The problem of drug shortages in the emergency department

I first experienced the impact of drug shortages in the U.S. in my first month of my residency training in emergency medicine. The most common drug used to sedate patients for intubation, etomidate, was on national shortage. I learned to use the second most common drug, Propofol, until it went on shortage too. We use it as the first line medication for sedation for painful procedures like re-aligning broken bones, draining painful abscesses and intubating. We resorted to using older combinations of medications that just didn’t work as well.

That was over six years ago. And now, we have even more shortages all the time. Literally, I am aware of drugs I cannot use because they are on shortage, such as various blood pressure medications, sedatives, and antibiotics. Several of the shortages have been critical drugs like sodium bicarbonate which is used to correct acidosis in very sick patients, and 50 percent dextrose, used to revive hypoglycemic patients. When dextrose went on shortage, we had to do calculations to use the neonate formulation for adults. This is a high-risk situation for potential errors that puts patients’ safety at risk.

At least once a week as I order life-saving antibiotics for a patient in sepsis, I must check for shortages of the preferred antibiotics first. Similarly, there is a shortage of normal saline (salt water) used for rehydration and to dissolve and deliver other drugs. There was a rumor that there was a “plastic sterile bag shortage because of the hurricane in Puerto Rico.” But if you investigate it further, it becomes apparent that the contracting practices of the group purchasing organizations (GPOs) cause the drug shortages we have become accustomed to dealing with in health care.

In the United States, we have multiple national drug shortages and an unprecedented rise in the cost of all pharmaceuticals and medical devices. The GPOs and pharmacy benefit managers (PBMs) do not do any research and development of drugs, manufacturing or handle any product. They simply serve as middlemen, granted federal safe harbor to take kickbacks in order for drug companies to have their product on the market, and for pharmacies to have a product to sell. The costs of pharmaceuticals have skyrocketed under this system, and at the same time companies have stopped making generic drugs rather than make them at a loss as a direct result of this payment scheme.

This has been difficult as an emergency physician, but I’ve learned many ways to work around these issues and still deliver safe and effective care. But my heart broke this month when I had a young patient whose parents had to bring him to the ER because of not being able to get the medication he is prescribed. His mother was so diligent, having a detailed record of his specialized care, and both parents were doing their best to care for their child with complex medical issues. He was on a less common medication, and even though he is prescribed this medication monthly, the pharmacy is not allowed to request it be shipped to them until five days before it is due to be refilled. The pharmacy is not allowed to have it on hand, or automatically ordered for this child. As a result, he ran out and had a sudden severe medical emergency. We stabilized him; but couldn’t help with the real problem: The only way to get the medication is through the pharmacy requesting it from the PBM. I found myself prescribing yet another workaround to hopefully carry them over to when they would be allowed to get the medication.

I am frustrated and saddened for my patient.  I worry about the safety of continually having to create workarounds when we have shortages of critical life-saving medications in the emergency department.  This is just my experience with the PBMs, but it is a nationwide crisis with countless victims. There is no reason for Congressionally-sanctioned kickbacks, but especially in this time when we have such high medication prices it just seems unethical for Congress to continue to allow this federally protected safe harbor to exist. Now is the time to do something about this problem and end the GPO/PBM strong-hold on the pharmaceutical supply chain that is costing patients financially, and in some cases, costing them their health.

Susan Derry is an emergency physician.  This article is contributed by Physicians Working Together and the National Physicians Week Virtual Conference.

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