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Pandemic Presents Unexpected Opportunity to Embrace Multimodal Analgesia and the Integrative Care Team

Treating hospitalized COVID patients has increased demand for pain-relieving and sedating agents such as fentanyl, placing unique challenges on the healthcare system. However, this may be the perfect time to explore analgesic alternatives and truly integrate care teams.

Background: Pandemic-Related Hospitalizations Pose Potential Pain-Med Shortages

Demands on the healthcare system have increased and evolved due to the COVID-19 pandemic. A larger proportion of hospitalized patients are requiring mechanical ventilation for up to 2 weeks and remaining hospitalized in critical care units for longer periods.1 The unique respiratory strain placed on patients by the SARS-CoV-2 virus has led to long periods of ventilation followed by the potential of developing physical dependence on opioid medications used for related sedation and pain control.

Increased demand for agents used for sedation including fentanyl has stressed the healthcare system and decreased supply of certain therapies for acute pain and short procedures. Fortunately, healthcare administrators and clinicians have been able to formulate preservation strategies to ensure that patients experiencing chronic pain, acute pain, or requiring palliative, end-of-life care have access to the medications they require.

In fact, individual hospitals and large healthcare systems are either preparing for or are already in the throes of the supply chain deficiencies resulting from the pandemic. To ascertain more information regarding what medication shortages and conservation strategies look like on the front-lines, the authors spoke with Suzanne Amato Nesbit, PharmD, BCPS, CPE, FCCP, a clinical pharmacy specialist in pain management at The Johns Hopkins Hospital.

Hospitals and healthcare systems are either preparing for or are already in the throes of the pain medication shortages resulting from the COVID pandemic. (Image: iStock)

Monitoring and Maintaining Supply: Site-Specific Examples

Johns Hopkins: How One Hospital is Staying Ahead of the Curve

Nesbit provided insight on how one institution is coping with these demands, including how her department is actively monitoring their supply of all opioids, paralytics, and sedatives through the creation of a COVID-19 drug supply committee task force. This task force is committed to monitoring current and projected use to stay ahead of the curve.

To conserve traditional sedatives and analgesics, Nesbit shared that her unit is utilizing methadone as a co-analgesic or transdermal fentanyl while titrating IV fentanyl, which she indicated allows for reduced IV fentanyl requirements. Such complex pharmacotherapeutic changes most often require the expertise of a pharmacist given the long and variable half-life and side effect profile of methadone, and consideration for time to steady state and sustained duration of action when using fentanyl transdermal products.2

Nesbit further noted that using methadone has allowed her team to stave off titration to higher doses of fentanyl and benzodiazepines usually required for sedation while enabling more rapid discontinuation of IV fentanyl if patients are transitioned to transdermal formulation.

Despite the increased demand coming from the critical care sector, many facilities are noting decreased or complete elimination of elective surgical procedures. This change has led to a decreased demand for patient-controlled analgesia devices (PCAs). Nesbit’s team has blocked the electronic medical record (EMR) order set for fentanyl and high concentration hydromorphone PCAs and loaded alerts into the EMR for any provider ordering an IV opioid to consider oral if possible. They are also working on conservation strategies to reduce waste from PCAs, such as by using the remaining medication as an intermittent bolus dose.

Fortunately, at the time of this interview (mid-June 2020), Nesbit had not yet needed to utilize alternatives to fentanyl as her team’s conservation strategies were adopted early and have been sufficient thus far. However, both remifentanil and IV sufentanil are being. Made available as options for acute pain patients. Sufentanil sublingual tablet (SST, Dsuvia), another potential option, is not currently in use at her facility.

Nesbit noted that she and her team have learned a great deal from the adaptations needed throughout the COVID19 pandemic. They may carry forward a number of the changes employed, such as conservation strategies, into the post-COVID “new normal.”

Critical Care in the Smaller Hospital Setting
One small hospital in upstate New York is building titratable order sets to allow use of sufentanil, remifentanil, and hydromorphone for continuous infusion in the setting of sedation in mechanically ventilated patient in the event that they have an inadequate supply of IV fentanyl. The same hospital has restricted use of IV fentanyl infusions to the intensive care unit and patients with significant renal dysfunction or advanced cirrhosis requiring an IV opioid.

Others are still reporting that oral opioid shortages may be on the horizon as they increase usage of these therapies in an effort to conserve IV for critical care.

Pharmacists, particularly those with specialty training, are well poised to serve as opioid stewards and help their physician, nurse practitioner, and physician assistant colleagues navigate these uncharted waters. (Image: iStock)

Avoiding Medical Errors in a Pandemic Environment: Let Clinical Pharmacists Help

Introducing unfamiliar medications and new dosing protocols in the midst of an already chaotic and stressful work environment due to COVID-19 may increase the risk of medical error and place patient’s safety at risk. This danger is especially relevant with regard to high potency mu-opioid receptor agonists such as fentanyl and its derivatives, hydromorphone, oxymorphone, and other medications for which dosing may not be a daily routine for prescribers and nurses.

Pharmacists, particularly those with specialty training, are well poised to serve as opioid stewards and help their physician, nurse practitioner, and physician assistant colleagues navigate these uncharted waters. For example, SST has been noted to be a useful option for patients requiring a parenteral opioid but for whom IV access is unnecessary or not possible to obtain. In this unique and unprecedented setting where IV opioids may not be available or may require conservation, a new opportunity for use of SST is presented.3

Many clinicians may be unfamiliar with the nuanced differences among fentanyl, sufentanil, alfentanil, and remifentanil in their various dosage forms. Significant differences in terminal half-life, bioavailability, and available dosage forms can complicate the transition from one to another in the event of a drug shortage.4 Table I illustrates some selected differences – as well as similarities – with fentanyl and its multiple derivatives. A more comprehensive review may be read in the previously published piece, Fentanyl: Separating Fact from Fiction. 

In addition to increasing use of fentanyl derivatives, clinicians may be able to capitalize on the pandemic-related decrease in elective surgeries by using oral opioids instead of parenteral whenever possible and by giving consideration to the use of buprenorphine instead, which is available as an injection, transdermal system or as a buccal film for pain. As a partial mu opioid with exceptional mu agonist activity, plus kappa and delta opioid antagonist properties, buprenorphine offers multiple advantages in the setting of respiratory illness. In particular, buprenorphine exhibits a ceiling effect on carbon dioxide accumulation, thereby reducing the risk of respiratory depression relative to pure mu-opioid agonists.5

 

As COVID closes many doors, new opportunities may be shaped in terms of lessons learned around pain care and team care. (Image: iStock)

COVID as an Unexpected Opportunity to Explore Multimodal Analgesia and Unite the Integrative Care Team

Overall, in the midst of this unprecedented moment in healthcare, opportunities to explore and utilize multimodal analgesia, adjuvants, and novel therapies (including ketamine) abound. Further benefit could be found in application of studies previously done in pursuit of opioid-sparing perioperative measures, such as use of gabapentinoids, acetaminophen, NSAIDs, IV Lidocaine, and glucocorticoids depending upon patient-specific factors and pain etiology.6

As Nesbit suggested, the silver-lining in the fog of a global pandemic may be the opportunity to repurpose and refresh some of our medication use practices while also more openly integrating the clinical expertise of pharmacists as an essential part of the medical management team. (Read or listen to a conversation between Dr. Nesbit, Dr. Fudin, and Dr. Gudin on the evolution of clinical pharmacy in pain management.) For many years, the pain management community has known that true a interdisciplinary, multimodal care should be emphasized. However, for a multitude of reasons – including financial and bureaucratic barriers – the medical community at large has not adopted such a model. Perhaps this global crisis is the catalyst for initiating much-needed change in this realm.

Now may be just the time to reduce medical waste, decrease healthcare costs, and fine-tune ways to improve patient care for the long-term. Standing by the virtue of patient-centered, individualized care during this time while also conserving essential resources poses a unique, hopefully once-in-a-lifetime challenge to us as healthcare providers and it is incumbent upon us to translate this into progress for the medical community at large.

Last updated on: June 24, 2020
Continue Reading:
COVID: Clinical Considerations for Acute and Post-Infection Symptoms
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