Fast-acting morphine running low for hospice patients

The injectable morphine that hospice workers in Palm Beach County prefer to use when their patients are hit with intense pain is running out.

The supply on hand in the last week of January would typically last only a week, but they are taking measures to stretch the inventory for a couple of months, said Dr. Faustina Gonzalez, chief medical officer for Trustbridge, the countywide hospice agency. Those measures include reserving the medicine for those who aren’t in a hospital and are being taken off life support.

That’s not to say the agency doesn’t have strong painkillers, including other forms of morphine, still in its arsenal. But injectable morphine acts faster by up to half an hour compared with the alternatives that are given by liquid drops or suppositories, Gonzalez said. Minutes aren’t trivial when cancer pain spikes or organs fail.

And suppliers tell Trustbridge the scarcity of the injectable may go on for months or even a year.

Palm Beach County hospice and its nearly 2,000 clients aren’t the only one feeling the pinch. An informal poll by the president of Florida Hospice and Palliative Care Association found similar supply crunches across the state and also in Michigan, New Jersey and rural Missouri.

“It’s everywhere,” said Mary Lynn McPherson, a professor at the University of Maryland School of Pharmacy, who conducts training for the National Hospice and Palliative Care Organization.

“I’ve had to develop a whole new slide show,” McPherson said. The presentation she takes on the road now describes to workers how and when to administer alternative drugs. “It’s a real problem.”

Hospitals, too, are experiencing intermittent shortages of certain morphine products, said Steven Lucio, associate vice president of pharmacy for the Texas-based company Vizient, which negotiates supply contracts on behalf of its member hospitals.

Trustbridge got the call from its supplier just two weeks ago, Gonzalez said.

But the shortage, corroborated by the U.S. Food and Drug Administration and the American Society of Health-System Pharmacists, appears to have been brewing since mid-summer.

Pointing to gaps in the supply is easy. Finding the cause is trickier.

Only a handful of companies make injectable morphine in the U.S., according to Vizient. Of those, the FDA lists shortages of 21 forms of the medicine in vials and pre-filled syringes of varying doses made by three companies.

The reasons listed on the FDA website for those shortages range from an increase in demand to a delay in manufacturing caused by a needed upgrade of a production plant in Kansas.

“The supply of morphine and other pain medicines is something we’ve had to address with our members,” Lucio said. “It ebbs and flows. There are times when things are better, more stable, and other times when it’s worse.”

The shortage due to demand could be related to the Drug Enforcement Administration’s move to cut  the volume of opioids manufacturers can produce by 20 percent, which started this year. Even if the target isn’t injectable morphine used to treat a hospice patient, the base ingredient remains the same and less of that ingredient in the market may have unintended consequences.

“It’s perfectly understandable why the DEA is trying to limit things. But the production doesn’t turn on a time,” Lucio said.

And the DEA’s move is unlikely to be the entire picture, Lucio noted.

One thing this morphine shortage is not: hurricane related. The devastation to Puerto Rico’s substantial medical supply industry by Hurricane Maria has been well-publicized. The supply of the small fluid-filled bags used in hospitals to dilute drugs and deliver them via an IV line to a patient was hit particularly hard. The FDA also lists a handful of other products affected by the storm. Morphine is not one of them.

But Puerto Rico does highlight what happens when a supply chain is narrow — as it is in the injectable market, Lucio said.

“You don’t have enough of a redundant supply. When one (manufacturer) has a production issue, the others can’t ramp up,” Lucio said.

Injectable morphine isn’t the first tool most hospice workers turn to for pain or difficulty breathing, McPherson said.

“The oral is always our preferred route. But if you have an acute situation, say the cancer erodes through something and pain skyrockets, it’s hard to chase that with an oral medication,” McPherson said.

Oral medication peaks in 45 minutes; an IV-delivered dose goes into effect in about 15, McPherson said. Those 30 minutes are crucial when dealing with the most extreme pain – “Imagine having four babies with a broken leg” pain, she said.

Also, switching from a familiar product to a “Plan B” one, creates a risk of potential dosing mistakes, said Vizient’s Lucio.

At any given time, Gonzalez estimates 30 to 40 of Trustbridge’s nearly 2,000 clients require opioid painkillers.

Gonzalez said patients and their families have been alerted when it made the switch from an injectable morphine to alternates such a liquid deposited between cheek and gum that enters the system by trickling into the stomach.

“The response has been very cooperative as long as their loved ones are being kept comfortable. That’s what matters to them,” Gonzalez said.

Florida’s hospice workers tended to more than 130,000 patients last year. The state is second only to California in its numbers. And even if one of the state’s 47 agencies has a supply of morphine to share, it couldn’t legally do so, said Paul Ledford, president and CEO of Florida’s Hospice and Palliative Care Association.

The manufacturers on the FDA’s shortage list anticipate delivery of some injectable products as soon as early February and others not until June 2019.

Ledford is optimistic that the suppliers will come through: “I do believe the market will meet the need.”

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