Drug Shortages In Emergency Rooms Become Critical

In the United States, about 1 in 20 people has to go to the emergency room (ER) in any given year, but there's a crisis brewing in American emergency care that can't be fixed with a suture, a bandage, or good medical advice.

According to the journal Academic Emergency Medicine, incidents of drug shortages have increased more than 400 percent between 2001 and 2014. The drug shortage list in hospital emergency rooms includes:

• Nalaxone, the only injectable drug for opiate overdoses, in high demand not just in ERs but for use by emergency medical technicians and police.
• Antivenin polyvalent injections for treating snake bites.
• Hydrocodone (Vicodin) for treating pain.
• Acyclovir for treating acute viral infections.
• Broad-spectrum antibiotics, used to treat serious bacterial infections during the two days it takes to run cultures in the lab to identify the specific bacteria causing the infection and the best treatment for those bacteria.
• "Gold-standard" antibiotics including aztreonam, used to treat serious infections in patients who are allergic to penicillin, and trimethoprim/sulfamethoxazole, used to treat pneumocystis pneumonia in AIDS patients.

All of these drugs and over 100 more are essential to treatment in some situations, and not having them is a threat not just to recovery but to survival itself.

Dr. Jesse Pines, director of the office for clinical practice innovation at George Washington University School of Medicine & Health Sciences and lead author of a study of the causes of chronic drug shortages in ER's in the United States says that there are a variety of reasons particular medications may be in short supply.

• 2.1 percent of the time the reason is a "business decision" by the pharmaceutical companies to focus on making drugs that are more profitable.
• 4.4 percent of the time there is a shortage of raw materials.
• 14.9 percent of the time demand simply exceeds the ability of the company to supply the drug.
• 25.6 percent of the time there are manufacturing delays. But
• 46 percent of the time there is no reason given for not supplying a medication.

In the United States, the FDA has limited power to prevent drug shortages. It can identify medically necessary drugs, medications that play a vital role in treating disease for which there are no substitutes. It cannot force drug companies to make a drug or to make more of a drug even if it is medically necessary, and it cannot tell drug companies the price to charge for a drug. Even when drug companies reduce the price of a drug, wholesalers may not pass the price reduction on to hospitals, and hospitals cannot be told how much to charge patients. There are, however, medical guidelines concerning who gets a drug that is in short supply.

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The FDA realizes that increasing supervision of the production of medically necessary drugs could achieve an unwanted result. Drug companies could decide that the cost of complying with FDA regulations would make producing a drug unprofitable and simply refuse to make it. (In other countries, such as Germany, this decision is not an option.) However, drug companies in cooperation with federal authorities and hospitals often manage to prevent drug shortages from becoming critical.

What Can Drug Companies, Government, Hospitals, And Patients Do to Prevent Drug Shortages

Government officials say that since President Obama issued an executive order in 2011 directing the FDA to stop drug shortages, cooperation between the FDA and drug companies has reduced the number of drugs in shortage by about half. This does not mean, unfortunately, that the chronic problem of drug shortages in emergency rooms has been solved.

The problems with keeping drugs in adequate supply are largely due to quality issues (sometimes companies have to recall defective products) and economic issues, not unexpected numbers of ER patients. Many of the products that run out in ERs are low-cost injectable medications for which insurance companies pay less than the cost of production. The drug manufacturers are forced to take a loss on these drugs, or stop producing them altogether. The result is that hospitals keep costs down and satisfy government regulations, but drug companies do not get in a hurry to make products on which they lose money. Ultimately, drug company officials say, the making of pharmaceuticals is a business. When businesses cannot earn a profit, they change their activities.

Where does all this leave patients? There's not a lot individual patients can do to tackle the larger problem of drug shortages, but there are things that individual patients can do to increase the probability they will get the treatments they need.

• When you have to go to an ER with snake bite or infection, try to go to a facility associated with a hospital system rather than with a stand-alone hospital. Emergency rooms associated with multiple hospitals often can borrow the medications they need from other emergency rooms associated with the same system.
• Keep up your insurance. In the emergency room, if you need a specific medication, and they have it, they are supposed to give it to you. However, in the United States, there are subtle and not-so-subtle ways of interpreting your lab results and choosing a diagnosis that justifies not giving you a drug that costs a lot of money when the hospital will not get reimbursed for it.
• If you have a chronic infection, be sure to take absolutely all of the antibiotics you are prescribed when you are discharged from the hospital. This can help reduce recurrence of infections that put you right back into the hospital.

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• Chemotherapy drugs, in addition to being mindbogglingly expensive, also are often in short supply. Make sure that you have discussed dosage with your oncologist. Sometimes lower doses of drugs actually work better than higher doses, and not just because they have fewer side effects. Don't take a self-selected "vacation" from treatment. Work on scheduling your treatments with your doctor for maximum effectiveness with minimal medication. 
• When you are outside the hospital, if your treatment is just too complicated for you to management, if you have too many medications in too many different doses for you to keep up with them, let your doctor know. Simplifying your treatment can help keep you out of the ER, which is good for you and for the emergency medical system.