Commentary: Brad Macy, RN, BSN, CHPN, Co-founder & President, Hospi Corporation

The injectable opioid shortage is challenging both hospices and hospitals alike. According to the recent Kaiser Health News article below, hospitals are grappling with both ethical and safety issues associated with the shortage as they seek alternatives to control pain. In response to this crisis the Macy Catheter is emerging as a safe and more cost-effective alternative to IV or subcutaneous administration. While the device has been FDA-cleared for a few years, it has recently gained substantial interest with hospitals, skilled nursing facilities, and hospice and palliative care organizations due to the shortage.

Some of the largest inpatient units throughout the U.S. have discovered the Macy Catheter as a highly effective solution that saves nursing time and decreases medication costs with less risk of injury from needle sticks or infection. These inpatient units are finding that it works just as well if not better than subcutaneous delivery.

Dr. Wendy Schmitz, M.D., Vice President of Medical Services, Ohio’s Hospice of Dayton said, “Based on my experience on our hospice inpatient unit, the Macy Catheter is faster than subcutaneous in controlling pain with opioids and I am able to control pain with less opioid dose adjustments. It is also very effective in most instances in quickly controlling terminal agitation and other symptoms. It saves nursing time and decreases medication cost and waste. I will never go back to my prior practice and will continue using the Macy Catheter.”

In November 2017 Dr. Schmitz received notice that they had four days before running out of parenteral doses of morphine, hydromorphone and fentanyl. The Hospice responded to the crisis by switching to the Macy Catheter as the first line choice for the delivery of medications. According to Dr. Schmitz, they have found it to work better in controlling pain and as good in controlling terminal agitation compared to subcutaneous. Because blood flow to the subcutaneous tissue decreases in patients near end-of-life this makes sense, but few studies have ever looked at subcutaneous medication efficacy near end-of-life.

Another example is Hospice of Buffalo, a sizable hospice in upstate New York. They recently completed a paper on the clinical and cost benefits of utilizing the Macy Catheter in the home and inpatient settings. Hospice Buffalo uses the Macy Catheter as a first line alternative before subcutaneous for most drugs and saved $92,000 in their inpatient unit using the catheter in 2017. Improving Care and Decreasing Costs: Utilizing the Macy Catheter for End of Life Symptom Management paper is available here.

The Other Opioid Crisis: Hospital Shortages Lead To Patient Pain, Medical Errors

The Other Opioid Crisis: Hospital Shortages Lead To Patient Pain, Medical ErrorsEven as opioids flood American communities and fuel widespread addiction, hospitals are facing a dangerous shortage of the powerful painkillers needed by patients in acute pain, according to doctors, pharmacists and a coalition of health groups.

The shortage, though more significant in some places than others, has left many hospitals and surgical centers scrambling to find enough injectable morphine, Dilaudid and fentanyl — drugs given to patients undergoing surgery, fighting cancer or suffering traumatic injuries. The shortfall, which has intensified since last summer, was triggered by manufacturing setbacks and a government effort to reduce addiction by restricting drug production.

As a result, hospital pharmacists are working long hours to find alternatives, forcing nurses to administer second-choice drugs or deliver standard drugs differently. That raises the risk of mistakes — and already has led to at least a few instances in which patients received potentially harmful doses, according to the nonprofit Institute for Safe Medication Practices, which works with health care providers to promote patient safety.

In the institute’s survey of hospital pharmacists last year, one provider reported that a patient received five times the appropriate amount of morphine when a smaller-dose vial was out of stock. In another case, a patient was mistakenly given too much sufentanil, which can be up to 10 times more powerful than fentanyl, the ideal medication for that situation.

In response to the shortages, doctors in states as far-flung as California, Illinois and Alabama are improvising the best they can. Some patients are receiving less potent medications like acetaminophen or muscle relaxants as hospitals direct their scant supplies to higher-priority cases. Other patients are languishing in pain because preferred, more powerful medications aren’t available, or because they have to wait for substitute oral drugs to kick in.

The American Society of Anesthesiologists confirmed that some elective surgeries, which can include gall bladder removal and hernia repair, have been postponed.

In a Feb. 27 letter to the U.S. Drug Enforcement Administration, a coalition of professional medical groups — including the American Hospital Association, the American Society of Clinical Oncology and the American Society of Health-System Pharmacists — said the shortages “increase the risk of medical errors” and are “potentially life-threatening.”

In addition, “having diminished supply of these critical drugs, or no supply at all, can cause suboptimal pain control or sedation for patients,” the group wrote.

The shortages involve prefilled syringes of these drugs, as well as small ampules and vials of liquid medication that can be added to bags of intravenous fluids.

Drug shortages are common, especially of certain injectable drugs, because few companies make them. But experts say opioid shortages carry a higher risk than other medications.

Giving the wrong dose of morphine, for example, “can lead to severe harm or fatalities,” explained Mike Ganio, a medication safety expert at the American Society of Health-System Pharmacists.

Calculating dosages can be difficult and seemingly small mistakes by pharmacists, doctors or nurses can make a big difference, experts said.

Marchelle Bernell, a nurse at St. Louis University Hospital in Missouri, said it would be easy for medical mistakes to occur during a shortage. For instance, in a fast-paced environment, a nurse could forget to program an electronic pump for the appropriate dose when given a mix of intravenous fluids and medication to which she was unaccustomed.

“The system has been set up safely for the drugs and the care processes that we ordinarily use,” said Dr. Beverly Philip, a Harvard University professor of anesthesiology who practices at Brigham and Women’s Hospital in Boston. “You change those drugs, and you change those care processes, and the safety that we had built in is just not there anymore.”

Chicago-based Marti Smith, a nurse and spokeswoman for the National Nurses United union, offered an example.

“If your drug comes in a prefilled syringe and at 1 milligram, and you need to give 1 milligram, it’s easy,” she said. “But if you have to pull it out of a 25-milligram vial, you know, it’s not that we’re not smart enough to figure it out, it just adds another layer of possible error.”

During the last major opioid shortage in 2010, two patients died from overdoses when a more powerful opioid was mistakenly prescribed, according to the institute. Other patients had to be revived after receiving inaccurate doses.

The shortage of the three medications, which is being tracked by the FDA, became critical last year as a result of manufacturing problems at Pfizer, which controls at least 60 percent of the market of injectable opioids, said Erin Fox, a drug shortage expert at the University of Utah.

A Pfizer spokesman, Steve Danehy, said its shortage started in June 2017 when the company cut back production while upgrading its plant in McPherson, Kan. The company is not currently distributing prefilled syringes “to ensure patient safety,” it said, because of problems with a third-party supplier it declined to name.

That followed a February 2017 report by the U.S. Food and Drug Administration that found significant violations at the McPherson plant. The agency cited “visible particulates” floating in the liquid medications and a “significant loss of control in your manufacturing process [that] represents a severe risk of harm to patients.” Pfizer said, however, that the FDA report wasn’t the impetus for the factory upgrades.

Other liquid-opioid manufacturers, including West-Ward Pharmaceuticals and Fresenius Kabi, are deluged with back orders, Fox said. Importing these heavily regulated narcotics from other countries is unprecedented and unlikely, she added, in part because it would require federal approval.

At the same time, in an attempt to reduce the misuse of opioid painkillers, the Drug Enforcement Administration called for a 25 percent reduction of all opioid manufacturing last year, and an additional 20 percent this year.

“DEA must balance the production of what is needed for legitimate use against the production of an excessive amount of these potentially harmful substances,” the agency said in August.

When the coalition of health groups penned its letter to the DEA last month, it asked the agency to loosen the restrictions for liquid opioids to ease the strain on hospitals.

The shortages are not being felt evenly across all hospitals. Dr. Melissa Dillmon, medical oncologist at the Harbin Clinic in Rome, Ga., said that by shopping around for other suppliers and using pill forms of the painkillers, her cancer patients are getting the pain relief they need.

Dr. Shalini Shah, the head of pain medicine at the University of California-Irvine health system, pulled together a team of 20 people in January to figure out how to meet patients’ needs. The group meets for an hour twice a week.

The group has established workarounds, such as giving tablet forms of the opioids to patients who can swallow, using local anesthetics like nerve blocks and substituting opiates with acetaminophen, ketamine and muscle relaxants.

“We essentially have to ration to patients that are most vulnerable,” Shah said.

Two other California hospital systems, Kaiser Permanente and Dignity Health in Sacramento, confirmed they’re experiencing shortages, and that staff are being judicious with their supplies and using alternative medications when necessary. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

At Helen Keller Hospital’s emergency department in Sheffield, Ala., earlier this month, a 20-year-old showed up with second-degree burns. Dr. Hamad Husainy said he didn’t have what he needed to keep her out of pain.

Sometime in January, the hospital ran out of Dilaudid, a drug seven times more potent than morphine, and has been low on other injectable opioids, he said.

Because Husainy’s patient was a former opioid user, she had a higher tolerance to the drugs. She needed something strong like Dilaudid to keep her out of pain during a two-hour ride to a burn center, he said.

“It really posed a problem,” said Husainy, who was certain she was in pain even after giving her several doses of the less potent morphine. “We did what we could, the best that we could,” he said.

Bernell, the St. Louis nurse, said some trauma patients have had to wait 30 minutes before getting pain relief because of the shortages.

“That’s too long,” said Bernell, a former intensive care nurse who now works in radiology.

Dr. Howie Mell, an emergency physician in Chicago, said his large hospital system, which he declined to name, hasn’t had Dilaudid since January. Morphine is being set aside for patients who need surgery, he said, and the facility has about a week’s supply of fentanyl.

Mell, who is also a spokesman for the American College of Emergency Physicians, said some emergency departments are considering using nitrous oxide, or “laughing gas,” to manage patient pain, he said.

When Mell first heard about the shortage six months ago, he thought a nationwide scarcity of the widely used drugs would force policymakers to “come up with a solution” before it became dire.

“But they didn’t,” he said.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

Hospi Corporation

1650 S. Amphlett Blvd
Suite 201
San Mateo, CA 94402
T: 888.509.3732
F: 510.648.3529

When the oral route is compromised, knowledgeable clinicians turn to the Macy Catheter®. The Macy Catheter is the best alternative for rapid administration of medication and fluids. Patented and FDA cleared, the Macy Catheter provides access to the clinically proven rectal route of delivery. It can be used in multiple settings, including hospice and palliative care, skilled nursing facilities, and the emergency department. The Macy Catheter improves patient care and nursing efficiency while decreasing the cost of care.

*Disclaimer: Anecdotal testimonials were provided by clinicians and are shared for general educational purposes with their permission. The Macy Catheter is a prescription device indicated to provide rectal access to administer liquids/medications. Hospi Corporation does not promote the use of particular medications to address particular conditions, and does not claim that the Macy Catheter can treat a particular condition. The prescribing healthcare professional is responsible for selecting medications for treatment, their dosage, and the route of delivery. The Macy Catheter can facilitate administration when the rectal route is prescribed.

Hospi Corporation

1650 S. Amphlett Blvd
Suite 201
San Mateo, CA 94402
T: 888.509.3732
F: 510.648.3529

 

When the oral route is compromised, knowledgeable clinicians turn to the Macy Catheter®. The Macy Catheter is the best alternative for rapid administration of medication and fluids. Patented and FDA cleared, the Macy Catheter provides access to the clinically proven rectal route of delivery. It can be used in multiple settings, including hospice and palliative care, skilled nursing facilities, and the emergency department. The Macy Catheter improves patient care and nursing efficiency while decreasing the cost of care.

*Disclaimer: Anecdotal testimonials were provided by clinicians and are shared for general educational purposes with their permission. The Macy Catheter is a prescription device indicated to provide rectal access to administer liquids/medications. Hospi Corporation does not promote the use of particular medications to address particular conditions, and does not claim that the Macy Catheter can treat a particular condition. The prescribing healthcare professional is responsible for selecting medications for treatment, their dosage, and the route of delivery. The Macy Catheter can facilitate administration when the rectal route is prescribed.