Alternatives to opioids in veterinary patients

Andrea Looney, DVM, DACVAA, CCRP, DACVSMR
Ethos Veterinary Health, Inc.
Posted on 2017-11-30 in Anesthesia & Analgesia

I have developed these options to reduce use of “potent opioids” in light of the national opioid backorder crisis. I anticipate this crisis continuing for some time given the manufacturer/producer cutbacks are due to diversion issues linked to ongoing street drug abuse, a problem not seen to resolve soon.

1. Try to reserve fentanyl CRIs at the established doses for those HIGH RISK patients with severe acute pain, especially axial pain, and those higher risk patients intolerable of other options. Low risk patients can probably utilize other drug classes or at minimum creative non fentanyl opioid use.

2. Doses of fentanyl for induction are usually large (10-20mcg/kg). Please try to Avoid the use of fentanyl for induction purposes…we have almost every other option available (Propofol, ketamine/midaz, ket/val, alfaxalone, even etomidate), so if you can use one of these instead, please do.

3. If you use fentanyl in continuous rate infusion (CRI) form either intra and/or postoperatively and you have no other options, please consider:

• Dosing on lean body weight
• Reducing the rate by half; many of our patients routinely placed at 5 to 8 mcg/kg/hr intra and postop actually can get by with much less!
• Reducing or stopping the infusion after 12 hours
• For dogs (especially large and large breed dogs), please dose on lean weight, and instead of diluting fentanyl according to various autocalculators, consider a CRI of “straight up” (undiluted) at XXXml/hr (the dilutions use and waste a lot of fentanyl)
• Adding micro dose ketamine CRI instead of or in addition to reduced fentanyl

4. Please use local blocks whenever possible. A well established evidence based advantage to using local blocks is the reduced need for any opioid intra and postoperatively. If you are wondering what local block to use, please reach out to our surgery department, VTS techs, or Looney for info on technique/placement, drugs and dosages

5. Nocita (liposomal bupivicaine) can be very beneficial in reducing the need for any CRI postoperatively, especially opioid=fentanyl CRIs. If you are unaware of this product, its indications, doses, etc, again please reach out to us and we can help guide you on its use and cost.

6. Please consider the use of anti-inflammatory drugs and techniques (again known to reduce reliance on opioids) such as

• Nonsteroidal anti-inflammatories
• Steroids
• Microdose ketamine
• Lidocaine CRIs
• Local and regional blocks
• Cryotherapy
• Laser therapy

7. Consider the use of preoperative oral gabapentin and or trazadone for both cats and dogs. A 3-10mg/kg po bid to tid dose night prior and or am thereof will reduce the need for both opioid and sedative in the perioperative period.

8. If an animal on a fentanyl infusion appears painful, instead of turning up the fentanyl consider

• Switching to A different opioid such as intermittent hydromorphone or morphine for dogs, intermittent buprenorphine for cats, morphine CRI for dogs.
• Adding a sedative such as oral gabapentin, butorphanol, microdose acepromazine or dexmedetomidine, oral trazadone further allowing reduction in injectable fentanyl

9. Finally, for our surgical cases, consider starting your anesthesia protocol with a premed which will use torb (ex. torb + ace OR torb + dexmed) and give your pure mu agonist (hydromorphone, morphine, buprenorphine etc) once the animal is on the surgical table (vs. prep table) as this will truly result in less need intraop and postop for any pain medication, especially opioids such as fentanyl. I attach a few papers which compare positively dexmedetomidine’s analgesia to pure mu agonist analgesia; for our LOW Risk cases please consider the use of dexmed in your premed.

10. Morphine intermittent injections or limited infusions can be effective for canine patients if we completely run out of hydromorphone, fentanyl, and methadone. Feel free to call or text me regarding dose or rate if you are not familiar with this drug for premed, intraop or intensive care use.

11. Fentanyl patches are not a great alternative in this time of crisis as they are a major form of diverted drug. Given this fact, and the fact that absorbtion is variable dependent on location, animals body temp, species, breed, and comorbidity, (and narcosis is common!) I would not suggest stocking and using this Form of fentanyl.

12. For patients that need to be discharged from the hospital on an opioid (and given tramadol’s control/lack of efficacy) consider hydrocodone tablets. Please access our webinar on its use, and check with state laws concerning prescription of CII agents regarding how to write the prescription, number of tablets allowable, etc.