The patient was found by paramedics and rushed to the hospital. He had taken over 80 aspirin tablets of 500 mg each — more than enough to be lethal. The ER staff prepared to administer the standard treatment for aspirin poisoning: sodium bicarbonate. Yes, this is the same stuff seen in movies that anxious characters take to relieve stomach upset and is followed by a burp. Chemically it's a simple, inexpensive medication and has been used for decades. In this case, the bicarbonate is a sterile solution given intravenously. But when the order was sent to the hospital pharmacy, the answer came back that there was no bicarbonate solution available. The only alternative would be to begin emergency dialysis, a far more expensive and risky procedure.
In the Maryland legislature we heard this story from a physician practicing at a university teaching hospital. In answer to an urgent distress call to nearby hospitals, a few vials were located and used to save the patient.
Stories like this are common throughout the nation as a crisis in medication shortage continues to expand. Basic medications are missing: injectable generics like epinephrine (for severe allergic reactions and cardiac resuscitation), Compazine (relief of nausea and vomiting), Novocain (local anesthesia), Ativan (seizure control).
At one hospital, weekend elective surgeries were canceled, and even emergency surgeries were threatened. They didn't have enough anesthetic to put people to sleep safely or the antidotes needed to wake them up.
But the problem goes deeper: patients are suffering and dying because they're not receiving optimal treatment. A year ago, The New England Journal of Medicine documented significantly worse outcomes in children with cancer when one medicine was substituted for another, and a recent survey of cancer doctors published last month reported that 82.7 percent "were unable to provide the preferred chemotherapy agent at least once … during the previous 6 months."
Brenda Frese, coach of the University of Maryland women's basketball team, became aware of the problem when one of her twin sons was in short supply for a medication he needed. She wrote, "from what I understand, the shortage [of life-saving drugs] isn't the result of a lack of natural resources or research dollars, but simply a choice by pharmaceutical companies because their profit margin on the drug isn't high enough. This is wrong on every level."
A pharmacist at Johns Hopkins Hospital testified before a Maryland legislative committee, "This morning I spent 3 hours on a conference call reviewing a list of 97 medications we're actively managing right now that are on shortage. We do not purchase any drugs that we cannot ensure the integrity of, but in some cases unfortunately that has caused us to say to a patient that we cannot provide you with treatment, and that's something we never want to do."
What happens next? The pharmacy staff tries to track down the missing meds, too often from suppliers of questionable reliability. A bargaining process ensues, carried out by fax and email. Costs often rise drastically as demand outstrips supply. For example, the price of doxycycline, an antibiotic used to treat Lyme disease, jumped from about $2.50 to between $80 and $150 for a 60-pill, one month treatment. Magnesium sulfate (used to treat toxemia in pregnancy) went from $9 to $400 for 25 vials.
Our national medication shortage stems from multiple causes. There are problems with manufacturing as companies (often located overseas) cut corners and risk contamination in medicines with small profit margins. A "gray market" has emerged, complete with price gouging and manipulation, hoarding and back-door delivery of medicines, some of which have been improperly stored.
This crisis needs immediate attention on many levels. The Food & Drug Administration's passive approach — limited to generating lists of impending drug shortages — should become proactive by expediting permits for qualified producers and creating an exchange system so medicines are distributed where needed. Hospitals could establish extensive buying consortiums and partner directly with manufacturers to eliminate the dozens of "middle men" engaged in profiteering. State health departments could create medication repositories for sharing, as was done during the flu vaccine shortage a few years ago. Ultimately, we need to bring pharmaceutical manufacturing back to the U.S., employing the latest and safest techniques for drug production.
As a practicing physician, I don't want to be reaching for a life-saving medicine when trying to manage a patient in crisis and finding that there's none to be found.
As a patient and family member, I want our doctors to have the right medicines available when treating my loved ones and me.
And as a legislator, I know that public awareness is essential to creating solutions. Just about all of us, our families, and our friends have had occasion to be treated with medicine or been admitted to a hospital in the past few years. There is cause for concern; we must let our representatives know that action is needed now to solve this mess.
Dan K. Morhaim is a physician and a member of the Maryland House of Delegates, representing District 11 in Baltimore County. His email is firstname.lastname@example.org.
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