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 (PFE) 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.