ER Drugs

Since 2000, there has been a 200 percent increase in the rate of overdose deaths involving opioid painkillers.

The U.S. Centers for Disease Control and Prevention (CDC) reported last month that the bulk of the increase — 80 percent — coincides with illicitly manufactured fentanyl, a synthetic opioid more potent than morphine.

The medication used to reverse fentanyl and other opioid overdoses, is naloxone, or Narcan. It costs only a few dollars per treatment.

But as the drugs increase in strength, the antidote needs to be just as strong. That means more naloxone is needed in hospitals and other medical facilities.

ER Drugs

On Monday, Renee Petzel Gimbar, PharmD, clinical assistant professor at the University of Illinois at Chicago College of Pharmacy, received an alert that the naloxone supply is running low.

That means the hospital can choose to stock up or plan to use alternatives when the pharmaceutical barrel runs dry.

An alternative in these scenarios, Petzel Gimbar said, is intubating the patient with a tube down their airway. It prevents people from choking on their vomit.

“We can’t always necessarily expect a spike in need,” she told Healthline. “But what’s cheaper, a drug that costs a few dollars or keeping someone in the hospital for days?”

Cheap generic drugs are the staple of emergency medicine. From simple bags of saline solution to snake anti-venom to drugs that treat common infectious diseases, they keep millions of people alive.

But these crucial drugs are often in short supply, especially in hospital emergency rooms.

Read More: Prescriptions for Hydrocodone Have Dropped Since DEA Classification Change »

Drug Shortages Becoming More Common

Using data from the University of Utah Drug Information Service, researchers at George Washington University (GWU) found from January 2001 to March 2014 there were nearly 2,000 drug shortages in the U.S., a third of those falling under the realm of emergency medicine.

The majority of drugs on the shortage list were generic sterile injectable drugs, impacting infectious disease, analgesia, and toxicology the most.

One drug high on the short list is lidocaine/epinephrine, commonly known as adrenaline. It’s an important component of the emergency physician’s tool chest when dealing with cardiac arrest.

An average of 1,557 people went into cardiac arrest each day in 2013, a statistic that continues to climb each year, according to the American Heart Association.

In some of these situations where no substitute is available, that’s where you may see some serious patient outcomes.
Dr. Jesse Pines, George Washington University

“For a lot of drugs that aren’t available, there are substitutes available that will work,” Dr. Jesse Pines, a professor of emergency medicine at GWU and senior author of the study, told Healthline. “In some of these situations where no substitute is available, that’s where you may see some serious patient outcomes.”

Other drugs that are commonly in short supply — with an average shortage time of nine months — include nitroglycerine injections, pantoprazole (stomach acid reducer), epinephrine, and hydromorphone, an opioid painkiller.

When these first-line drugs aren’t available, emergency staff often reverts to a different medicine, which can have more side effects. This also means doctors and nurses are using medications they aren’t as familiar with.

Petzel Gimbar says she never envisioned how much she’d need to rely on her pharmacy training while performing emergency medicine. So much so, that the realities of drug shortages are now addressed with new medical students.

“We’re seeing a change in the culture in the way we teach students because this is more common,” she said. “Drug shortages, in general, are something we deal with on a daily basis.”

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Why Some Drugs Come up Short

There are numerous reasons why drugs are in short supply, but researchers aren’t always given the answers.

In the GWU study, in nearly half of these instances the drug manufacturers didn’t explain why their short supply.

Jonathan Watanabe, PharmD, PhD, an assistant professor of clinical pharmacy in the Skaggs School of Pharmacy and Pharmaceutical Sciences at the University of California, San Diego, said these drug shortages are “creeping into more clinical areas.”

“This has been a real flashpoint for the last five years,” he told Healthline. “It hasn’t gotten any better, in terms of manufacturers not giving reasons for shortages.”

Drug shortage occurrence in emergency medicine fell between 2002 and 2008 but have risen by more than 400 percent since the 2008 decline in the U.S. economy. While other industries have been able to stabilize, generic drug manufacturing continues to lag behind.

It’s due, in part, to financial reasons. These emergency department medications are cheap generics, which translates to a lower profit margin for manufacturers.

During that time, many compounding pharmacies closed or switched to producing drugs with a higher profit margin. In addition, few manufacturers produced sterile injectable drugs, creating a market with low capacity in times of high need. 

A 2014 report by the General Accounting Office found quality issues with drug manufacturers and the response by the U.S. Food and Drug Administration (FDA) played a role.

In 2012, 58 percent of the drugs on the shortage list were produced by at least one facility under FDA remediation.

The GWU team found that one in four drug shortages were due to manufacturing delays and 15 percent were due to supply and demand issues.

These types of drugs also have low reimbursement rates from Medicare compared with other drugs, leaving the free market the ultimate decider in manufacturing decisions.

“The things that go into shortages typically end up being the thing with the lowest reimbursement,” Watanabe said. “You’re trying to have the free market decide and it’s really tough right now.”

Other contributing factors to drug shortages, according to the American Society of Health-System Pharmacists, include disruption in the supply of raw or bulk materials, voluntary recalls, changes in drug formulation, inventory issues, and natural disasters damaging manufacturing facilities.

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Creative Solutions for Shortages

There are a host of different ways emergency departments can plan for shortages, including becoming better versed in alternative drugs available as well as attempting to forecast supply and demand.

Hoarding medications, however, isn’t a sustainable long-term solution. 

Dr. Marco Coppola, D.O., adjunct clinical professor of emergency medicine at the University of North Texas Health Science Center and chief medical officer and emergency physician of Family ER+ Urgent Care in Texas, said overstocking drugs could mean they would expire before they are used.

“A viable solution is to prolong the ridiculously short expiration dates of medication,” he told Healthline. “In times of extreme shortage, expiration dates should be forgiven temporarily until adequate drug supplies are replenished.” 

On almost every shift, emergency physicians face different challenges and must make the best possible decision for the patient.
Dr. Marco Coppola, University of North Texas Health Science Center

According to the Shelf Life Extension Program and the Department of Defense, 88 percent of 122 drugs tested remained effective for up to three years past their expiration dates.

Until meaningful and lasting solutions to generic drug manufacturing can be solved, shortages remain a part of emergency medicine.

Of all the physicians who can quickly overcome shortages and make quick decisions on alternative therapies, it’s the emergency physician, Coppola said.  

“On almost every shift, emergency physicians face different challenges and must make the best possible decision for the patient,” he said. “Many times we have to improvise treatment based on a unique patient presentation.”