In operating rooms across the country, anesthesia providers are dealing with an unprecedented shortage of many of the injectable opioids and local anesthetics they rely on to manage patients' pain during and after surgery. It's an opioid crisis that's every bit as serious as the abuse of prescription painkillers plaguing the nation.

We have dealt with drug shortages before, but we've never seen such a prolonged and widespread shortage like the one that we are currently experiencing. The top 5 drugs in shortest supply are injectable formulations of hydromorphone, fentanyl and morphine, as well as bupivacaine and epinephrine, according to an American Society of Anesthesiologists (ASA) member survey (see "Top 10 Drugs in Shortest Supply").

The shortage has forced all of us to improvise, conserving and rationing what drugs we already have and using less familiar IV opioids, such as sufentanil and remifentanil. When we are continually changing protocols and forced to deviate from our usual practices, the chance of dosing errors is an obvious danger.

"I'm having to use much older drugs with more significant side effects that seriously impact efficiency, quality and patient satisfaction," says one ASA survey respondent. "Patient safety is also at risk since many healthcare professionals have little to no experience dealing with these older drugs."

We are all increasing our use of regional anesthesia and other multimodal techniques. The run on local anesthetics has reportedly diminished supplies of bupivacaine, lidocaine and ropivacaine, plunging them into shortage as well.

"The local anesthetic shortage caused us to suspend our acute pain service for nearly 4 weeks, resulting in patients experiencing more pain, higher narcotic usage and unnecessary admission," says a survey respondent.

Another alternative is to use oral opioids, but as a survey respondent noted, oral treatments take far longer to work than IV treatment.

"So patients who have had major surgeries are suffering in pain due to a lack of quick-acting medications," says the anesthesiologist. "I have had patients ask me about the drug shortages as they have been publicized in the news and they fear surgery due to the impending pain they'll have post-operatively."

What's causing the shortage?

A confluence of events has conspired to create the acute drug shortage, perhaps chief among them the DEA's decision to cut all opioid production by 25% in 2016 and by an additional 20% in 2017. The federal government's well-intended policy to curb the opioid crisis is negatively impacting the care thousands of patients undergoing surgery receive every day.

Then there was a manufacturing snafu. A Pfizer plant that produced the majority of prefilled opioid syringes ceased production in 2017 after experiencing technical problems. Pfizer says full production is not expected to resume at the plant until early next year. In the meantime, many of us spend our days finding workarounds to safely manage patients' pain. OSM