Most doctors and health policy experts these days are focused on the overabundance of pills fueling the opioid crisis gripping the United States. Cancer doctors like me lie awake at night worrying about the looming shortage of injectable opioids that we need to treat our in-pain and dying patients.
Patients like Tommy Hogan (all of the names in this article have been changed to protect patients’ identities). At age 40, he was diagnosed with lung cancer, even though he never smoked. Despite the best efforts of his medical team, the cancer continued to grow and spread to other parts of his body. Two years later, Tommy was in a home hospice program.
A few days ago, his wife brought him to the hospital. That’s unusual for people in hospice; their symptoms are usually managed by nurses and doctors at home until they eventually succumb to their disease. When I walked into Tommy’s room, I immediately understood why he was here: air hunger. People with rapidly growing lung cancer often feel like they can’t get enough air. It’s a terrible and terrifying sensation; they feel like they are drowning. Tommy was sitting bolt upright in the bed, his eyes wide with panic, breathing five times faster than normal, straining with each breath.
His air hunger was something we could definitely ease. Opioids are excellent at doing that. Finding the right oral dose can take hours, even days. Tommy needed help right away, so an intravenous opioid was our only option. Soon after starting an infusion of Dilaudid, an opioid, his breathing got easier and his pain and anxiety subsided. Tommy died about 36 hours later, with his family at his bedside. My team’s ability to administer an intravenous opioid at an escalating dose allowed Tommy to have a peaceful final few hours with his family.
Until recently, I took for granted my ability to use this essential medication. Now I worry every day that I won’t be able to provide it to my patients.
Well-intended DEA policies to control the opioid epidemic in the U.S. aim to “balance the production of what is needed for legitimate use against the production of an excessive amount of these potentially harmful substances.” But decisions to cut all opioid production by 25 percent in 2016 and by an additional 20 percent in 2017 have threatened the availability of opioids for terminally ill cancer patients in hospitals across the U.S. This problem has been confounded by Pfizer’s acquisition of Hospira. Hospira was previously responsible for manufacturing the majority of the country’s sterile injectable pharmaceuticals, or generic intravenous medications such as the opioids used in hospitals. The move means that 60 percent of our country’s intravenous opioids are being made by a single pharmaceutical company.
After the acquisition, Pfizer added a Hospira facility in McPherson, Kansas to its production process. But that plant, which produced the majority of prefilled opioid syringes in the U.S., had to halt production in 2017 after experiencing technical problems. That dealt Pfizer a manufacturing setback from which it has not yet been able to recover.
The shortage is predicted to last for the next 12 to 18 months. Our hospital’s current supply of intravenous opioids will last about four weeks at best. Seasoned pharmacists at my hospital, who have seen many drug shortages over their careers, have told me this is the worst one they have seen in more than a decade.
Opioids are the gold standard for treating cancer-related pain. Some of my patients can take opioid pills to ease their pain. Others, like Tommy, need intravenous delivery.
Olivia is a 19-year-old with leukemia. One of the side effects of her bone marrow transplant was mucositis, an intensely painful breakdown of the lining of her mouth. She wasn’t able to swallow her own spit, let alone a pill. She needed an intravenous opioid to get her through that period.
Lainey is a 65-year-old with newly diagnosed cancer that has spread to her spine. After arriving in the emergency department with crippling pain and paralysis in her legs, she was rushed to emergency surgery to remove the tumor. After the operation, her pain had to be controlled quickly and effectively. Intravenous opioids were the way to do this until we found the right oral regimen over the next several days.
There’s no question that decades of unchecked opioid production, marketing, and prescribing led us to where we are today, with more than 40,000 deaths from opioid overdoses a year. We clearly need to target that abuse. But during those decades, many doctors were using opioids appropriately for patients who truly needed them. It’s equally important that federal and state efforts to rein in opioid abuse don’t force people who need these medications to suffer for a single day without them.
I am a mother as well as an oncologist. I don’t want to worry about my son gaining access to potentially deadly pills. But I can’t practice good medicine without having access to essential medications like intravenous opioids for severe pain and air hunger. Acceptable quality of life for terminally ill patients admitted to hospitals can’t be sacrificed in the rush to control a different public health emergency.
For many patients, there sadly comes a time when there are no further therapies to fight their cancer. While this represents a major shift in the focus of care, it is not a case of “there is nothing left to do,” as patients and their family members often phrase it. Managing symptoms at the end of a person’s journey with cancer is just as important as all the chemotherapy, surgery, and radiation provided along the way. Opioids are an essential part of that management.
As we teeter on the brink of a nationwide shortage of injectable opioids, I rely on weekly meetings with my colleagues in the fields of palliative care, interventional radiology, nursing, and pharmacy to come up with innovative ways to treat cancer-related pain if and when our supply of intravenous opioids does run out. While it is a shame that an entire class of medications essential to the treatment of my patients may not be available soon, I am encouraged by the tenacity and resilience of my fellow clinicians in facing this challenge, and as always by the courage of my patients.
But I hope and pray that the day will never come when I have to tell one of my patients “There is nothing we can do.”
Tara E. Soumerai, M.D., is a medical oncologist at the Massachusetts General Hospital Cancer Center and an instructor in medicine at Harvard Medical School. The opinions expressed here are the author’s and do not necessarily reflect those of her employer.
Thank you for such a thoughtful article.
I was just diagnosed with breast cancer two days ago.
I’m also in recovery from opiate addiction to my pain medication. I’ve been clean and sober for 2 1/2 years. No relapse. I wasn’t as hard core as many I saw in treatment. I was and am grateful for that,not as far along in my disease.
But the most terrifying thing someone with a prior opiate addiction can hear is you have cancer.
I’m terrified that the stigma attached to me will prevent adequate pain management. I’m told I will likely have to go through it without ANYTHING for my pain.
I will likely choose not to go through treatment at all if this is the case.
I fear taking these medications but I fear not taking them too.
Your article struck more fear into me. I don’t know what stage I am yet. I’ll learn next week.
I wish I had a compassionate doctor like you. There are so few these days. I think if I had a compassionate doctor, someone who would listen I believe with closely monitored and coordinated care, I could be treated adequately and even remain in my treatment program. My suboxone doctor promised to advocate adequate pain treatment and when treatment ends continue on suboxone. This is called compassionate care.
I pray I’m not terminal and have to face what Tommy did. My Mom died of lung cancer too. But her pain was adequately.
Wish there was some way to have the DEA, FDA and doctors afraid to do their jobs, be in so much pain like the people they are refusing opioids to so, they beg for it themselves. Then tell them they can’t have any. Learn to live with it, they are not worth helping or the government says no. If they had to watch a family member that they care for go through the never-ending pain. They would say screw the addicts, help my family. There needs to be a change now. I just wish they had to suffer too. Without help.
I lost my Daddy to Lung Cancer and Colon Cancer. He was healthy until his 30 foot fall landing on his feet. Around 12 yrs later (after his fall and several surgeries), his body just couldn’t fight off these arising fatal diseases. He had his pain meds readily available. Thank God. I couldn’t imagine him going through what I saw without the opioid pain meds.
I also want to say, I am a chronic pain patient with my own SEVERE daily pain. I’ve been in pain mngmt for 12+ years, While I understand the excruciating pain of cancer. Is my pain not pain also. Where is my voice in all of this? I have been cut down so low I cannot get relief. Stress causes Cancer I know it does. All the pain from not having my meds is causing me irreparable damage.
I might add I lost my Sister to overdose, so I know that pain all too well, she thought she could “handle her limit” problems is it was Soma, and that drug was built up in her system. It put her in a coma once, briefly, caused a stroke, then her overdose while she was alone….😰😵😓🙁
One thing I keep going back to is, why are we all being punished, I mean some buy alcohol and drive, killing innocent people, but if I believe the CDC, DEA, FDA then I must also believe that every person who buys and drinks alcohol will surely drive and ultimately kill while drunk. Hmm? sounds ridiculous right? That’s because it is. But it is the same thing the CDC is saying.
I metabolize my medication differently than another, what is good for one is not good for all. To Hades with their Morphine equivalent. it’s ridiculous. I mean 5 methadone to 1 morphine equivalent ????? that’s laughable, I’ve been on 180 mg methadone for more than 10 yrs. I don’t get high. I don’t abuse my medication. This month I get 20 mg methadone and if DEA CDC have anything to say about it I won’t get that much in June!!!!!!! Do I not have a right to pain treatment even though I don’t have cancer? Im in so much pain right now I cannot get up. It’s just wrong!!!!!!
The DEA should have been doing their job in making sure the “pill mills” never got started. My doctor has always done drugs screening, medical tests, etc. Why are we being punished. Its no wonder people have gone to the streets, an addict WILL get their drug. And now I’m laying there price. And all the millions of Cancer patients and chronic pain patients alike. Pain is pain!!!!!! Some worse, absolutely. But I shouldn’t be. denied pain meds because I don’t have cancer.
The sad thing is that the people who are addicted to opioids probably never really recieved a prescription for themselves! They’re either using fake pills or heroin laced with illegal fentanyl. Which is definitely different because I have chronic pain from multiple very very rare autoimmune disorders and when it’s cut off I’ll probably be forced to use suicide as my only option because due to the nature of it I can’t use NSAIDS because it’s ability to produce ulcers throughout my digestive system, SSRI’s have no impact since it’s not neuropathic pain, the placebo with needles acupuncture causes inflammation and ulcers on my skin where they puncture it, drinking alcohol severe inflammatory reaction or use the supposedly wonderful marijuana put my pain levels to the highest they’ve ever been, yet the medical board of my state just sent me a request to review my health records because they feel my doctor of 20 years is not treating me appropriately! Not because they know a single thing about my condition or the sickeningly(literally) high number of failed attempts to use other pain control some of them resulting in life threatening anaphylaxis but because it’s fentanyl and not below the magical 90 mme dose! The stupidity of the newest war on drugs against those in pain needs to stop!
My son died of colon cancer in 2012 at age 28. I had been a hospice nurse for 10 years at that time. Of course, because of his bowel obstruction a morphine pump was essential to manage his pain. I am also a chronic pain patient and while I am not on opioids presently, I did well on low dose for over 8 years. The lack of consideration for appropriate opiate use and the demonization of pharmaceutical opiates has disgusted me. I understand the concern about possible addiction but as I’ve said many times “these are not the droids you’re looking for”. Heroin and illicit Fentanyl with now rising meth and cocaine are the offenders. Meanwhile, patients deserving palliation of their symptoms become pawns in a poorly thought out political game.
Frightening! Infused Dillaudid was the only drug that helped during my hospital stays to deal with the terrible discomfort of CIPN. Pills for me did not have the same effect and I was fortunate the infusable drug was always there.
Veterinarians are also facing such shortages.