Efforts to curb opioids during America's drug abuse crisis has created a problematic side effect for South Carolina's hospitals: They don't have enough of the drugs for their patients.
The IV form of opioid painkillers such as fentanyl, ketamine and hydromorphone has been in short supply for months after the Drug Enforcement Administration put tougher restrictions on the amount companies can make.
The manufacturers have been criticized for filling the nation's communities with painkillers, fueling an epidemic of opioid addiction and overdoses.
Experts say opioid pills are most often the culprits behind this abuse. It is not those drugs, but the liquid form that hospitals depend upon for general surgery, sedation, trauma treatment and pain management. And it is those drugs — namely ketamine, fentanyl and hydromorphone — that are in critically low supply.
Pfizer, a major injectable drug supplier, had to stop production of the medications after the Food and Drug Administration found problems at a manufacturing facility in Kansas. Work to upgrade the facility took longer than expected, Pfizer wrote in a letter to its customers in November.
In that letter, Pfizer said syringes would not be available until 2019.
Roper St. Francis' medication safety officer, Kim Gaillard, said the system gets 60 percent of its IV opioid drugs from Pfizer.
Representatives of Palmetto Health, the Medical University of South Carolina and Roper St. Francis all said they have people working full-time to buy more of the drugs. But so are other health care systems, and only a handful of manufacturers produce each of the drugs.
"We’re competing with every hospital in the country," Gaillard said.
Clinicians have had to find solutions. Gaillard was sure to stress there are other medications in many cases. Other types of painkillers have worked just as well in some surgeries, she said. The shortage has led the hospital system to speed up its review of different ways to deal with pain.
"I know that this is alarming," Gaillard said, "but we have other strategies."
Leaders at MUSC restricted ketamine, fentanyl and hydromophone to the system's intensive care unit, emergency department and operating rooms. An email circulated to MUSC prescribers cited "critical shortages."
Clinicians were told they need to convert all patients to morphine, if possible. The email warned further restrictions are possible.
Heather Easterling, administrator of pharmacy services at MUSC Medical Center, said in a statement the pharmacy team is working with wholesalers every day to order more of the medications. The DEA's restrictions are at the heart of the issue, she said.
The DEA's quotas are quarterly, so Easterling said the shortages hospitals are seeing may continue at least until mid-April.
Easterling said hydromorphone and fentanyl in IV form are important for anesthesia and for managing sickle-cell disease, for example.
Rod Whiting, spokesman for Trident Health, said the system is experiencing a shortage of those two drugs as well. He said the issue has not affected patients' care.
Tidelands Health spokesman Carl Lindquist said the system is dealing with shortages by shuffling drug inventory.
At the Veterans Affairs hospital in Charleston, a spokeswoman said the procurement officers have managed to keep the drugs in stock.
Jennifer Bair, director of pharmacy for Palmetto Health Richland, said she is in contact with other hospital leaders and all are struggling with the shortage.
Patients cannot take the painkillers orally for a number of reasons, she explained. Many require a continuous IV drip to manage their pain. The system is making an effort to switch people to the oral drug when possible, she said.
Bair said it is a daily, time-consuming problem providers are having to deal with.
"It’s kind of a moving target for us to stay ahead," she said.
And while Palmetto hasn't seen any patient's care falter from the shortage, she acknowledged the juggle could open up the possibility of a mistake.
Shortages have affected patient care across the country, a report from the Institute for Safe Medication Practices showed. The study, released in January, surveyed 300 health care workers, mainly those who work in pharmacies, and 71 percent said they couldn't give patients the recommended treatment because of the shortages.
In one example, a double dose of hydromorphone was given because the smaller amount wasn't available.
The Institute for Safe Medication Practices was one of five groups to send a letter to the DEA on Feb. 27 asking the agency to consider increasing its production cap.
"Supply options are dwindling," they wrote.