BY: SAMANTHA BARTLETT, DVM
Although its impact has been felt in the realm of human medicine, the current opioid shortage has been especially frustrating for veterinarians. The shortage is, for the most part, a result of lack of production by a single manufacturer. Pfizer is currently suspending production due to a plant overhaul in Kansas. The catastrophic hurricanes in Puerto Rico have also taken some production off-line, leaving the burden to be shouldered by the other remaining manufacturers. In addition, the DEA is proposing a decrease in the already reduced manufacturing quotas for frequently abuse opioids to help mitigate the current human opioid crisis. This impacts veterinary medicine as well since most of the drugs are also used in veterinary procedures.
Thankfully there are a few veterinary only products that are still in production and haven’t been affected by the limits on production for human medicine. Zoetis produces butorphanol and Simbadol for veterinary use. Butorphanol can work for mildly painful procedures that can be completed quickly. It works much better when combined with other analgesia such as dexmedetomidine. Simbadol is the brand name of a long-acting buprenorphine. It is licensed to be a 24-hour pain relief for cats. The labeled dose is to be give subcutaneously. Do not give the labeled dose intramuscularly. However, Simbadol can be used off-label in feline or canine patients at the same dosage and administration route as regular buprenorphine at a dose of 0.02mg/kg to give pain relief for a duration of about 6 hours.
Outside of opioids for pain relief, pain can be relieved and avoided by alternative pharmaceutical and non-pharmaceutical approaches. Of course, NSAIDs can are often are used to help lessen pain, but in extremely painful procedures, other measures are necessary. Consider the use of gabapentin pre- and post-operatively to help reduce wind-up pain from surgical interventions. Dexmedetomidine and ketamine also have analgesic properties, particularly when combined with opioids. These medications are also useful as CRIs in hospitalized surgical patients. Cerenia may also provide mild visceral analgesia and certainly can help to control discomfort of nausea induced by anesthesia or surgical manipulation when given pre-operatively. Local blocks can reduce or eliminate the need for opiates as a method of analgesia in surgical patients. Nocita is an extended release bupivacaine with a 72 hour duration of action. It is licensed for use in cruciate surgeries, but is used off-label in any surgery where bupivacaine is used.
Non pharmaceutical options also exist. Cryotherapy with or without compression can help reduce pain for up to 24 hours. Acupuncture can also be used to reduce pain in certain situations. Therapeutic laser can has been shown to reduce inflammation and speed up healing. Laser therapy is not advisable with local anesthetics. Good surgical techniques as well as minimally invasive approaches are also a key component of reducing and preventing surgical pain.
A good starting point to help with development of multi-modal pain management protocols is AAHA’s Pain Management Guidelines. For an overview of dosing, pharmacokinetics and uses of other pain medications, watch Dr. Garret Pachtinger’s blog post on the VetGirl website (https://vetgirlontherun.com/alternative-analgesic-options-with-the-opioid-shortage-vetgirl-veterinary-continuing-education-blog/). Another resource for advice is to consult with an Anesthesiologist at your local specialty or teaching hospital. While opioids definitely have their place in analgesia and anesthesia, there are alternatives to help prioritize their use in the current environment of shortages.
