Opinion: When IV opioids are in short supply at the hospital, who gets pain relief?

STAT News · Feb 17, 2026 · Collected from RSS

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When there is not enough pain medicine to go around, who gets it? The teenager in agony after a crushed leg, or the 80 year old down the hall dying an excruciating death from cancer? Medication shortages are now a routine feature of American health care. At any moment, the Food and Drug Administration tracks dozens, often hundreds, of drugs in short supply, from antibiotics to chemotherapy agents. Hospitals have learned to adapt, substitute, and improvise. But shortages of intravenous opioids are different. Because their supply is unusually fragile, shortages are more likely. And when they occur the consequences are not typically death, but severe, preventable suffering. According to the FDA, there are currently shortages of IV morphine, hydromorphone, and fentanyl. We’ve seen it in our own hospital systems in recent months. Hospitals can often rotate medications to ensure sufficient treatment of pain. But these shortages also trigger hospitals’ scarce resource planning processes. These shortages arise because the IV opioid supply chain is vulnerable at every step. Manufacturing is concentrated among only a few companies, leaving little redundancy when something goes wrong. Sterile injectable drug plants remain susceptible to what used to be called “once-in-a-century” events — hurricanes, floods, power outages — that now occur regularly. And because IV opioids are so tightly regulated throughout production and distribution, manufacturers cannot simply increase output when shortages appear. When any of these pressures hit, hospitals suddenly find themselves without the medications they rely on to control severe pain. After Hurricane Maria devastated Puerto Rico in 2017, production of IV opioids faltered nationwide. The disruption worsened already-existing shortages of anesthesia and pain medications, a crisis that rippled through operating rooms, oncology units, and emergency departments. And today, somewhere in the United States, a hospital still does not have enough IV opioids for every patient who needs them. Yet despite the inevitability of these shortages, there is no accepted ethical framework for allocating scarce opioids. Clinicians are left to ration suffering at the bedside, alone, under pressure, and without guidance. Familiar scarcity frameworks fail During the Covid-19 pandemic, hospitals developed triage protocols for ventilators, ICU beds, and other lifesaving resources. Those frameworks were built around a clear question: how to save the most lives when not everyone can be saved. Pain medication shortages pose a different problem. Pain and the medications used to treat it generally do not determine who lives or dies. They determine who suffers, and by how much. That difference makes standard scarcity tools a poor fit. First-come, first-served rewards luck and timing. Prognosis-based tools are irrelevant when the outcome is suffering, not survival. And relying solely on clinical judgment risks perpetuating long-standing disparities in pain treatment, especially for women and racial and ethnic minorities. Pain itself complicates matters further. It is subjective, difficult to measure, and experienced in degrees. Is one patient’s severe pain morally worse than several patients’ moderate pain? Should trauma patients, children, or people who are dying be prioritized? What about people with high opioid tolerance? Most institutions have no procedures for answering these questions. In the absence of guidance, clinicians improvise. Who receives scarce medication may depend on who appears more visibly distressed, who has a more assertive advocate, or which clinician is most persuasive with the pharmacy. Two patients with similar injuries may experience vastly different levels of relief. We would never tolerate this level of arbitrariness in allocating lifesaving care. We should not accept it when what is at stake is profound, preventable pain. That’s why distributing pain medication needs its own ethical framework. A better ethical framework for pain Pain medicine scarcity differs from other kinds of medical scarcity in at least three key ways. Pain is continuous rather than binary. Pain medications are divisible: small amounts can be spread across many patients or concentrated among a few. And pain and its relief are deeply subjective. A framework designed to answer who lives cannot simply be revised to decide who suffers. A different architecture is required, one grounded in minimizing the worst suffering and doing so fairly. Some of this work has begun. In recent research, we propose a framework for allocating scarce pain medication built specifically for this challenge. Instead of asking who is most likely to survive, it begins by asking how to reduce severe suffering first, while respecting patients’ own reports of pain. It also recognizes that certain groups, including children and people actively dying, may deserve priority. Crucially, these decisions must be made in advance, at the institutional level. They cannot be left to clinicians forced to ration suffering in real time. The fragility of the IV opioid supply chain makes such planning unavoidable. Shortages of IV opioids are a predictable feature of how American medicine is organized: centralized production, vulnerable facilities, and rigid regulatory constraints. Which leaves us with a choice. We can continue leaving clinicians to make impossible decisions arbitrarily and capriciously, or we can acknowledge that relieving pain is one of medicine’s core obligations — one that deserves the same foresight, planning, and ethical clarity we bring to any other scarce medical resources. Parker Crutchfield is professor, medical ethics, humanities, and law at Western Michigan University Homer Stryker M.D. School of Medicine. Casey Chmura is a second-year resident in J. Willis Hurst Internal Medicine Residency Program. Abram Brummett is an assistant professor of medical humanities and clinical bioethics at Oakland University William Beaumont School of Medicine.