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Winter 2011

Preparing for the Worst

Across Hopkins, pharmacists and practitioners grapple with mounting drug shortages.

By: Stephanie Shapiro
Date: February 18, 2011

shortage of pills
Illustration by Sherrill Cooper

Merrie Griffin, chief nurse anesthetist at Hopkins Hospital, witnesses daily the “lifesaving” benefits of electroconvulsive therapy (ECT) for patients with major depression. To ensure ECT patients’ comfort and swift recovery from the procedure, Griffin and Department of Psychiatry colleagues have long relied on succinylcholine, a fast-acting neuromuscular blocking agent that lasts about five minutes and is free of troubling side effects.

Recently, though, a succinylcholine shortage forced psychiatry’s anesthesia team to replace it with rocuronium, another blocking agent. While safe, this drug is longer lasting than succinylcholine, and it must be reversed with two drugs followed up by a sedative and, as needed, medication to control blood pressure and heart rate.

The carefully calibrated cocktail doesn’t affect patient outcomes, but it does complicate and prolong treatment. The succinylcholine outage “has had a tremendous effect across the country,” Griffin says. “A lot of programs have stopped doing ECT because it’s now more complicated to do.”

Throughout Johns Hopkins Medicine, pharmacists and providers are making similar adjustments and developing procedures to address an unprecedented nationwide shortage of dozens of mainstay drugs used for emergencies, pain treatment, and diagnostic and anesthetic purposes.

“It’s becoming much more challenging to manage these drug shortages, which obviously impacts the way we treat our patients,” says Brian Pinto, drug information specialist at Hopkins Hospital. “This is not just a pharmacy issue, it’s a patient care issue.”

A scarcity of raw materials, FDA crackdowns on safety violations, voluntary recalls, and discontinued production of unprofitable products account for most drug shortages. Compounding the problem is the increasingly unpredictable nature of drug supply chains.

When a particular drug will become available is often anybody’s guess, says Edina Avdic, a clinical pharmacist at Hopkins Hospital who specializes in infectious diseases. “It’s a huge problem. For us, the most frustrating thing is figuring out what path to take for making medication decisions without knowing when a shortage is going to resolve. It’s particularly difficult to go through the process of restricting something that is used widely, since you don’t know if it will be available tomorrow or in a few days. If the drug does come, you might be okay for a month, but not for six months.”

In determining the best alternatives to unavailable drugs, efficacy and safety are paramount, Pinto says. Before assessing costs, Hopkins pharmacists also examine whether the supply chain for the alternative medication is reliable. “The last thing we want to do is switch from drug A to drug B and realize, Whoops, we can’t get that one anymore,” Pinto says.

Even with a plan, “it’s really kind of a roller coaster,” says John Lewin, division director of the critical care pharmacy. “We’ve been teetering on a shortage of intravenous diuretics required by patients with really bad heart failure. If we run out of those, it would be a disaster. We started to think about restrictions and then pulled in stakeholders to decide where we are not going to use it and where we are going to use it and put a plan in place.”

“After all that planning, we got a shipment in the next day,” Lewin says. “Quite a few drugs have been like that. You’re spinning your wheels and spending all those hours worrying about it and then it comes in at the last minute just before you run out, but you have to be prepared for the worst.”

The challenges to solving chronic drug shortages are formidable. “In a free market system you can’t demand that a company continue to make a drug if it decides it’s not profitable or the margin is not great enough to continue to market that drug,” says Daniel Ashby, senior director of pharmacy at Hopkins. As a partial remedy, he advocates the creation of a class of orphan drugs “that have a smaller market but will provide price protection for patent holders and incentives for companies to meet the need.”