ASRA Pain Medicine Update

As I am writing this, spring has turned to summer and, with it, I have been exposed to the wild weather swings that one can expect when living in Wisconsin. One day, we have record high temperatures. The next is spent shivering and huddled around a fire.

“It has taken some effort, but given all of the medication shortages we are currently facing, now might be the time for us to contemplate using techniques or agents we would not have previously considered.”

Within my own practice, I have encountered an entirely new set of changes, challenges, and practice swings. We have been forced to creatively provide compassionate and effective patient care in an era of medication and equipment shortages. Never before have I been forced to pay so much attention to what was in my spinal kit, because medications and even kits themselves are in short supply and high demand. If you want hyperbaric bupivacaine, good luck: this medication is locked away and guarded 24/7 by three trained assassins (or so it seems) so that it remains available only for obstetric patients. Each week, we receive sobering reminders from our pharmacist colleagues about dwindling medication supplies for our institution and any “hot” leads they may have on how to obtain a medication in short supply.

Although the shortages have certainly been frustrating, they have provided pain specialists a real opportunity to demonstrate our worth to patients, colleagues, and hospital administrators. It has taken some effort, but given all of the medication shortages we are currently facing, now might be the time for us to contemplate using techniques or agents we would not have previously considered. Maybe methadone can provide the N-methyl-D-aspartate receptor blockade that you are looking for. Perhaps magnesium or dexmedetomidine might be just what a perioperative patient suffering from chronic pain is lacking (coincidentally, both of these agents are featured in this issue). Perhaps now is the time to reach across the aisle to your chronic pain colleague for advice on how to manage a patient with an intrathecal pump or spinal cord stimulator.

The benefit of the medication shortages is that it has forced us to rethink what is possible from a regional anesthesia perspective. Previously at my home institution, any patient with rib fractures not a candidate for epidural analgesia was routinely administered a ketamine infusion. As I write this, we no longer have adequate supplies of ketamine for this to continue to be a viable option. Thanks to attendance at annual ASRA meetings, the members of our group have been equipped to meet these challenges with new and creative approaches to dealing with a number of pain and medication shortage-related issues. The description of the fall ASRA meeting is phenomenal, and it appears that this conference is going to take over where the World Congress left off.

The one thing I can say is “hang in there.” You are not alone. We are all in the same boat with regard to these career challenges and medication shortages. If you have a question or a way to work around a given medication shortage, either get your question or the secret to your success out there for other ASRA members to provide guidance or benefit from (see May’s ASRA News article, “A Primer for Setting Up Your Professional Twitter Account”). It is certainly heartening to know that ASRA leadership and the American Society of Anesthesiologists are working on the medication shortage issues (see article in this edition by Dr. Mariano).

On an unrelated note, if you are looking for a new challenge or a way to build your skills in ultrasound management, ASRA can provide that too. I am thrilled that I will be able to attend ASRA’s Introduction to Point-of-Care Ultrasound (POCUS) course this December in Chicago. I am tremendously excited to work on developing and mastering this relatively novel and valuable skill set. I hope to meet some of you there. If you weren’t able to register for this offering, the course will be held again March 2–3, 2019 (registration opens soon).