Have you heard this line lately? - I'm sorry, but we don't have your medicine in stock.
Have you gone to 10 different chemists, all telling you the same thing?
Have you eventually had to have your prescription changed to something else?
Well I'm here to try and explain why there are so many drug shortages, and explain why I've gone with the heading - Drug Shortages for Dummies. I'm definitely not referring to the reader. But you'll have the wait until the end until I explain it!
Drug shortages is becoming a common theme across community pharmacy in NI, and is frustrating for everyone, not least for the poor pharmacist who's having to have these difficult conversations everyday with patients and their carers.
Before I get into the nitty gritty of the causes and problems caused by these drug shortages for patients, please be aware your pharmacist will have done their upmost best to source your drug. Up to an hour a day is being spent in most pharmacies trying to just source routine drugs that we normally sourced in a few seconds by clicking an order button on the computer.
Prior to having to admit we cannot source your drug your pharmacist will have
-rang several wholesalers to see if they have it.
-if the wholesaler does have it, the price may have been inflated by the manufacturer. They pharmacist may then have to ring the BSO (business service organisation) in Belfast (that is, the people that pay us for our drugs), and see if they will pay the inflated price.
-if the BSO has said they aren't sure if they can cover that inflated price, depending on how much we stand to lose the pharmacist may buy it in anyway - hoping the BSO will send out correspondence to say it will be covered later in the month. (see below)
-if the wholesaler doesn't have the product, the pharmacist has most likely rang their GP practice and spoken with the practice pharmacist and they have mutually agreed a way forward - for example, the patient will be changed to a different drug and appropriate monitoring carried out by clinic and pharmacist of both!
Then the pharmacist will communicate this to you.
Phew! Did you get all that?! That's one drug for one patient...but so many of our patients are affected by this, that this process is repeated and repeated daily.
So what ultimately does a drug shortage mean?
Ultimately its the patient that pays the highest price. There are incidences when life saving medications are unavailable - for example, penicillin was as rare as hens teeth when there was a spike in scarlet fever and strep A a few months back.
The fear was so real that we would run out of antibiotics that a 'serious shortage protocol' was put into place in NI and across the UK. This basically meant the pharmacist had the discretion to choose from a list of other suitable antibiotics if a GP prescribed penicillin and it wasn't available. This was to ensure that GP surgeries and Emergency Departments weren't awash with worried patients looking for antibiotics.
It also puts huge stress on the NHS. Everyone working within the NHS will feel the impact. If you have to change a patient to a different drug, their ailment may not heal as well. They may need to have new bloods and monitoring done. A number of psychiatric drugs were unavailable, and patients who were stable for years had to change their medications and some clinicians have reported relapses/inpatient stays etc.
It also increases the financial burden on the NHS. Many alternatives are more expensive than the previous drugs patients were on. Or occasionally where a drug is available but is it limited supplies, manufacturers will hike up the price. The BSO (see above) many not increase the price they pay pharmacies (or not do it promptly) and pharmacies are running at a loss.
Last week, I paid over £5.00 for atorvastatin 80mg, and to date the BSO have said I'll be paid £1.32 per pack. No concessions have been made - so I'm at a loss every time I dispense atorvastatin - which is several times a day (every 3rd script I receive has atorvastatin on it). The BSO may issue a concessionary price in August for drugs dispensed in August, but last week was July. So will I get paid for those???? Who knows!
Be mindful when you hear HSCB representatives say they've invested more money into pharmacy than ever before. Its paying for the increased price of drugs, it definitely isn't going into my pocket. But the spin doctors have vertigo spinning that line!
What types of drugs are unavailable
A full list of drug shortages in NI can be viewed here
Shortages Information (hscni.net)
By far the biggest shortage is Hormonal Replacement Therapy (HRT). Almost half of the drug shortage list is made up of HRT products. This is extremely distressing for the patient. After years of perhaps not knowing what was wrong with you and then getting a miracle cure and having it snatched away is very cruel. I know some readers will say that its hardly life or death, but actually, for some women it has saved their lives! And its the sheer volume of patients this affects - 51% of the people on the planet are female. If we all women are fortunate enough to live to aged 50, we'll all go through menopause. And 20% of us will probably have troublesome symptoms that require HRT of some form. I'm not going to do the math on this one - but its affecting a lot of women - so much so, there's a public petition gone to parliament to beg MP's to improve the supply chain of HRT.
Then as I said, there was a UK shortage of penicillin caused by a spike in Strep A and scarlet fever infections - but in addition - there is also a world wide increase in syphilis. This is impacting supply.
At the moment we're facing a huge shortage of drugs called GLP1's. These are wonder drugs in the treatment of type 2 diabetes. In addition to the blood glucose lowering capabilities of these drugs, they are great at helping diabetic patients lose weight (increased BMI is the greatest risk for developing diabetes). They aren't licensed for weight lose alone, so you can only take it if your an uncontrolled diabetic with a BMI > 28. They are also not first line treatment for diabetes, but have a very important role in management, both with helping weight loss and ensuring some patients blood glucose come back to pre diabetic levels. I have found this shortage particularly challenging as its so hard to ring a diabetic patient who has got their diabetes and weight under control, only to tell them we have to change them to something else. Unfortunately, lots of patients regain the weight when these drugs are stopped.
Other drugs affected by the shortage are alendronic acid for osteoporosis, atorvastatin for high cholesterol, some anti epileptics, and medications for ADHD. The list is endless, and I'm sure you don't want me to go through it one by one.
In addition to prescription medications, we have disrupted or limited supply of basic over the counter medications such as liquid paracetamol, Nurofen, Solpadeine, cold and flu preps
I currently estimate that if I add the atorvastatin situation in, drug shortages are affecting about 50% of my patients.
So what's causing the shortage
Like most people, you'll probably automatically say Brexit. So far, it doesn't seem to be the issue. It actually a world wide issue, and the Republic of Ireland, the rest of Europe and USA are facing the same problems.
The problem simply seems to be supply and demand. Better detection of health problems means more demand for medicines across the world. In addition, if there is a peak in a particular condition, such as Strep A, we are likely to see a shortage, and on this case it led to an acute shortage of penicillin.
HRT demand has also been off the scale since its safety has been proven against its small increased risk of breast cancer by those taking it. Contraceptive medications and ADHD medications have also seen a massive increase in their usage.
But supply and demand is only one issue. A quarter of medicines supplied in NI are supplied by UK, a quarter is supplied by Europe and a third is supplied from India.
UK suppliers are reporting its increasingly difficult to trade in UK due to labour costs, ingredients costs etc. In addition, many of these companies where working under tax breaks, and they are about to expire. Could they leave the UK? We'll see.
Importing medicines is also proving difficult. Believe it or believe it not, there's a shortage of shipping containers! This makes its v difficult to get medicines here in a timely manner.
The devastating effects that covid had on the population of India has meant their labour force has shrunk, which is having a huge effect on us. India has also reported difficulties in sourcing raw materials for certain products.
In addition, there's a lot of bureaucracy around getting new drugs on to the market in the UK. So if you are the only supplier of a branded drug and your patent has expired, it is a lengthy process for another drug manufacturer with a cheaper alternative to get their drug on the market.
Poor planning within the marketplace and lack of communication around drug shortages from the manufacturers to pharmacists has exacerbated drug shortages.
So there you have it - Drug Shortages for Dummies! And I said I'd explain this heading at the end.
I cannot help but feel pharmacists are the dummies here, because if your local shop keeper bought in a loaf of bread for £5.00 (before profit) and you offered to only pay £1.32 for it - do you think he'd sell it to you? I think we all know the answer. It's clear the current situation is unsustainable. But to stop dispensing would mean the system will collapse even quicker.
So next time we tell you we don't have your medicine in stock, be aware we're dying inside!
Thanks for taking the time to read this, Siobhan x
Fixing the UK’s medicines shortage crisis - The Pharmaceutical Journal (pharmaceutical-journal.com)