By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy
The screen is dark except for the glowing ember from a cigarette. The creepy theme from the X-files starts up. The “Cigarette Smoking Man” is about to tell Mulder a tid bit about how a secret group of conspirators is keeping evidence of the aliens under wraps. I loved the TV show the X-files. There are real life conspiracy theories too. From JFK to the current 9-11 truthers who claim the US government brought down the twin towers to give George W. Bush an excuse to invade Iraq, many people believe shadowy figures manipulate world events behind the scenes.
Although not quite a conspiracy, drug shortages in the pharmacy sometimes feel like shadowy figures are messing with us. A segment on the news highlighted how the epilepsy drug phenytoin had gone on back order and wasn’t available. This is a drug that has been around for 50 years. I was at Pharmacy and Therapeutics Committee meeting at St. Paul’s Care Home. As the meeting was wrapping up the Director of Nursing, Carol de la Fuentes, asked if drug shortages would be effecting the nursing home. I told her they already were. Over the past couple of years I have had to contact the doctor to change care home patient’s medications due to shortages. I had a patient’s wife come flying into the pharmacy at the end of the day. Her husband had been discharged from a Winnipeg hospital and they drove back to Dauphin to fill his prescription. The first pharmacy she went do didn’t have the liquid penicillin the doctor had ordered. I had to explain to her we didn’t have liquid penicillin either. I explained it was on back order and as far as I knew no one in Manitoba had it. We discussed her options and we decided to try filling the pill form of penicillin and she would try crushing it for her husband.
Drug shortages have always been a part of pharmacy practice, so aren’t really conspiracy worthy. In fact, shortages are a part of every business. I was talking to Brian Kuzyk from Eclipse Auto and he said he recently had to wait 9 days for a mirror for a lady’s jeep. Some of his all time worst headaches included waiting weeks on a quarter panel and half a year on a roof. But in the past couple of years, the drug shortages in the pharmacy seem to be getting much worse. In late 2010 the Canadian Pharmacists Association or CPhA did a Drug Shortage survey of pharmacists across Canada. As compared to a similar survey in 2004, the pharmacists surveyed reported having more trouble getting medications. The 2010 survey found community pharmacists spent 30 minutes every 3 hour shift trying to deal with drug shortage problems. It was also found hospital pharmacies had staff dedicated to just managing the drug shortages. The survey found from the patients’ perspectives, the most commonly reported concerns were anxiety, confusion, frustration, and anger, as a result of changes to drug prescriptions and the need for more frequent pharmacist and physician visits. The shortage problem is arguably worse in hospitals. If the shorted medication is an anesthetic, surgeries can be delayed or cancelled. If the shorted medication is a cancer chemotherapy drug, procedures can be delayed or less tested alternatives may have to be used.
So what is causing this problem? This is where the conspiracy theories start. Here are some of the competing theories. Theory number one: A few years ago Canada’s biggest generic drug manufacturer, Apotex, was trying to break into the US market. So they had to have their plants inspected by the Food and Drug Administration or FDA. Although Apotex’s plants met Canadian standards, they didn’t meet US standards. So, Apotex had to shut down its plants to re-tool to US standards. Since Apotex was the biggest generic drug manufacturer, the other generic companies couldn’t pick up the slack and we got shortages. Theory number 2: Ontario recently capped how much they would pay for generic drugs. The cap was supposed to make medications more affordable. The theory says that since Ontario is the largest market in Canada, this cap made several generic medications unprofitable so companies just stopped making them. The generic companies deny this theory. Theory number 3: Eighty percent of the raw materials to make medications are now imported from India and China. There is less government control in these countries so the raw materials are often contaminated. So when drug manufacturers in the US and Europe make their pills and test them, the medications don’t pass European and American standards. So the drug manufacturer has to do a recall and the medication goes on back order.
The problem of shortages is not just in Canada. If misery loves company, we have a lot of company. In the US, drug shortages have been described as “life threatening” and are believed to be the worst in 20 years. The FDA even has a drug shortages list with over 70 medications listed on it as of Oct 20/11. In Europe there are shortages in the UK. The reason cited is the UK currency is weak, and pharmacists there are selling medication to the rest of Europe. Australia has had recent shortages of the blood thinner heparin. So we are not alone with these issues.
What can be done about these shortages? While we can’t fix the problem with every shortage, at the Dauphin Clinic Pharmacy we have a secret weapon. We can compound medications. A few months ago the female hormone called medroxyprogesterone acetate was shorted. We were able to get a hold of medroxyprogesterone acetate powder and compound it into a capsule. About six months ago amitriptyline was shorted. Again we were able to compound a capsule. At the moment, the liquid antibiotic sulfatrim is on back order. Again we were able to compound our own version of the medication. While we can’t always compound everything that goes on back order, we can always give it a try. Sometimes our compounding skills will let us keep a patient on the medication they are used to during a shortage. Sometimes we have to talk to the doctor about changing a patient to a different medication.
I know drug shortages aren’t really a conspiracy. But by using compounding, sometimes I get to feel a little like Fox Mulder from the X- Files battling the forces of evil. Remember: The Truth is Out There.
The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.
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Saskatchewan Drug Information Services (SDIS): www.druginfo.usask.ca/healthcare_professional/drug_shortages.php
CADTH Drug Supply Disruptions: www.cadth.ca/en/products/environmental-scanning/environmental-scans/environmental-scans-18?utm_source=es-18&utm_medium=webmail&utm_content=cc-newsletter&utm_campaign=04-26-11
CPhA Drug Shortages Guide: www.pharmacists.ca/content/hcp/resource_centre/practice_resources/pdf/Drug%20Shortages_Sept2010.pdf
CPhA Drug Shortages 2010 survey: http://www.pharmacists.ca/content/About_CPHA/Whats_Happening/CPhA_in_the_News/CPhADrugShortagesReport_Dec2010.pdf