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///2013 Abstract Details
2013 Abstract Details2019-08-02T16:57:45-05:00

Neuraxial opioids in an era of critical drug shortages: A review of intrathecal hydromorphone

Abstract Number: F 15
Abstract Type: Meta Analysis/Review of the Literature

Andrea M Hages D.O.1 ; H. Jane Huffnagle D.O.2; Michelle Beam D.O.3; Suzanne Huffnagle D.O.4; Michelle Mele M.D.5

Critical drug shortages affect all areas of medicine. Lack of one drug ultimately leads to shortages of others as clinicians use alternatives. In 2010, 178 shortages were reported, rising to 251 in 2011; primarily affected are chemotherapeutics and sterile injectables.(1) The cause is multi-factorial, including manufacturing problems, economics, and trouble obtaining raw materials.(1) Anesthesiologists are forced to modify anesthetic plans by using alternative medications, changing the anesthetic procedure, and postponing/cancelling cases. Drug substitutions may be more costly, have undesirable side effects, or more adverse events.(1)

Intrathecal (IT) preservative free morphine is often added to the spinal anesthetic for cesarean sections (C/S) to decrease postoperative pain for 12-24 hours and has significant IV and oral opioid sparing effects.(2) With the critical shortage of this formulation, we performed a literature review to find an equivalent IT hydromorphone dose.

A search of the keywords intrathecal and hydromorphone was performed in Google Scholar, Cochrane Registry, SCOPUS, MEDLINE, and CINAHL. Although, IT hydromorphone use in acute postoperative pain is limited, there is an abundance of literature supporting its use in chronic pain. While morphine and ziconotide are the only agents approved by the US Food and Drug Administration (FDA) for IT use, pain practitioners commonly prescribe hydromorphone for IT pumps.(3) The most recent Polyanalgesic Consensus Conference (PACC) of 2012 included IT hydromorphone as an acceptable opioid for chronic use. Its inclusion for the management of neuropathic and nociceptive pain infers hydromorphone’s relative neurologic safety, as it is used in much higher doses than for C/S.(3)

We found two RCTs studying IT hydromorphone for acute postoperative pain: one in arthroscopic knee surgery(4) and one in total hip/knee replacement(5). Dosages varied and neither correlates with C/S pain. A retrospective chart review and a case report of IT hydromorphone in C/S suggest 50-100 mcg of IT hydromorphone is effective, with a safety profile similar to morphine.(6,7)

In conclusion, few prospective RCTs study the use of IT hydromorphone in acute postoperative pain. Since hydromorphone is not approved by the FDA for IT use, morphine is routinely administered. Based on this review, 50-100 mcg of IT hydromorphone may be an alternative to 100-200 mcg of IT morphine for C/S; dose finding studies are necessary. Preemptively studying alternative medications prior to critical drug shortages has become necessary.

References:

1. BMJ 2012;345:e8551

2. Acute Pain Management. Cambridge University Press, 2009:230-44

3. Neuromodulation 2012;15(5):436-66

4. Eur J Anaesthesiol 2012;29(1):17-21

5. J Bone Joint Surg Am 1991;73(3):424-8

6. AANA J 2012;80(4 Suppl):S25-32

7. AANA J 2011;79(5):427-32

8. Anesth Analg 2005;101(5 Suppl):S30-43

SOAP 2013