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There is now a shortage of parenteral -- which means intravenous or intramuscular -- pain medicine in the hospital. Opioid pain medicine. A friend sent me this article from the New England Journal of Medicine: Parenteral Opioid Shortage — Treating Pain during the Opioid-Overdose Epidemic.

We are now up to 27,000-30,000 unintentional overdose deaths a year in the US, primarily opioids often combined with other things that sedate: alcohol, ambien, benzodiazepines, sonata, valium, soma, barbituates, illegal drugs and kratom. It's a bit hard to tell if a heroin overdose is intentional or unintentional and the same with overdose deaths from pills. With dealers cutting heroin with fentanyl and making fake hydrocodone and fake oxycodone pills out of fentanyl and carfentanil, it is just spectacularly bad and lethal.

And what does this have to do with squirrels?

The New England Journal of Medicine says that there is a new severe shortage of the three most common intravenous pain medicines: morphine, hydromorphone, and fentanyl. Congress pressed pharmaceutical companies to make 20% less opioids to combat the opioid crisis. Apparently the companies may have noticed that they make less off the iv medicine sold to cancer centers and hospitals, so that's where they decreased it. Pills make more money. Ah, greed, the American ideal.

What are the potential results of this shortage? We give iv opioids to trauma patients, patients on ventilators, patients post surgery that cannot take oral opioids, patients who are vomiting, have a kidney stone, have an infection and can't swallow safely, patients with cancer on chemotherapy. Who can't swallow or can't keep something down. So here: "Shortages of the three best-known parenteral opioids may increase the risk for medication errors when it becomes necessary to switch a patient to a less familiar drug or to use opioid-sparing drug combinations. Opioids are already among the drugs most frequently involved in medication errors in hospitals. There are also increased risks of delayed time to analgesia and of side effects resulting in unnecessary patient suffering and delayed hospital discharge."

The article continues: "Usually, after a physician orders parenteral opioids (sometimes hours later), the pharmacy will notify the physician that the requested opioid is not available. The physician must then access the patient’s medical record, calculate the opioid dose ratio and adjustments for switching to an alternative opioid, try to notify the patient, and write new orders. This process is time consuming and stressful and will further discourage physicians other than palliative care and pain specialists from prescribing opioids."

Switching opioids is tricky. For oral medication there is a table with the morphine dose equivalent, but we are instructed to drop the dose of the new medicine by 1/3 because it is imperfect and no one wants to risk overdosing and killing a patient.

But reading on this sentence makes me consider assumptions: "Most hospitalized patients and almost all patients with cancer need opioids, either on a temporary basis after surgery or painful treatments such as stem-cell transplantation, or longer for cancer-related pain or dyspnea." Now, wait. Do most hospitalized and almost all patients with cancer need opioids? Is that really true? Do we die without opioids?

And that brings me to the squirrels. I remember an article about adult squirrels having healed fractures. I don't think the squirrels get pain medicine. Here is an article: https://www.jstor.org/stable/4095791?seq=1#page_scan_tab_contents. Of 65 Eastern grey squirrel adults xrayed, 4.6% (3 squirrels) had healed fractures of the long bones of the legs. That's not a very high percentage. But look on: 33% of gibbons (hylobates sp), 34% of orangutans and 28% of capuchin and proboscis monkeys examined in a veterinary practice had healed fractures. And all of the baboons over 13 years old had healed fractures. "The frequency of healed fractures in arboreal primates suggests an amazing resilience to serious injury, although the number of animals that suffer fractures and die from predation, shock or starvation before their bones heal is unknown."

It's a bit humbling, isn't it? We treat pain to reduce suffering, but "need" opioids is wrong headed and misleading. People with massive trauma, shock and major surgery may truly need opioids and sedation to survive. But for other pain problems, it is less clear. We want people to not hurt and not suffer, but pain is neurological survival information. Reducing inflammation may slow healing after surgeries and surgeons are wanting people to not use ibuprofen. Do we know whether reducing pain speeds healing? Or does it complicate or slow it? Squirrels and baboons can apparently survive trauma and falls and fractures sometimes and heal without pain medicine. And I can think of other examples that make me question "needing" opioids.

1. My sister had cancer, breast cancer. After her initial treatment it recurred in two years. She kept going with treatment and lived for another five years. What she told me was "If I say my pain is more than 4, the doctor will give me a prescription for pain medicine. So I say four. They don't ask if I have any and they don't ask if I need it. They just write it." Toward the end of her life she had a primary care doctor, an oncologist, a radiation oncologist, a neurologist and a surgeon. She had a basket with 5 different kinds of pain medicine in her dining room, hydrocodone, oxycodone, morphine, MS contin and fentanyl patches. I wrote out a titration if she needed more fentanyl, because none of her doctors had done it. The prescriptions were from different providers, so obviously none of them were paying attention to what the others were doing. She did NOT want to overdose and die early. I was appalled by the carelessness of her California physicians.

2. I had a patient who was intubated in spite of being "do not intubate". He had horrible emphysema, tobacco damage. Pneumonia again which can scar damaged lungs. It was difficult to get him off the ventilator but we did. He was on oxygen and constantly short of breath. Six nurses in a row, one every 8 hours, came on shift and promptly called me. "He needs a prescription for morphine."
Me: "Did you talk to him?"
Nurse: "He is really short of breath."
Me: "Did you read the chart?"
Nurse: "He really needs morphine."
Me: "He hallucinates with morphine and he doesn't want it and it says that on the chart. You called me without reading his allergies or talking to him. No, he cannot have morphine and doesn't want it."
By the 6th nurse I was frustrated. After the same conversation, I said, "Please write a verbal order. The next nurse who calls me for a morphine order is to be written up as well as which ever nurse who goes off duty without passing on his intolerance to morphine."
That fixed it BUT: who was being treated? The nurses knew that he'd breath more easily with morphine. But it would not cure him and he saw monsters with morphine. The nurses were treating because he LOOKED uncomfortable. He WAS uncomfortable. But he was WORSE with morphine.

3. Pain is really really important to survival. When I was in medical school I rotated through vascular surgery. There was a man in his early 20s who had survived a point blank shot gun to his upper leg. Vascular had saved the leg, with a huge surgery. But.... he had no feeling in the leg. The nerves could not be repaired. Essentially he was walking on a leg that was dead to pain. No sensation. Pain free, right? This turns out to be really bad, because when you stub your toe or bang your shin or step on a thumbtack, you KNOW because it HURTS. He did not hurt. So his foot and lower leg was getting injured and infected because he couldn't feel the injuries. He needed to do a daily check visually everywhere on his leg because he couldn't feel it. The argument among the surgeons was if he would have been better off with an amputation. I don't know. But we cannot survive without the information pain gives us. Diabetics are another group: with bad neuropathy they lose all feeling in their feet. We did skin grafts on a man with numb feet who had placed them on a wood stove to warm them. He had burns that he could not feel, all the way through his skin, requiring skin grafts to heal.

I have one patient who would like more pain medicine. He does have chronic pain, but he also works on cars. His back hurts when he lies on cold concrete for too long under a car. I am siding with his back. I refuse to give more medicine to allow him to abuse his poor back muscles and joints.

I have a friend who works in orthopedics. Patients have interesting expectations. Some expect no pain at all. Even if they were having 8/10 pain in that hip and then, hello, hip replacements require cutting a hole through skin and muscle and chisels and glue. It seems a little unreasonable or wishful or crazy to expect post surgical pain to be a zero. And if the person IS given tons of opioids, well, they are sedated and may have trouble working with physical therapy, going to the bathroom, swallowing safely and are a higher fall risk. Some of the orthopedic surgeons are good at setting the expectation that pain will be reduced some by medication after surgery, but not until the person is sedated and not to levels that increase risk.

We need to be thoughtful about medicines. As few medicines as possible and only if really needed. I include all pills in that, supplements and vitamins as well. Pills do not grow on trees, they are made in labs, including vitamins and supplements. We want the magic pill, but really we should be exercising, eating a good diet, keeping stress at reasonable level, and living long lives of kindness to others.

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