There’s a baby food shortage occurring in the United States. Imagine, first toilet paper and then baby food! I guess it’s a good thing that a shortage never occurred with drugs.
Of course, it has. I started putting together a weekly list of drug shortages when I was in my first hospital in the early 1980s. The American Society of Health-System Pharmacists (ASHP) has an up-to-date list on its website. In addition, from time to time, I’ve seen drug shortage articles in major newspapers.
Yet, medication shortages don’t seem to get the same attention that other products do. I’ve often wondered why. The reason for the shortage is basically the same as non-drug items. Usually, there are only a handful of manufacturers that make the product. Then one company ceases production for any number of reasons (licensing issues, government shutdown, inability to get materials, or poor profitability). The remaining companies can’t keep up with the demand. Or they aren’t quite ready yet to ramp up production of the medication. Thus, a drug shortage occurs.
I can’t see why a medication shortage just isn’t as newsworthy as baby formula or toilet paper shortage. I feel a shortage of Dextrose 50% is just as important as baby formula. Dextrose 50% is used in codes, stored in crash carts, and used in making IV bags. But yet, the shortage is not well reported.
Demands Being Made
There was a lot of mistrust between the doctors and my pharmacy in the early 1980s. The doctors were always viewed as the most important people in the hospital. The doctors were always right and everyone else was always wrong. Whatever the doctors wanted— they got.
Doctors didn’t believe me when I told them about drug shortages in my hospital. They thought that I was just being difficult. If a doctor wanted a specific drug, I was expected to get it for them.
If I didn’t then I could expect to get a phone call from the Vice President of Medical Affairs. There were times when a drug shortage existed and the medication was simply not available. During these times, this is what I often heard from the doctors
“I don’t care if there is a drug shortage. Find a way to get some.” This went back to basic disbelief. I’ve worked in hospitals for many years. My dedication was always to the patient. I was well aware of the high cost of medications. I also watched my budget. However, I had never gotten a drug that a doctor wanted for their patient.
But, there was another reason that my pharmacy didn’t have certain drugs. My hospital had a poor money management system. We didn’t pay our bills. Quite often our wholesaler or other companies put us on credit hold. They would not ship medications or other supplies to other departments. until our hospital paid or prepaid a certain dollar amount.
Thus, my pharmacy had its own drug shortage list. One that went well beyond the “official” drug shortages list.
The doctors knew about our financial impediments when it came to obtaining medication. But they didn’t care. Thus, they were well aware of why other facilities could get medications while we weren’t able to.
But instead of pleading their cases to the financial decision makers of the hospital, they chose to complain to me and my pharmacy department. It was our fault! They expected me to borrow a plethora of medications from other hospital pharmacies. Which was an unrealistic expectation.
“How come my other hospitals have it?” I heard this from many of the doctors. However, this wasn’t true.
My pharmacy orders a supply of flu vaccines every year for our clinics, patients, and employees. Even if my pharmacy had flu vaccine left over from the previous year, we ordered a new supply every year. It arrived during the summer and our hospital would start administering the vaccine in September.
In the early 2000s, there was a problem with the flu vaccine supply. This was because a major supplier was unable to deliver about fifty million doses of the vaccine to the United States. Hence the nationwide shortage.
Thus, claims that another hospital was able to obtain their allotment were simply not true. No one was able to obtain the vaccine.\
And yet, no one believed me. As much as I stated that there was a massive shortage in the United States, there was always some doctor who claimed that their other hospital was able to get it (not true).
When this occurred, I would challenge the doctor. I would ask him to name the hospital pharmacy that supposedly had it. Sometimes the doctor would provide a name. Sometimes the doctor would not. But when the doctor did name a hospital pharmacy that had it, I would call the hospital pharmacy. And I was always right. They denied having the flu vaccine. Because there was a nationwide shortage and they never got their shipment.
I remembered being at a meeting. I had just reported on the unavailability of the flu vaccine. I was expecting the usual objections and disbelief. But suddenly, one of the physicians reached into his briefcase and threw a newspaper on the table.
There, on the front page, was an article telling about the flu vaccine shortage. It seemed that a major supplier was unable to deliver 50 million doses to the United States— thereby creating a drug shortage.
The room was quiet. No one claimed that another hospital was able to get it. Everyone agreed that the flu vaccine shortage existed. I was finally right in my claims.
“Can’t you borrow some from another hospital?” This assumed that another facility was able to get some product. But there were some problems with that request.
First of all, I knew what medications were in short supply. My entire staff did. So did other hospital pharmacies. Thus, when I was able to obtain a supply of medication— it was for my hospital’s patients. Why would I have been willing to share it? I would have liked to help out another facility, but my first commitment was to my own hospital. I needed the drugs for the patients in my hospital.
Usually, when medications are in short supply, a few companies pop up that specialize in hard-to-find medications. These companies are generally successful in finding some products— though not in the quantities that the hospital usually needed. These companies also charged exorbitant prices for the medications. I used the term “black market” when referring to these companies.
The problem with obtaining medications from these companies was that once our pharmacy did it for one doctor’s patient, then every doctor expected us to do it for their patients. Because of this reason (and because of the high cost), I tried to save the black market medications for “emergency” situations. However, as I said, once I obtained medications for one doctor’s emergency, other doctors claimed emergency situations as well.
Problems Starting A Patient’s Medication
From time to time I had the opportunity to obtain hard-to-find medications. However, I was always hesitant to do so. Most times this created a hardship for the patient. The problem arose after the patient’s limited supply was exhausted.
Let’s assume that I was able to get a small supply of hard-to-find pain medication for a patient (10 tablets). I knew that getting any additional drug would be highly unlikely. So I would ask the doctor, “What happens in a few days after the patient uses all ten tablets for their pain? What happens then?” I knew that getting any more medication would be virtually impossible. The patient would be starting a medication and then abruptly stopping it. This would be detrimental to the patient.
Fooling Me Twice
I only had a problem with borrowing medication once in my career. I received a call from an Assistant Director of Pharmacy (ADOP) from another hospital. She had a patient who needed a particular injectable drug. It was very expensive. She inquired whether our pharmacy carried the product and if they could borrow some.
I was reluctant at first. But then, I remembered all the times that other hospitals let us borrow medication for our patients. In this case, my pharmacy was able to help out another pharmacy’s patient. I agreed and allowed the other pharmacy to borrow the drug.
I explained my pharmacy’s procedure. I asked the other pharmacy to send me a drug that we commonly used in an appropriate dollar equivalent to cover the cost. The ADOP asked if instead, she could return the medication when her supply arrived in a few days. I said that was fine. She thanked me and stated that a certain sales representative would come by and pick up that drug in the afternoon. That was fine, too.
The sales representative came that afternoon. He had signed paperwork on the hospital’s letterhead, from the ADOP, requesting the medication. I gave him the drug. He also gave me his business card with his contact information.
About two weeks went by. I hadn’t heard from the Assistant Director of Pharmacy or the sales representative about replacing my medication. I decided to call the sales representative. He told me that the pharmacy that needed the drug wasn’t even in his territory. He was just helping out. He was doing a favor for another sales representative. He gave me the phone number of the other sales representative.
I called the other sales representative. She knew absolutely nothing about this transaction and was unable to help. She suggested that I contact the ADOP. I contacted the pharmacy on several occasions. I never was able to speak to the ADOP. I was always switched to her voicemail. I left several messages. My phone calls were never returned. The drug was never replaced.
About a month later, I received a phone call from the original sales representative who had previously come to borrow the medication for the other hospital. It seemed that the hospital pharmacy had another patient who needed the medication they had borrowed before. He asked if he could borrow some for the hospital pharmacy to use for this patient.
Again, I always tried to help a patient or pharmacy in need. I never minded helping another patient in another facility. But, fool me once— shame on you. Fool me twice — shame on me! I was annoyed how the sales representative(s) and the pharmacy manager could find me when they needed the medication. But couldn’t be bothered, when it came time to return the medication. I said no.
Creating Drug Shortage Awareness
Drug shortages were always inevitable in my hospital. My pharmacy tried not to hoard medications that were in short supply or pay black market prices. Our best strategy was awareness.
My pharmacy produced the usual newsletters, sent out group emails, and made announcements at meetings. But my pharmacy maintained two bulletin boards. One was outside the cafeteria (everyone goes to the cafeteria). The other bulletin board was outside the doctor’s lounge.
Drugs that were in short supply and drugs that were unavailable were listed. These lists were constantly updated— so they were always quite current. Furthermore, my clinical pharmacists worked with key physicians in order to suggest alternative drugs and therapies whenever possible.
By minimizing surprises, we were able to suggest alternative medications that were available in order to best help our patients. This greatly improved the relationship between our physicians and my pharmacy.
Drug shortages are nothing new. They were around then and are around now. Unfortunately, drug shortages will always exist. However, my pharmacy’s procedure of providing information and working with physicians is a practice that is quite successful in today’s society.
Daniel Shifrin, R.P., M.S. is a recently retired pharmacist who enjoys sharing his insights about hospital pharmacy. He is proud to own one of the largest collections of Pharmacy Stamp First Day Covers.