Injectable opioid shortages put hospitals on brink of public health crisis

Penn Presbyterian Medical Center (https://goo.gl/maps/eirwk2nuHCu)

Penn Presbyterian Medical Center (https://goo.gl/maps/eirwk2nuHCu)

As the director of pharmacy at Penn Presbyterian Medical Center, Neshaminy Kasbekar used to place orders for injectable opioids a couple of times a week so that the staff would have a week’s supply on hand at any one point.

Now, she’s placing orders every day.

“I’m scrambling right now,” she said.

The hospital is getting 30 percent less injectable morphine, fentanyl, and Dilaudid than it did a year ago. That’s when a Pfizer manufacturing plant in Kansas cut back production due to quality issues and plant upgrades. Pfizer produces 60 percent of the country’s injectable opioids.

As they wait for supplies to stabilize, Kasbekar and her staff have gotten creative. They’ve purchased injectables in higher concentrations and bigger vials, using those to make smaller measures that they then send to the floors.

They are also rationing injectable opioids for all but the sickest patients — those who are in intensive care or who are undergoing surgery. For the rest, Kasbekar and her staff are encouraging the use of other medications, including oral painkillers or higher doses of over-the-counter remedies such as Tylenol or nonsteroidal anti-inflammatory drugs.

Some smaller hospitals have had to discontinue certain elective procedures because they couldn’t provide injectable painkillers for the patients. That hasn’t happened at Penn, Kasbekar said, but it is more difficult to get what’s needed.

“We’re not at a point where we’ve completely run out, and we’re in trouble,” she said. “But we are concerned that it’s coming — three, four months from now.”

Other hospitals in the region, including Temple, have also experienced shortages; like Penn, they are finding ways to maintain patient care. But getting an adequate supply from other manufacturers — including Akorn, Fresenius Kabi USA, and Hikma (formerly West-Ward Pharmaceuticals) — has been a challenge because those companies don’t have the capacity to fill the void Pfizer has left.

“We’re making progress in mitigating the shortages,” said Matthew Kuhn, a spokesman for Fresenius Kabi, “but given the high demand and limited supply of these specialized drugs, we expect availability of injectable opioids to be constrained and shortages to persist for months.”

In a statement on its web site, Hikma points to controlled substance quotas by the Drug Enforcement Administration for limiting its ability to increase supply.

In the meantime, Kazbekar and her staff continue to meet daily, sometimes twice a day. Given how fast everything is moving, she worries about the possibility of someone making a deadly mistake.

“We’re changing out product on the floors, we have concentrations that are changing, and so, as a result, it could potentially lead to medication errors,” she said. “So we’re really trying to be thoughtful in how we’re doing this, and the manufacturers aren’t really leaving much room for that.”

Pfizer recently sent hospitals a memo explaining how to filter injectable medications that had been held back due to potential particle contamination. The company doesn’t expect supplies to return to normal levels until the first quarter of 2019.

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