around the country. This is true both for hospitals that serve people and those that serve their pets. Reports are coming in that in some hospitals, elective surgeries for people — gall bladder removal, hernia repair — are being postponed, while some people in postoperative recovery are said to be receiving less potent pain medication than they need.
What’s true for people is true for dogs, says Alicia Karas, DVM, a board-certified veterinary anesthesiologist
on the faculty at Tufts Cummings School as well as hospital director at TuftsVETS, a specialty referral and emergency hospital that cares for dogs (and cats) in
Walpole, Massachusetts.
The lack of available opioids in medical settings is in large part the result of a call by the U.S. Drug Enforcement Administration for pharmaceutical manufacturers to cut opioid production by 25 percent last year and an additional 20 percent this year in order to reduce opioid supplies that might translate into opioid misuse. On top of that, drug company Pfizer, which is estimated to control at least 60 percent of the injectable opioid market, has had manufacturing problems in at least one of its plants.
The opioid shortage in the medical setting is playing out in any number of ways. For instance, says Dr. Karas, “right now I’m not aware of any practice having trouble getting enough Butorphanol, which is okay for, like, suturing a laceration. But it’s not enough to manage the pain of cutting open the abdomen during a major surgery.”
Another opioid that remains in “pretty good supply” is buprenorphine, Dr. Karas reports, “but the price has skyrocketed. It used to be $8 to $10 a dose. Now, a single dose for a 30-pound dog is $30. If you need it every 6 hours for 30 hours, it adds up. You can afford it for a small dog but not a big one. So what do you do?”
Shortages of various opioids hasn’t to date been a devastating problem at large teaching hospitals like the one at Tufts, Dr. Karas says. They have several anesthesiologists on board whose deep knowledge of pain medications and other anesthetics allows them to act nimbly during shortages of this or that opioid, making substitutions and knowing what potential complications to look for — and correct — during monitoring. “We even have a staff of actual pharmacists,” she says, who have been schooled to problem solve when it comes to getting enough drugs and also to confer about substitutions when one is in short supply.
“If methadone is on backorder,” Dr. Karas says, “I’ll use hydromorphone or fentanyl, or vice versa. But a general practitioner might not be able to pull an alternative out of her back pocket.”
That is, the primary care veterinarian who may have been using one anesthesia protocol for a long time probably doesn’t have a lot of knowledge about alternatives at her fingertips. Her job has required her to cover many different aspects of veterinary care all at once rather than focus just on pain management. The problem with that, Dr. Karas says, is that “one size fits all is okay for ponchos but, in this environment, not for pain management.” A shortage doesn’t mean something can’t be substituted, she explains, but you have to know what to give and how much of it, what to give less of in conjunction with it, and what side effects to look for and correct, if necessary. And as shortages come and go, the target solutions keep moving, which leaves more room for error.
“If there is one fortunate aspect of this situation,” Dr. Karas writes to her fellow veterinarians in a paper entitled Keeping Control in the Face of Unpredictable Opioid Drug Availability, “it is that it reminds us of the fact that adequate control of pain has become an ethical mandate in our practices and also gives us an opportunity to explore some fantastic options for multi-modal analgesia that will further broaden our ability to treat pain.” These include local anesthetics (see page 10 of this story) in addition to combinations of smaller amounts of opioids that heretofore haven’t been tried.
“We keep forging ahead, trying new state-of-the-art techniques, and I think we’re going to find more alternatives,” Dr. Karas says. “It’s all a work in progress.” Opioids have their disadvantages, too, she makes clear, including breathing problems for some along with constipation.
In the meantime, she points veterinarians to what she says is a “fantastic resource: the World Small Animal Veterinary Association Global Pain Council Guidelines, a 60-page mini textbook on small animal pain medicine written by an international panel of pain experts.” It includes drug protocols for situations like orthopedic surgery and C sections, outlining what to do when controlled drugs are not available. In some countries, Dr. Karas says, the ability for veterinarians to procure opioids is even more difficult, and these guidelines “are a real lifeline for those in specific situations.” Go to www.wsava.org and type “Global Pain Council Guidelines” in the search bar.
