As a pharmacist, Jason Chou didn't major in international relations. But a few days after the Hamas attack on Israel threw the Middle East into crisis, he and his colleagues started thinking about drug shortages.
"We have to look and say, well, is there production of any kind coming out of Israel?," said Chou, vice president of pharmacy services for Ochsner Health in New Orleans. "It's not just the drug, too. So that's the other thing that I think we've become more sensitive to is that you have the active drug ingredient, but then you have non-active ingredients, you have vials, containers, packaging. So all of that stuff can impact ... drug availability."
So far, Chou is concerned about a handful of items, but nothing has caused a big problem yet.
He and other members of End Drug Shortages Alliance, a consortium of organizations affected by drug shortages, find themselves trying to anticipate drug shortages before they happen. They try to enough product stocked to weather whatever storm comes their way.
And sometimes it is a literal storm. A tornado wiped out a Pfizer warehouse of drugs in July. Many of the drugs were already in short supply.
There were 243 different drug shortages as of Nov. 1, according to the American Society of Health System Pharmacists, which keeps track. The situation is a bit better than it was over the summer when the number of shortages approached a 20-year record high. But the ones that have lingered have been severe, especially for generic injectable drugs.
The raw number of shortages doesn't tell the whole story, says Michael Ganio, senior director of Pharmacy Practice and Quality with ASHP. For some pharmacists, this is the worst it's been in their decades-long careers, he says, calling the current situation "alarming" and "heartbreaking."
And the kinds of drugs in short supply worsens the problems.
"Some of them involve oncology drugs, things we use to treat cancer," he says. "And of course, those patients are already going through a personal struggle. But now you layer on top of that the fact that the drug that is preferred to treat their cancer may not be available."
Recent oncology drug shortages have included cisplatin and carboplatin, generic drugs that are workhorses in chemotherapy.
But oncology isn't the only part of the hospital missing crucial medications.
When a patient's heart stops beating or they stop breathing, hospitals call a "code blue." That prompts medical staff to rush with a crash cart to revive the patient. But there have been crucial shortages of drugs needed for crash carts, like painkillers, overdose reversers and even simple saline IV bags.
Those shortages leave patients, doctors and nurses in a difficult position.
"This is when you are moving and shaking to make sure that we can help maintain life," says Aisha Terry, President elect of the American College of Emergency Physicians. "And when we go to that crash cart in the middle of an emergency and can't find the medications that we need, it really is not only a failure of the system, but absolutely a failure to that patient who came to us seeking help with literally sustaining their life."
Sometimes, shortages hit patients who are seeking relief for chronic pain.
Pauline Cass, pharmacy manager at Stoughton Hospital in Stoughton, Wisc., spoke to NPR one afternoon in September about patients awaiting steroid injections for joint pain.
"We have zero vials," Cass says. "And we have six patients scheduled in the next two weeks who need the radiologists to use that injectable when they do joint injections."
So far, the hospital hasn't had to turn anyone away, because the staff has been been able to find the drug eventually. But appointments were delayed.
A recent survey by the ECRI Institute found that shortages compromised patient care. Health care workers told the nonprofit they were sometimes unable to give patients the best drug for their condition, administered less effective drugs, delayed care and even made medical errors.
About a quarter of health care workers responding to the survey said they were aware of at least one error in the last six months as a result of a shortage. For example, one patient received half the dose of the anesthesia drug ketamine.
The shortages prompt hospital pharmacy employees to work overtime, hunting down alternative medications. It also strains hospital budgets, especially in places where hospitals are already struggling to stay open.
About half of the hospitals ASHP surveyed in mid-July say they're having to spend 5% to 10% more on overtime thanks to the shortages. And about half say they've had to spend 6% to 15% more on drugs.
That's because hospitals typically have purchasing contracts to get the best prices on the generic drugs they need. When the contracted options dry up, hospitals buy drugs off-contract, a more expensive solution.
"The same drug just made by a different manufacturer can cost us double or triple the amount that we'd be spending if we were buying it on contract," says Chris Laman, Vice President of Strategy for Columbia Memorial Hospital in Astoria, Ore..
A hospital pharmacist who works with Laman, Jeffrey Chow, experienced a drug shortage firsthand earlier this year.
When he got a mole on his scalp biopsied, he learned that the regular numbing injection – lidocaine and epinephrine – wasn't in stock. He received only lidocaine.
Normally, the epinephrine constricts blood vessels to reduce bleeding. Without it, Chow bled profusely. Blood trickled down his forehead where he could see it.
"We had to get more gauze," says Chow, the outpatient pharmacy manager at Columbia Memorial Hospital in Astoria, Oregon. "It took a while to get it to stop or slow down enough to where we could bandage it up so that I could leave."
Before that,Chow said he'd grown somewhat numb to the chronic shortages plaguing the health care system. "It was kind of just an eye-opening situation of how much it really can affect customers if they can't get what they need."
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