Drug Shortages

Drug shortages present more than a few challenges to the EOL community. Many constituencies, patients, clinicians, and the organizations that provide care, are affected. Challenges include consistent symptom management (very problematic when cascading supply shortages compel, what seems to be, continuous drug rotation), potential patient distress (you’re changing my pain medication AGAIN!), comfortable prescribing (what’s the conversion rate between midazolam and phenobarbital?) and financial control (parenteral levitiracetam costs WHAT!?).

The landscape of drug shortages is constantly changing— we even have a problem quantifying how many there are! Not a day goes by that something isn’t in a shortage situation. But, how widespread is the problem (in a specific geography) and how is it affecting care? In this quarter’s publication of the AAHPM Quarterly we discussed some of the causes of drug shortages and the steps the FDA and manufacturers can and are taking to help alleviate the problem, but we did not discuss the problem at the patient prescription level.

Unfortunately, because of the nature of our complex drug manufacturing and distribution system, we cannot clearly identify when, or if, any given shortage will affect a given community. Notification of a shortage does not come with an alternative prescribing pathway— that’s left to the prescriber community. Further complicating the problem is that substitution behaviors cause drugs that were almost never in a shortage situation to “go short.” Additionally, in search of alternate symptom management solutions, we move from the perch of what we’re experienced with and know works to that which is less clear or predictable.

What specific problems have you had and how have you managed them? How do you receive notification of drug shortages? Comment below to discuss your problems and how you solved them, or present your current problem and search for a solution.

Greg Dyke, BS RPH

2 thoughts on “Drug Shortages

  1. Last year we had several months when parenteral lorazepam and midazolam were in very short supply. In our inpatient unit, we continued to use lorazepam prn but when we started scheduled doses, we converted to phenobarbital. I hadn’t previously used much phenobarb and I found it quite effective – I’ve continued to use it even though the shortage is resolved.

    We are not affected by the current issue with parenteral hydromorphone.

    We find out about shortages from our hospital pharmacy (for the inpatient unit) and from Hospice Pharmacia (for the home hospice program). I’m interested to hear what others are doing.

  2. I am a general anesthesiologist, and previously had a practice that included pain management and palliative care. The root cause of pharmaceutical shortages appears to be a dysfunctional supply chain caused by Group Purchasing Organizations. The GAO has looked into this and supports this causation.
    GPOs have a “Safe Harbor” that exempt them from Antikickback rules, which means the pipeline from manufacturer to our patients doesn’t work in any normal way. We need to solve this.

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