A hospital buying saline solution bags from a veterinary hospital. A vet hospital that can’t get saline bags because it’s last in line. Premature babies without nutrition and supplements. Toddlers without antibiotics for ear infections. Doctors unable to find drugs, and coming up with short-notice workarounds.
I heard an earful about drug shortages pervading the U.S. healthcare system recently, and wrote about it, in a post titled “U.S. drug shortages imperil cancer, maternity and other treatments.” Once I posted, I started hearing other stories.
One doctor wrote on Facebook: “We can’t get Atropine, Lidocaine depending upon the month, Normal Saline liter bags (usually have to buy from a Veterinary Hospital), Epi and forget about adenosine injectable. The attempted refill of the crash cart always gets the same “its on back order”!)”
Another doctor, who practices in the Midwest, wrote on Facebook about short-supply drugs: “Injectible lorazepam. The most commonly used concentration of amoxicillin [pediatric] suspension. Prochlorperazine injectable shortage prompted the return of droperidol to our formulary.”
He added for detail: “Lorazepam is a very commonly used sedative and was carried on just about every advanced ambulance until supply issues forced a switch to something else.
“Prochlorperazine is a commonly used anti nausea medicine. Many hospitals refused to allow doctors to give droperidol, a similar medication to prochlorperazine, because of a black box warning about arrhythmias. Then hospitals gave up and allowed droperidol back when the other antiemetics were on short supply. Which conveniently forced the hospitals to admit that the black box warning was fabricated by the pharma industry to help market ondansetron, which they had by then also run out of.”
The drug shortages range widely: “There were 309 active, ongoing drug shortages — the highest number in nearly a decade and close to the all-time high of 320 shortages” at the end of the second quarter, according to a recent study by the the American Society of Health-System Pharmacists of more than 1,000 ASHP members. The shortages are the worst in a decade, the study said.
‘This week you won’t have this’
“Why do I have to do this?” the Midwest doctor said in a phone interview, describing the effect on him and his patients. “It’s stupid. It’s a hassle. It makes us wonder what has happened to make such things no longer accessible.
“Aren’t we getting better? Why are we getting worse?” he said, noting that the doctors use workarounds to avoid affecting patients.
He said they often get warnings from hospital leadership about medication shortages: “This week you won’t have this, so you need a workaround. And then we have to remember which directive is in effect.”
This takes time, he said — and time is valuable when a patient is in crisis. It’s also wearing. (He spoke on condition that I not identify him so he could be candid and not affect his job.)
“If you have to change for a medical reason that’s fine,” he said of switching medications. “But if i have to override to something that frankly is inferior — it’s cognitive effort to convince myself, ‘Yes, I ought to do it this way for no good reason.’
“It wears a mind down. You go slower, you’re more depressed, you’re frustrated and snappy.
“If things happen to a doctor’s practice that are beyond your control, it’s leading to stress, aggravation, depression. It weighs on you. You’re not performing as highly as you did.
“Doctors in general don’t tolerate this well.”
He said he also took a pay cut recently, with management saying the hospital lost money during the pandemic and now needs to get out of the red. Management took a bigger pay cut than doctors did, he said, and they did say that they managed to avoid job losses in tough economic times.
“That’s another thing I have to mentally deal with,” he said. “I’m working just as hard, with all these things that vary my practice.
“How can we be the best in the world if we keep running out of stuff?”
Two suggestions
In the previous post, I heard of a doctor who had to choose between giving a scarce cancer drug to either a 20-year-old cancer patient or a 28-year-old lymphoma patient. Another had no albuterol to treat either a child with asthma or an older person with chronic obstructive pulmonary disorder — so a doctor had to choose workarounds for both.
The Midwest doctor said two courses of action could make a difference with drug shortages. First, he said, is radical transparency: How much do things cost? Where is the money going?
“Ask any Joe Schmo on the street, they want to know,” he said. “How much will it cost? Where is the money going? But other people, in the system, have absolutely no interest at all in having anybody know where the dollars are going, because they’re going somewhere they shouldn’t go.
“And where should the money go? It could be going to excess manufacturing capacity” to correct shortages of medications, he said.
A second course of action, he said, is declaring the entire industry to be regulated.
“If you can’t live without it, it should be like a regulated utility,” like water or power, he said. “Once you make it a regulated utility, you can craft parameters on it to make it do what you want it to do.
“That’s why water is regulated: If I had money, I could make a jungle in the Mojave Desert. But then Los Angeles would have no water.
“There’s a great deal more transparency in a regulated utility than there is in a for-profit utility.
“It’s time to decide how important this is for national security. So far, we have decided it is not important for national security. But Covid taught us some lessons. We know where the fragile points are — we don’t care to look at them.”
‘No oversight’
Another doctor wrote on a Facebook group for medical professionals: “I think everyone on here is aware of this. Some basic drugs.
“My take is that there is no oversight of this, so if it is no longer profitable to make. They stop. No one is forced to supply it so suddenly there is no more.”
When I wrote the previous post, I learned doctors may be aware of this, but many patients are not.
If your drug is on shortage, you may be coping. But you may also be ambushed if your preemie baby cannot get nutrition in the hospital — or if that nutrition is lacking because the trace minerals are on shortage. Or you may not know. If you cannot get Ritalin, you may think shortages are isolated to your need, but it seems clear that many people, from ADHD patients to cancer patients to pregnant women to preemies and emergency cases and a lot of other people, are being affected.
Think: If 99 percent of the pharmacists in the survey mentioned above said it’s a problem, what are we as lay people missing?
Dr. Marion Mass, a Philadelphia pediatrician, spoke to me at length for my earlier post, and gave many examples — and she said the doctor is unlikely to tell the patients, so they may never. know.
The drug industry is a huge one: 66% of Americans take one or more prescriptions, and there were 4.73 billion prescriptions dispensed in the U.S. in 2022
Mass wrote a letter this summer to U.S. Senate Finance Committee Ranking Member Mike Crapo (R-Idaho) and U.S. House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-Washington), in response to their request for information from subject matter experts and stakeholders about the increase in drug shortages.
“Free2care is a coalition of physician and patient advocacy organizations. We include 34 member groups that encompass 8 million citizens and 70,000 of those are physicians.
“Many of our members are employed by hospitals and do not want their names on the record. When Free2Care sent out an email inquiring about drug shortages to a random group of about 200 physicians, we got back over 100 nearly immediate responses. Below are a few of the stories that illustrate the problem.”
Preterm babies
A neonatologist spoke about the problems with nutrition for infants, and then Mass wrote about it in her letter and added, quoting this doctor: “It’s not just meds and solutions. It’s equipment. We also had an issue with umbilical catheter trays. These are sterilized trays of equipment that help us thread a central line into the umbilical vessels of babies smaller than 700 grams. Infants that would fit into the palm of your hands. So we take time we don’t have, time away from our patient care and make the trays ourselves. We don’t get choices, we have to make due for the most vulnerable infants in America.”
“For the record, the rate of preterm birth in the United States is highest for black infants (14.4%), followed by American Indian/Alaska Natives (11.8%), Hispanics (10.0%), and is 9.3% for whites. “
“- From an ICU physician in North Dakota:
“IV calcitrol is used in hemodialysis patients. We had none. Solucortef is essential for very sick ICU patients. We had to ration it.”
“- From a pediatric hospitalist in suburban Philadelphia
“The medication used to treat patients very sick with croup is racemic epinephrine. It’s standard of care to give to any pediatric patient with stridor, which indicates significant upper airway obstruction. We were told it was in shortage and had to ration it. Had to give it to who we thought were the sickest patients. Croup patients are breathing through a straw and can get sicker very quickly. You can’t always predict.”
Seizures and addiction withdrawal
-From an ER physician in Idaho
“We were short on IV lorezapam. We use it for seizures as a first line med, and for patients who suffer from alcohol addiction in withdrawal. We also had no premixed syringes of epinephrine in the Emergency room. We need epinephrine to start someones heart when it stops. Nurses had to take time to mix the epinephrine into syringes at a time when seconds count.”
Another doctor on the Facebook group wrote, “Anticompetitive behavior has predictable consequences. Didn’t the IP holders of EpiPen’s competition refuse to pay kickbacks a few years ago because the consumer lost any price advantage?”
To which another doctor answered: “when you talk to people that try to break into the market, they’ll tell you that things are done in very odd ways, like envelopes or slipped under doors, and language appears on contract that says things like my company will pay XXX dollars to gain XXX percent of the market share”
Another doctor wrote: “There is a facet of this story I have never heard explained, the shortage of common drugs that we have seen in the past 20 years. Things like – Normal saline. Not hard to manufacture – I can truly make it at home. What drives these shortages? They never occurred prior to about 2000. “
And another replied: “PBMs charging formulary fees puts small businesses out of business. So now you have one or two companies making saline or bicarbonate and a hurricane hits the plant or a sterility issue and no one else makes it or can’t keep up with demand.”
‘No opioids’
Listen to the pharmacists, nurses and doctors on Reddit with some more evidence:
“My pharmacy has has no opioids and it’s been a nightmare. Literally no oxycodone products.”
What about imports? One wrote about the safety of imported drugs: “Yes, a whopping 6% of the foreign manufacturers that supply in excess of 80% of the United States drug supply were inspected in 2022. Not sure I’d bet my life on the quality, safety, or efficacy of every drug coming in at face value.
“https://www.propublica.org/article/fda-drugs-medication-inspections-china-india-manufacturers
“wait, locasamide is going on backorder? … my brother takes it for seizures, and has to have it filled at a pharmacy different from the one i work at, so i cant watch his meds as carefully as i’d like. thank you for posting about this.”
“mad that janssen/patriot isn’t making generic concerta anymore but also patented the release mechanism. trigen’s generic only lasts 5 hours and makes me sick on some days due to the shoddy and unreliable quality and release mechanisms”
“Welcome to the hospital! Here is a glass of water, a banana, and a stick to bite on…until we run out of sticks.”
“My pharmacy has (some-fucking-how!) never been out of adderall, but earlier this week they were out of gabapentin. No idea if it was just a fluke, or if I’m looking at a future where I can’t get my prescription filled.”
“You forgot nephron”
“It is a combination of shortages and pharmacies/wholesalers hitting ordering thresholds. Nightmares, man.”
“Our hospital is entirely out of dilaudid and oxycodone right now”
Pain medications
“I think it was 2016 when the CDC started putting recommendations into place. Many physicians just decided they didn’t want to deal with it and stopped prescribing opioids right away. Some doctors gave enough meds to last until the patient could get into a pain clinic. Some doctors just cut them off. That left patients with no way of treating their pain if a pain clinic wasn’t available or had a long waiting list or no other doctor would help them. I know of 2 people who committed suicide because they could not get meds, too much pain, and horrible withdrawal. Both were patients in their 50s who had been on pain meds for many years and didn’t abuse. Then there are all the others that turned to meth or would buy oxy on the streets. Which, especially now, is extremely dangerous. … I take opioids. I am drug tested every 3 months and have to have an in person appointment with my physician every 4 months to go over pain and check to see if I’m okay in person. I also can’t get pain meds from any other doctor. This is not a problem for me and I believe is akin to the recommendations. I am fortunate that my rheumatologist is willing to still prescribe me opioids.”
“In my area it’s not a shortage, it’s the new dea rules on narcotics. Pharmacies get to elect for their allotment for the month. All of the pharmacies in my area are electing for their chronic pain patients allotments but not saving any room for new prescriptions like post op patients.”
“Not all pharmacies get to elect an allotment. I’m a hospice RN and our local pharmacy is being told they cannot increase their Roxanol or fentanyl patch distribution dispute the pharmacy caring for 180 hospice patients currently using those medications regularly. The head pharmacist has been having meetings with the DEA and keeping records of how many times they are unable to fill an opioid prescription for one of our hospice patients and it’s being sourced out to show that her allotment needs significantly increased.”
“Patient here who was recently told my Tylenol with codeine can’t be filled for another 3 weeks due to shortage / back order.”
“But brand name is available. $$$$ Not kidding: there is medication available, but it’s marked up outrageously (like $300 for a normally $60 bottle of 100.) PBM’s again are the problem here: they will pay only the contracted amount, say $20/30 tablets, so the pharmacies cannot afford to stock what’s available.”
“Yes, we basically have everything other than fentanyl on back order in the ER now. And my hospital is a vet hospital so we’re at the back of the line. It’s honestly getting scary.”
