Fentanyl shortages or DEA policing healthcare?

JBMmom, MSN, NP · Apr 6, 2018

We were recently told that morphine and dilaudid supplies were temporarily out in our hospital and we started pushing fentanyl on the med surg units. Our orders were generally on the order of 25 micrograms, so we were wasting 75 micrograms every time. When we had dilaudid, a popular dose was 1.2 mg, and it would require a 0.8mg waste every time- (we were out of 0.5). If there wasn't so much waste, we probably wouldn't have these shortages!

Mavrick, BSN, RN · Apr 7, 2018

Hey guys. I'm a travel nurse in the cath lab. Up until my most recent contract I've been giving versed and fentanyl to my hearts content. But, suddenly I'm at a lab that isn't allowing fentanyl? I was told at first it was shortages in FL. I thought, no, because I just left a contract in south FL and we had plenty of fentanyl. Then just this week we were all told it's because the DEA is regulating the amount of fentanyl we give. Particularly in the county I'm working in (one of the harder hit by the opioid crisis). While I am sympathetic to the fact that there's millions of people dying because of overdoses and opioids have become a national health crisis, I am incredibly angry that we are doing CARDIAC INTERVENTIONS on patients that are not completely sedated or are in pain while we're doing the procedure. Anesthesia and OR get fentanyl, why are our patients not able to receive the same care? I feel a moral obligation to help the people that are on the table! 4 of versed and a lot are still talking, but I could give 2 and 50 and they're peacefully sleeping while we work. Is this going to be an ongoing problem? Anyone else experiencing this? What about peripheral interventions....that dye burns! Pharmacy has told us we can sub with dilaudid but I've found they're harder to wake up and have more respiratory depression with 2 and 1-2...it lasts longer. This is ridiculous. Why is the government interfering with our patient care

There is no excuse to allow your patient to be in pain because you don't know how to administer any other kind of pain medication than Fentanyl.

In the PACU we give Dilaudid, Morphine, Demerol, Toradol, Acetaminophen and Versed depending on the situation. Some patients are allergic to Fentanyl and can't have it so we find another way to treat their pain.

FurBabyMom, MSN, RN · Apr 7, 2018

So...not being able to sedate or manage patinet's pain is a problem. That should be handled by the facility - there should be some alternative approved for use when the usual combination of medications is unavailable.

It's not the DEA cracking down on healthcare. Though, there are some pharmacuetical companies dialing back production on some of their narcotics. It really is that many items and not just pain medications are on back order. The answer to the why is most likely aftermath of Hurricane Maria in Puerto Rico. There is a map floating about somewhere - not sure it's been shared here, but you should look at how many healthcare related companies have part or all of their production process in Puerto Rico. We have had an amazing volume of things go on rolling back orders since last fall (not that back orders are new). We've had issues with supplies of staplers and cartridges, other implants and devices are more difficult to acquire, local anesthetic agents, sodium bicarb (we're now not allowed to open it outside of a code situation), IV fluids, sterile fluids for irrigation, etc.

The reason that some facilities seem to "have" items other don't is simple. Some facilities and/or systems are aggressive with purchasing or stockpiling their most commonly needed supplies and medications. If they use enough in a high enough quantity then it likely won't expire. A couple of "big" health systems have started standardization practices which might include code drug drawers being standard in all of the "system" hospitals and clinics. That allows the system to buy standardized items and concentrations in bulk, and reduce individual costs. I was somewhere recently and if I recall correct, the topic of a change (increase) in cost to acquire medications came up. It makes sense that if demand goes up, prices go up too. This is probably true for some supplies and devices too.

Polskijames · Apr 7, 2018

Maverick- The issue is not that I don't know how to give anything other than fentanyl. In this particular lab, the moderate sedation is ordered by the physician. So I as the nurse cannot give anything other than what they order. Many of the interventionalists are still walking in and saying "2 and 50" and we tell them "we don't carry fentanyl anymore" then rattle off the alternatives. Most of them have said they won't be giving dilaudid. I've convinced a couple to give Benadryl with the versed, and some morphine. Other labs it's different; the circulating nurse can give whatever sedation they want under the guise of the procedural physician. So the issue isn't "what do I do we don't have fentanyl, oh well they'll just have to suffer". It's that this particular group of MDs will not be sedating with the alternatives we have.

Mavrick, BSN, RN · Apr 9, 2018

Maverick- The issue is not that I don't know how to give anything other than fentanyl. In this particular lab, the moderate sedation is ordered by the physician. So I as the nurse cannot give anything other than what they order. Many of the interventionalists are still walking in and saying "2 and 50" and we tell them "we don't carry fentanyl anymore" then rattle off the alternatives. Most of them have said they won't be giving dilaudid. I've convinced a couple to give Benadryl with the versed, and some morphine. Other labs it's different; the circulating nurse can give whatever sedation they want under the guise of the procedural physician. So the issue isn't "what do I do we don't have fentanyl, oh well they'll just have to suffer". It's that this particular group of MDs will not be sedating with the alternatives we have.

I apologize if I got it wrong. It seemed like you were complaining that it is the government's fault that you are not able to adequately medicate your patients.

Now it sounds like your doctors are too ignorant to change their practice when told the same old way is not available. What have they done in the past when a patient was allergic to Fentanyl?

Several articles have stated that the shortage is mostly related to production problems at the plant in Kansas. Puerto Rico seems to be the source of most of the IV solution shortages.

Rocknurse, MSN, APRN, NP · Apr 9, 2018

There is no shortage, other than that that has been designed. If you believe it's due to Puerto Rico I have a bridge to sell you. This is deliberate in my opinion. It's so very clear to me how this is playing out.

elkpark · Apr 9, 2018

There is no shortage, other than that that has been designed. If you believe it's due to Puerto Rico I have a bridge to sell you. This is deliberate in my opinion. It's so very clear to me how this is playing out.

Again, not Puerto Rico, but a Pfizer plant that had to be taken off-line for modifications. Or maybe everyone's just falling for the conspiracy ...

A Nov. 27 letter to customers from Pfizer Injectables states, "Due to longer than expected timelines for upgrade work required at our McPherson manufacturing facility, the currently anticipated full recovery dates for prioritized prefilled syringes (PFS) have moved to 1Q19 and deprioritized syringes have moved to 2Q19. We will continue to manufacture and deliver select presentations throughout the upgrade work taking place but do anticipate backorders and product shortages."

Shortage of pain drugs results from manufacturing issue

The supply of injectable painkillers has been hamstrung as Pfizer continues to upgrade its McPherson facility in Kansas that produces the prefilled syringes. The upgrade has taken longer than expected and a third-party supplier ran into a technical issue, which has halted production. The plant was one of a number Pfizer added when it acquired Hospira in 2015 for approximately $17 billion. Pfizer said in a statement to Modern Healthcare that it is resolving the shortages as quickly as possible. Other companies can't make up the difference because they don't have the capacity.

Injectable opioid shortage compromises care - Modern Healthcare Transformation Hub - Modern Healthcare

In contrast, three pharmaceutical fentanyl providers -- Akron, West-Ward and Pfizer -- are experiencing shortages of many versions of the injectable citrate form of the drug. According to the American Society of Health-Systems Pharmacists, a combination of increased demand and manufacturing delays are behind the pharmaceutical fentanyl shortages. Fentanyl product backorders range from intermittent to delays as long as the third quarter of 2018 (for prefilled Carpuject syringes).

https://www.forbes.com/sites/davidkroll/2017/10/31/the-u-s-has-a-fentanyl-shortage-in-the-clinic-not-on-the-streets/#359768b62d0e

A good, juicy government conspiracy theory is so much more satisfying, though ...

Kitkat_389 · Apr 10, 2018

We are on short supply of fentanyl in my hospital so we have had to use demerol instead. It works just as well in terms of sedating the patient, but increases the chances of hypotension.