Shortages of common medicines are proving bothersome and sometimes distressing for patients, as well as adding to the workload of pharmacists and GPs. The problem has become a chronic one and there are few solutions on the horizon.
The Irish Pharmacy Union recently surveyed its members on the issue and 97 per cent of respondents felt the shortages were getting worse and 86 per cent expected that pattern to continue.
“I’ve been a pharmacist for 25 years and I’ve never seen it as bad as this,” says Kathy Maher from Duleek, Co Meath. “It’s proving really challenging for patients but it’s hard to know what to say to them, as there are myriad reasons behind the shortage we’re seeing.”
More than 220 medicines now feature on the list of items with specific shortages maintained by the Health Products Regulatory Authority (HPRA). It includes treatments for pain relief, infections, anxiety, sleep disorders, seizures and diabetes as well as over-the-counter and prescription eye drops. Solpadeine and ibuprofen are the latest additions.
There are multiple workarounds to individual product shortages, from substituting other products to breaking up multipacks to supply smaller volumes. When hormone replacement therapy (HRT) was in short supply last year, pharmacists switched their patients from patches to gels, or cut patches in half to make them last longer.
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Inventiveness can only stretch so far, though, and is no substitute for tackling the causes of the problem. There are so many, however, it’s hard to know where to start.
Price has loomed large in much of the coverage of product shortages, driven by the assertions by Azure Pharmaceuticals, a manufacturer of common off-patent drugs, that Ireland is paying up to four times less than neighbouring countries for certain medicines.
This may be true; only 70 per cent of Irish shortages are common to other European countries. However, it does not explain the shortages of drugs like Solpadeine, whose over-the-counter price is higher here than in the UK. Neither are the actual manufacturers of scarce medicines citing price as a reason for the shortages.
The most common reasons cited on the HPRA’s list are manufacturing delays, unexpected increases in demand and the unavailability of key ingredients.
Some peaks in demand are more predictable than others. The surge in winter viruses sent demand for cough mixtures and penicillin rocketing, resulting in shortages. Last year, HRT products became scare after issues around the menopause were prominently highlighted in the media.
Many drugs are compounds whose ingredients are manufactured separately in many different countries before being finished, often in another country again. Supply chains are sophisticated but tight. Unexpected events such as the war in Ukraine, which has pushed up energy prices, can impact on these supply chains.
The Covid pandemic reduced demand for antibiotics, and so manufacturers cut output. More recently, the unfettered spread of Covid-19 in China has led to a surge in illnesses, resulting in disruption of manufacturing capacity.
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Even Brexit has had a malign influence on drug supply. Before the UK left the EU, the same product information could be used for both Britain and Ireland, but now any drug sold here has to be packaged and provide information specifically for the Irish market, resulting in more delays.
Maher would like the Department of Health to introduce a serious shortage protocol and put it on a legislative basis. This would allow pharmacists to substitute a different product, with the same clinical impact, for the one prescribed by a GP, where this was not available.
At present, the pharmacist has to go back to the GP to get the prescription rewritten. This adds to the doctor’s work burden, fails to take account of the extensive training completed by pharmacists and leads to delays for the patient, especially at weekends.
Another suggestion Maher makes is for the Health Service Executive to issue reimbursement codes to allow pharmacists use unlicensed products. For example, prednisilone, a common steroid, is currently in short supply but Maher says she could supply patients from UK packs if this was allowed – same drug, just different packaging.
So far, the problem has stopped short of being a major crisis. When pharmacies in 29 European countries were surveyed recently on the issue, four said the shortages had been linked to patient deaths.
Maher worries about the impact of the shortages on patient compliance.
“It’s very difficult for me to have to explain to, say, elderly patients that their regular medication has changed shape or size this week. Any doubt or fear on their part may affect the compliance they need to adhere to,” she says.
The European Medicines Agency last week decided not to ask the European Commission to declare the shortage of antibiotics a “major event” given existing measures to tackle the shortfall were working in the short term. For now, the bets are on the system muddling through.