The specialty hospital that I work for recently started using a new form of opioid pain control called Recuvyra (pronounced ree-cuv-rah) manufactured by Elanco. It is a new form of the pure mu opioid agonist Fentanyl, for which there is already an adhesive gel patch and injectable form of the drug. Ok, so just another form of Fentanyl, right? Well, we had a very knowledgeable Elanco representative give a presentation about the product and then an extensive Q&A session afterwards. Oh, and lunch was provided. Everyone gets a little more excited about a new product when free food is involved. So, Recuvyra comes with its own special syringes (regular syringes cannot be used) and applicator tips. It is applied to the dorsal area between the shoulder blades much like topical flea preventative. After it is applied, it is absorbed transdermally and provides a continuous systemic delivery of Fentanyl for 4 days (although the Elanco rep said it can last up to 7 days).
When we received the product, every hospital employee that was to be administering the pain medication had to complete an online training session, take a quiz, and print out a completion certificate for their employee file before they were even allowed to pick up a bottle of Recuvyra. The veterinarians go through an extensive education process to the owners of Recuvyra candidates, and a consent form with the veterinarian and owner both present is signed. Then, there is other documentation and alerts to include in the patient’s file and on its cage. Seems like a big to-do, doesn’t it? Well, in all seriousness this product warrants it. In everything the Elanco presentation and training session taught us, one thing beamed brightly in the forefront of everyone’s mind: Recuvyra is 1,000 times more potent than injectable Fentanyl. No I did not miscount zeros, that’s 50mg/mL of Reucvyra versus 50micrograms/mL of injectable Fentanyl. I’m sure that makes a lot of eyes widen, and maybe you’re even wondering why would a hospital would carry such a potent drug that has potential safety and human abuse risks?
Well, from what my fellow technicians and I can tell after about a month of using Recuvyra, is that for all intents and purposes, it does achieve its goal for pain management. It has eliminated the need for multiple dosing of opioids such as morphine or hydromorphone. According to studies, the continuous release of the transdermal Fentanyl in Recuvyra prevents the “peaks and valleys” of single injections of opioids providing more constant pain relief. It also lasts longer than the Fentanyl patches. From our post operative pain assessments, the patients do seem comfortable with Recuvyra and do not require additional opioid pain relief. We do still prescribe oral NSAIDS and Tramadol, just like we would if we were giving morphine or hydromorphone. Recuvyra also obviously eliminates the need to maintain an IV line and pump for a continuous rate infusion of opioids. In short, that is the positive of this new mode of Fentanyl delivery: IT WORKS!
And now, I’m sure you want to know about the negatives. Before I get into the negatives, let me first say that we do use this product with great success on certain healthy dogs that need a high level of pain control. Also keep in mind, it is a new product and we are still tweaking our anesthetic protocol when using it, so it may just take some more experimentation and some getting used to. I don’t want to completely bash the product because I do think it is very effective at pain management. However, I do have some concerns and annoyances with Recuvyra. Here’s why:
Safety concerns to employees. Remember that Recuvyra is 1,000 times more concentrated than the injectable Fentanyl you might be used to using. Combine that with the fact that this can be absorbed, it poses a significant risk to employees during application and handling of the drug. Notice I said can. A huge positive to this drug is that it cannot be absorbed through human skin, which decreases that potential risk to employees by… well, a lot. However, there is a chance that it can be absorbed through cuts in the skin or mucous membranes (eyes, nasal passages, mouth, etc.). And if it does, chances are you’re going to feel some effects due to its potency. This risk is reduced if not almost eliminated by dressing up in Hazmat suits like the scientists in the 1980’s E.T. movie. No really; we wear plastic waterproof gowns, safety goggles, and gloves while drawing up the medication, applying it, and standing with the dog for 5 minutes while it dries. Furthermore, two people are required at all times during application process. A few other safety and application concerns include (but are not limited to):
- WHERE you apply this product: ONLY dorsally between the shoulder blades
- HOW you apply this product: 0.5ml per spot, which each spot 2-3cm apart; no shaving required
- WHAT SPECIES you apply this product: this product is ONLY for dogs; DO NOT apply to cats (or any other critter); the transdermal technology does not work with felines’ unique physiology
Safety concerns to owners and children. The drug is supposedly “dry” after 5 minutes, but Elanco recommends that direct contact to the Recuvyra application site is to be avoided 72 hours after application. The Elanco rep actually told us about a study where adult men deliberately sucked on Recuvyra application sites (yes, you did indeed read that correctly) and blood levels of the drug in these men were minimal for the first 72 hours and next to zero thereafter; and that’s after trying REALLY hard to remove the product after it was applied. Based on this study, they determined that the risk of getting product residue on your skin after 5 minutes is minimal, but is probably slightly higher for children. So, we inform owners that any children at home must be isolated from the dog and they themselves shouldn’t touch the application site until after that 72 hour window. Now, I don’t have children, but it seems to me that it would be kind of hard to keep a child away from the family pet and then subsequently putting their hands in their mouths. But, again, the risk of product residue is minimal (just ask the completely sober/lucid adult men choking on dog hair who were sorely disappointed after completing their Recuvyra drug trial).
Induction concerns. With almost all of our Recuvyra patients so far, we have had to add a sedative (acepromazine) and a benzodiazepine (usually midazolam) along with a maximum dose of induction agent (either Propfol or Ketamine/Valium) to get the patient anywhere near being able to intubate. Most of the time with our other pure mu opioids, it is sufficient to add either ace OR midazolam and still have some induction agent left over after intubating. That being said, once they are on a good plane of anesthesia, they usually do not need additional injectable pain medication during or after surgery. Keep in mind that, unlike an opioid CRI, the rate at which Recuvyra is delivered cannot be adjusted.
Post operative concerns. This area seems to be the biggest drawback to Recuvyra in our experience. We have quite a few of our patients experience hypothermia both pre and post operatively after receiving Recuvyra. Our Bair hugger warming units are working overtime on these patients as their hypothermia can start before we even get them on the surgery table, and then persist for as much as 24 to 48 hours! Recovery time is lengthy for patients as many of them also experience significant sedation post operatively. We have had to extend some patient’s hospitalization after surgery solely due to Recuvyra side effects (hypothermia, sedation), although the rest of the patients’ vital signs have remained stable. A few owners have also complained about their dog’s inappetence within the 4 day period that Recuvyra is effective. Kudos to Elanco, however, because not a single one of these side effects were a surprise to us. Although we didn’t expect the side effects to be as common as we have experienced, both the presentation and online training module discussed at length the main side effects of Recuvyra: hypothermia, pronounced sedation, and inappetence. They also mentioned vomiting and diarrhea as side effects which we have not seen. The training module also goes into detail about how to reverse Recuvyra if needed, which can be done with Naloxone or Naltrexone (just like any of the other pure mu opioids). Since Recuvyra will outlast single doses of these reversal agents, however, multiple doses every 1 to 3 hours would be needed until the side effects subside. We have not had to reverse Recuvyra in any of our patients so far.
In summary, we have found that Recuvyra does provide long-lasting potent analgesia for our surgical patients. So far, the best use we have found for Recuvyra is for our generally healthy patients receiving elective orthopedic procedures. The safety concerns can be minimized and manageable with extensive staff training and client education, but be prepared to spend some extra time training and educating because this product requires precise application and safety protocols in order to be effective and safe. Also be prepared for hospital staff to spend a great deal of time monitoring these patients both pre and post operatively as we have found that hypothermia and prolonged sedation are not rare occurrences. For more information, please visit Elanco’s training course at http://www.recuvyratraining.com where you can also read a copy of the package insert.