Opioid Shortages Prompt Alternative Pain Management Protocols

Jan 30, 2018 / Practitioner Updates

In an effort to combat the opioid epidemic, the DEA decreased opioid production by 25% in 2017, and plans to continue to decrease production in 2018. As many of the more commonly used full mu agonists such as morphine, hydromorphone, and fentanyl become harder to acquire (and remaining supplies are diverted to human hospitals), veterinarians will be challenged to provide adequate pain management to their patients.

At this time, we expect the opioid drug shortages will grow worse before they get better. It is likely that veterinarians will need to alter their current pain management protocols. We’ve compiled some tips and dosages below.

If you have additional questions regarding alternative pain management therapies in your patients, please contact Dr. Ashley Mitek at amitek2@illinois.edu, or call the Veterinary Teaching Hospital referral coordinator at (217) 333-5311 to speak with the anesthesiologist on duty.

Quick Tips

  • Consider loco-regional anesthesia whenever possible
  • Non-opioid injectable medications such as dexmedetomidine, ketamine, and lidocaine can be analgesic and used as constant rate infusions for painful patients
  • Non-opioid oral medications such as NSAIDs, amantadine, and gabapentin can be beneficial
  • Multi-modal analgesia is the practice of administering several different medications that have differing mechanisms of action, but, taken as a whole, provide analgesia superior to that of one drug alone. Multi-modal analgesia protocols are recommended whenever possible.
  • Remember that acepromazine, trazadone, butorphanol, midazolam, diazepam, propofol, and alfaxalone have minimal to no analgesic properties, though other properties of these medications may be beneficial in painful animals
  • Tramadol has limited efficacy
  • Although intravenous fentanyl is efficacious in dogs and cats, fentanyl patches have been shown to have variable absorption rates

 

 Local Anesthetics Dosage Duration of Action Comments
Lidocaine2 mg/kg 1-2 hrs
Bupivacaine1 mg/kg 4-6 hrs Do not inject IV
Adding Dexmedetomidine to local anesthetic mixture

1 mcg/mL of local anesthetic

Extends duration of action
Nocita (liposome-encapsulated bupivacaine)5.3 mg/kgMay provide up to 72 hours durationOne-time use vial

Examples:

  • Ring blocks for distal limb procedures (declaws, paw pad laceration, etc.), mass removals, etc.
  • Lidocaine or bupivacaine splash blocks for enucleations or ovariohysterectomies
  • Line blocks for laparotomy incisions

 

 Intravenous Agents Dosage Duration of Action Comments
Dexmedetomidine (one-time dose)1 mcg/kg IV, 4 mcg/kg IM (dogs), 8 mcg/kg IM (cats)<45 minutesCardiovascular effects may prevent use in many patients; use as an adjunctive analgesic agent only
Dexmedetomidine CRI1 mcg/kg loading dose, then 1 mcg/kg/hr
Lidocaine

2 mg/kg loading dose IV, then 2-4 mg/kg/hr

Do not administer IV in cats
Ketamine0.5 mg/kg loading dose, then 0.2-0.5 mg/kg/hr
Buprenorphine0.02 mg/kg IV or IM6 hoursAppropriate for mild to moderate pain
Extended-release buprenorphine (Simbadol)0.24 mg/kg IV or IM 24 hoursCats only; appropriate for mild to moderate pain

Example:

  • Lidocaine/Ketamine CRI for fracture repair, limb amputation

 

 Other Medications Dosage Dosing Frequency Comments
Gabapentin5-10 mg/kg8 hours
Amantadine3-5 mg/kg24 hours
Carprofen

2.2 mg/kg

12 hours (alternatively 4.4 mg/kg every 24 hours)Dogs only
Meloxicam0.1 mg/kg SQ or PO (dogs)24 hours
Deracoxib3-4 mg/kgEvery 24 hours for 7 days, then decrease to 1-2 mg/kg dailyDogs only
Robenacoxib (Onsior)2 mg/kgDaily for up to 3 daysCats only
Maropitant1-2 mg/kg IV, IM or POEvery 12-24 hoursHas analgesic properties with few cardiovascular effects; ideal as an analgesic adjunct

 

—Dr. Stephanie Keating and Dr. Ashley Mitek, with contributions from ISVMA