OMAThoughts white paper focuses on solutions to chronic drug shortages worsened by COVID-19
Drug shortages in Canada are not new, but the COVID-19 pandemic has placed new pressures on the supply and distribution of medications, highlighting the seriousness of the issue and its impact on patients, physicians and other health-care providers.
In A Remedy for Canada’s Drug Shortage Dilemma, an OMAThoughts white paper released in January 2021, the OMA recommends short and long-term solutions to ongoing drug shortages across the country and ways to address the additional burden the pandemic has placed on drug supply and distribution.
The onset of the pandemic in early 2020 immediately raised red flags about securing sufficient supplies of imported active pharmaceutical ingredients (APIs) from China and India, which supply most of the APIs used in North America. Between early March and mid-June 2020, the Ontario government asked doctors and pharmacists to dispense 30 days or less of medication at a time for Ontario Drug Benefit recipients to ensure there was an adequate supply during the first wave of COVID-19.
In August 2020, Canada’s doctors and pharmacists wrote to the federal government, pointing to shortages of essential and critical care medications exacerbated by the pandemic, including propofol, ketamine, succinylcholine, fentanyl and midazolam. These drugs are essential in the treatment of COVID-19 patients in critical care and are also used in operating rooms, emergency departments and palliative care settings. Health-care professionals have also seen shortages in antibiotics.
“There’s no question that the pandemic has worsened medication shortages,” said OMA Chief of Economics, Policy & Research and white paper co-author Dr. Jim Wright. “The impact of drug shortages on patients can be devastating, including increased suffering, treatment delays, financial burdens and a higher risk of overdose and underdose. The white paper will be relevant beyond COVID-19, recognizing we need strategies in place to address drug shortages in the future.” To develop its white paper, the OMA conducted an extensive review of Canadian and international resources and reports developed before and during the pandemic. It also consulted with provincial and national stakeholders, including physicians, pharmacists, associations and regulators.
Palliative care medications for patients who choose to be at home during their end-of-life care are typically placed in pre-filled syringes drawn up by community pharmacists and nurses. According to National Association of Pharmacy Regulatory Authorities standards, these syringes must be used within 24 hours. However, the Canadian Society of Palliative Care Physicians has recommended to provincial pharmacy regulators that pre-filled medications be exempted from the 24-hour requirement to better meet the needs of palliative care patients, limit waste and conserve the drug supply.
“The OMA supports this recommendation as a way to enhance timely access to drugs needed for symptom control, reduce the risk of drug errors and minimize the risk of health-care provider exposure to COVID-19 in patients’ homes,” Wright said. The white paper recommends that the Ontario College of Pharmacists should work with the OMA, Ministry of Health, Ontario Pharmacists Association (OPA) and other stakeholders to explore this and other options to enhance access to medications used at the end of life prepared by community pharmacists, such as pre-filled syringes.
Redistributing and reallocating unused medication can also conserve supply, particularly for drugs that have been in high demand during the pandemic. Canada has a patchwork of legislation, regulations and policies governing the return and redistribution of unused drugs. In Nova Scotia, for example, pharmacists can return previously dispensed medication—such as drugs used for medical assistance in dying (MAiD)—to their inventory in accordance with specified eligibility criteria.
In Ontario, however, community pharmacies cannot re-dispense unused injectable medications in palliative care Symptom Relief/Response Kits (SRKs) or MAiD kits that have been under the control of a regulated health professional.
“Given the significant wastage of unused drugs, the OMA recommends that the Ministry of Health, in collaboration with pharmacy regulators, professional associations and key stakeholders, should make legislative, regulatory and policy changes to support the safe return and redistribution of high-demand unused medication—such as SRKs and MAiD kits—in hospital and community settings,” Wright said. To further minimize the wastage of unused drugs, the white paper says the Ministry should work with stakeholders to identify changes to medication management systems in settings where there is high use of medications—such as long-term care homes, retirement homes and hospices.
When there are drug shortages, it can be challenging and time-consuming for prescribers and pharmacists to determine appropriate drug substitutions and alternatives for patients.
The white paper recommends that the Ministry of Health, in collaboration with the OMA, Ontario Health, OPA, Registered Nurses’ Association of Ontario and the Nurse Practitioners’ Association of Ontario, should create a dedicated online platform focused on resources and supports for drug substitutions and therapeutic alternatives.
“This platform should be accessible to prescribers, nurse practitioners and pharmacists to support informed decision-making and safe practices when considering drug substitutions and alternatives,” Wright added.
Ontario’s lack of available, accurate, real-time information on community drug supply and distribution is a major impediment to managing drug shortages. While the Drug Shortages Canada website provides updates, users describe it as vague, impractical for community use and lacking detail on the reasons for shortages. It also does not provide information about inventory remaining in the system.
“The absence of reliable data on community drug supply can create frustrating delays in providing medications to patients,” Wright explained. “For example, when prescribers aren’t aware of shortages, pharmacists must contact them to discuss substitutions or alternatives.” The white paper recommends that federal, provincial and territorial governments should work with key stakeholders and health-care providers to develop and implement a centralized drug-supply monitoring system that provides real-time updates on community drug supply and distribution. These updates should include information on the reasons for the drug shortages and how long the shortages are expected to last.
As the pandemic has demonstrated, disruption during any phase of Canada’s drug supply chain can have a huge impact on drug availability across the country. The white paper, therefore, recommends that the federal government strengthen the domestic drug-manufacturing sector to increase the production of essential drugs in Canada.
“We are encouraged by and support the federal government’s recent steps to strengthen domestic drug manufacturing,” Wright said. “Our paper also recommends that the federal, provincial and territorial governments work with hospital and community stakeholders to continue to develop and monitor Canada’s essential medication list and ensure a sufficient supply of drugs in the National Emergency Strategic Stockpile.”
Wright said the white paper, which has been well received, is intended to stimulate discussion and generate additional solutions. The OMA will continue to work with government and other stakeholders to address the ongoing issue of medication shortages.
“COVID-19 has highlighted the impact that drug shortages have on patients and health-care providers,” said Wright. “In anticipation of future waves of COVID-19 and other pandemics, we need to proactively put measures in place to make sure we have the essential medications Canadians depend on. All of us—physicians, pharmacists, regulators and governments—need to work together to manage current shortages and prevent future ones.”
Susan Hanna is a Toronto-based writer.