A new drug problem for Hampton Roads: Not enough

One day this month, Jim Dice learned news that made him nervous.

Children’s Hospital of The King’s Daughters was down to about a week’s supply of calcium gluconate, an electrolyte used in intravenous feedings for patients.

Dice, the Norfolk hospital’s pharmacy director, sent an email asking for help through a national pediatric pharmacy buying group.

It took a day to hear that a fresh supply was on the way. A few days later, a grinning staff member announced the arrival of a week’s worth of the electrolyte.

Then a back order – enough for a month or two – unexpectedly appeared.

“If you scream loud enough, you’ll get a little bit,” Dice said. “There’s always that chance, but so far I have been able to get the drug.”

It’s a drama that’s becoming routine at Hampton Roads hospitals.

Over the past six years, the number of drugs the Food and Drug Administration considers to be in short supply has nearly tripled, a trend expected to continue.

That’s left pharmacists scrambling for medications ranging from cancer treatments to anesthetics. Because many of the scarce drugs are administered by injection or intravenously, hospitals have been hit particularly hard, but retail pharmacies also have felt the pinch.

Nationally, some health care providers have reported harm to patients – and even deaths – due to inadequate supply of a drug or mistakes involving an alternative, according to a survey last year by the Institute for Safe Medication Practices.

Local hospital officials say patient care here hasn’t suffered, but they worry about the future.

“We have been able, at least up until now, to provide good alternatives,” said Dr. Joel Bundy, a kidney specialist who is the incoming medical staff president at Chesapeake Regional Medical Center. “But I think that day is going to come when we’re going to need a medication and we’re not going to be able to get it. It’s not going to be just here in Hampton Roads; this is going to be a national and even an international issue.”

Federal officials give several reasons for the shortages, including a lack of raw materials for manufacturing some drugs and an increase in demand for others.

Some companies have ceased making older medications or generic versions that are less profitable. Sometimes, they stop manufacturing a drug because it is too costly to adhere to the FDA’s standards.

Hospitals in Hampton Roads are coping by using approved substitute medications, conserving what they have and finding alternative sources for the drugs – sometimes at markups of 400 percent or more.

At Bon Secours Hampton Roads Health System, any substitution must be greenlighted by a committee of physicians. For example, they recently allowed a European version of the anesthetic propofol.

When Bon Secours ran out of premixed IV bags of nitroglycerin, a drug used to treat heart conditions, pharmacists made their own bags of the drug using a supply that came in vials.

They also screened patients to determine whether they could ingest multivitamins orally when the injectable version was scarce. “We’re saving it for the sickest people,” said Carol Carson, a clinical pharmacy specialist for Bon Secours.

At Sentara Healthcare’s hospitals, doctors were encouraged to conserve two of the most crucial drugs on the shortage list, said Tim Jennings, the health system’s vice president of pharmacy. Norepinephrine maintains blood pressure in critically ill patients, and succinylcholine paralyzes muscles so a patient won’t gag when a tube must be inserted in the windpipe.

“We were able to spare that succinylcholine so that we didn’t ever come to a situation where we didn’t have it when we really, really needed it,” Jennings said. “We had to use it very sparingly and appropriately, and we had to use other agents in its place.”

It becomes more frustrating when a substitute starts to run out, he said. And some drugs that have appeared on the shortage lists – such as penicillin and some injectable steroids – are considered the “gold standard” for treating specific problems, despite having substitutes.

“The analogy at home is, sometimes you just need a plain old screwdriver,” Jennings said.

To avoid medication mistakes, hospital pharmacists are educating physicians on the changes, affixing cautionary stickers to the packages and even stocking the alternative medicines in different areas.

At Sentara, notes about substitutes are programmed into the electronic medical records system, Jennings said. “We’re fortunate because in our system if you order one, it will tell you what the right dose of the other one is.”

Health systems like Sentara and Bon Secours share scarce drugs among their local hospitals and sometimes even help each other out. CHKD is plugged into a national buying group with other children’s health care providers.

Often, hospitals scrape up supplies of the drugs from specialty distributors, companies that buy medicines in short supply and sell them at higher prices.

Hospitals will ask for a drug pedigree – a listing of the medication’s chain of custody – to ensure that pharmacists know where it has been, said Beth Branham, local systems pharmacy materials coordinator for Bon Secours.

The price inflation can be astronomical. Chesapeake Regional has paid $35 for a dose of norepinephrine that used to cost $1.50.

“If the hospital pays more for drugs, Medicare and insurance companies do not reimburse us for the increase in cost,” wrote Chesapeake Regional’s pharmacy director Bobby J. Ison in an email. “The hospital must absorb the financial loss.”

The increase is passed on to self-pay patients, but not most covered by government or private insurance, Ison wrote.

Local hospital officials said they didn’t know how much the drug shortages cost their organizations. However, a March report by the Premier healthcare alliance estimated that U.S. hospitals paid at least an extra $200 million annually to purchase expensive generic or therapeutic substitutes.

To help the situation, U.S. Sen. Amy Klobuchar, D-Minn., has introduced a bill requiring manufacturers to give the FDA early notification of problems that could lead to potential drug shortages.

Such a measure would give hospitals more time to prepare for the inadequate supply of a particular drug, but not solve the problem completely, pharmacists said.

However, they say they’re becoming accustomed to handling the spate of drug shortages.

“We’ve kind of gotten used to it,” Branham said. “I hope it’s not the new normal, though.”

Amy Jeter, (757) 446-2730, amy.jeter@pilotonline.com