By Samantha Hilker

Amid a national opioid crisis where there seems to be heroin everywhere you look, EMS services are struggling to obtain medications needed to treat patients.  As we continue to have conversations about the impact of these drug shortages on local, state and national levels a quote from The Rime of the Ancient Mariner keeps rattling around in my head; 

“Water, water, everywhere and all the boards did shrink.  Water, water, everywhere, nor a drop to drink” Samuel Taylor Coleridge

Many have cited the over-prescribing and easy availability of opioid medications as the underlying cause for the current opioid crisis and, in response, the FDA and DEA reduced the number of opioids that could be produced in 2017; on the list of reductions was morphine, fentanyl, and hydromorphone among others.  The overall goal of implementing the quota system as outlined HERE was to “reduce the potential for diversion of schedule II medications for non-medical use while maintaining production for legitimate medical use through a 25 percent buffer for supply levels in 2013 through 2016.”  According to the article, much of the reduction ordered for 2017 is a result of eliminating the overstock related to the 25 percent buffer. 

The ordered reduction of schedule II drug manufacturing coupled with Puerto Rico (the home of a major medical supply and drug manufacturing facility) being essentially wiped out by hurricane Maria is leaving EMS services across the country between a rock and a hard place.  On the surface, it seems like a relatively easy fix – one medication is in shortage and becomes hard (or impossible) to obtain, so you chose an alternate and amend your protocols.  But what do you do when your alternative hits the shortage list and becomes hard (or impossible) to get?  How do we appropriately balance delivery of high-quality patient care while constantly adjusting protocols and supply while avoiding medication errors? 

Dr. John Russell, President, Cape County Private Ambulance, and Chair, AAA Professional Standards Committee offered the following insight:

“Morphine is short for a couple reasons, prefilled syringe manufacturing issue being one, the second being the FDA and DEA sets a limit on how much narcotic can be manufactured in a year. Fentanyl has become the drug of choice for most EMS medical directors for narcotic pain control due to its predictability, short half-life (wears off quick) and it has less hypotension potential than morphine. Again, Fentanyl prefilled syringes are short because of the syringe issue but ampules and vials seem to be available, we just have to practice good drug administration techniques (filter needle to draw up from the ampule, double check dosing with our partner etc.) Hydromorphone (Dilaudid) has been a popular alternative to morphine particularly in hospital but it too is now in short supply mostly from increased demand and hoarding. As you can see there is a domino effect on the drug class when one goes short the demand is moved to another and it becomes a vicious cycle.

Alternatives to opiate pain meds include IV Acetaminophen, Ketorolac (Toradol), and even oral meds such as naproxen and ibuprofen. Certainly, the armed services have successfully used Ketamine for pain but generally speaking it’s a niche drug for trauma use and comes with a whole set of side effect and management issues most paramedics are not familiar with.

When we are forced into an alternative presentation of a drug such as epinephrine or fentanyl vials, we prepackage everything needed to administer in a Ziploc bag and label the bag.  a vial of med, appropriate syringe or saline if the drug needs to be diluted, a filter needle if the drug is pulled from ampule or a safety draw needle if from a vial. We also put a cheat card in to make clear the amount to be administered for a particular dose.

We eliminated D50W and D25W from our drug list and instead now just infuse a bolus of D10W from a 250cc bag at 1 ml/kg of patient weight. Works well. Cheap fix.

As for epinephrine we package a 1cc 1 mg 1:1,000 vial or ampule with a 10 cc saline flush syringe and draw needle. We instruct the medic to waste 1 cc of the flush, draw up 1cc of 1:1,000 epi and mix well (functionally now 1:10,000) or 1 mg in 10 cc of 1:10,000 which is the same as the prefilled syringes commonly used. Similar kits can be put together for other drugs.”

Several services in Wisconsin have a state-approved protocol to utilize expired medications in times of shortage – Bell Ambulance has graciously shared their expired medication policy, so others can use as a template for creating one for their service.  Dr. Suzanne Martens, Medical Director, Orange Cross Ambulance and State of Wisconsin EMS Medical Director encourages services to put together reasonable training plans and protocols for alternative medications that can be submitted to the state for approval, and potentially shared as models for other services. 

DOWNLOAD SAMPLE EXPIRED MED POLICY

This is an issue that is affecting EMS and hospitals across the country and there are no magic answers, only band-aids, and workarounds.  New protocols, different medications in varying concentrations and packaging, and use of multiple vendors are all tactics used by services to manage the supply chain interruption.  Dr. John Russell illustrates the current situation brilliantly with the following statement:

“… these are stop-gap measures and certainly raise the chance for medication error and take more time to use but until the supply system gets fixed I’m afraid we will be playing McGyver with a lot of our drugs.”

References

Affairs, D. P. (2016, October 4). DEA Reduces Amount of Opioid Controlled Substances to be Manufactured in 2017. Retrieved from DEA: https://www.dea.gov/divisions/hq/2016/hq100416.shtml

Braithwaite, MD, MPH, S., & Myers, MD, MPH, B. (2013). Retrieved from http://www.naemsp.org/Documents/2013%20Annual%20Meeting%20Handouts/HANDOUT%202013%20Myers%20Drug%20Shortage.pdf

Drug Shortage. (2018, March 26). Retrieved from U.S. Department of Health and Human Services: https://www.fda.gov/Drugs/DrugSafety/DrugShortages/default.htm

Lynch, S. N. (2018, April 17). U.S. drug agency proposes rules to rein in opioid manufacturing. Retrieved from Reuters: https://in.reuters.com/article/us-usa-justice-dea-opioids/u-s-drug-agency-to-propose-rules-to-rein-in-opioid-manufacturing-idINKBN1HO2U1

Pharmacists, A. S.-S. (2018). Drug Shortage List. Retrieved from American Society of Health-System Pharmacists: https://www.ashp.org/Drug-Shortages/Current-Shortages/Drug-Shortages-List?page=CurrentShortages

Thomas, K. (2017, October 23). U.S. Hospitals Wrestle With Shortages of Drug Supplies Made in Puerto Rico. Retrieved from New York Times: https://www.nytimes.com/2017/10/23/health/puerto-rico-hurricane-maria-drug-shortage.html