Part of Angela Sandlin’s job as a pharmacy director has been to keep a list of the drugs that are in short supply, which, over the years, have run the gamut — from contrast agents used for X-rays and other scans, to blood pressure medications and antibiotics.
But the shortages lately have gotten worse and pharmacists are “trying to walk a tightrope,” Sandlin said.
As U.S. drug shortages hit near-record highs earlier this year, pharmacists are finding it harder to shield patients from the impact. The American Society of Health-System Pharmacists, which tracks drug supply issues, found there were 301 active shortages in the U.S. during the first three months of 2023 — the biggest total in nearly a decade.
It got “uncomfortably close” to the all-time high of 320 simultaneous shortages, said Michael Ganio, ASHP’s senior director of pharmacy practice and quality.
At Baptist Health La Grange, where Sandlin works, providers have been limping through with patients who rely on Adderall, a stimulant used to manage attention deficit hyperactivity disorder. A key strategy they’ve used, Sandlin said, is giving patients 30-day supplies rather than 90-day supplies of their prescription.
“That way, three patients get it for this month, you know, instead of one person getting 90. And then the next month, we get another supply in, and we're able to fill them again,” she said.
Adderall is far from the only drug that’s been hit by extended shortages pushing pharmacists and physicians to have to make difficult decisions.
Current shortages include some widely used medications like chemotherapy drugs, the antibiotic amoxicillin, and semaglutide injections, marketed under the brand names Ozempic and Wegovy, used for diabetes and weight-loss treatments.
A recent report by the Senate Committee on Homeland Security found that new drug shortages spiked by nearly 30 percent last year compared to 2021.
Health care providers have typically been able to blunt the impact of drug shortages on patients by using various tactics, including prescribing other forms of the medicine or alternative drugs. Patients may not even be aware there’s a shortage.
But “once something is not available … it’s just a matter of time before that equalizes across the country,” Ganio said.
In the Midwest and South, pharmacists who serve patients in Kentucky and Southern Indiana told Side Effects their hospitals or community pharmacies have had to resort to workarounds to keep their patients supplied with what they need.
Many reasons behind the shortages
Drug shortages in the U.S. are not new phenomena. They are a standard part of the logistics for hospitals, according to Joe Hall of Louisville-based Norton Healthcare.
“We, like other hospital systems, have been experiencing shortages of critical drugs for several years,” said Hall, citing cancer treatments and narcotics as examples.
The health system regularly places backorders for products and tries to diversify their sources, including ordering directly from manufacturers and drug wholesalers. “Then, we move product throughout our hospital system so that no one hospital runs out,” Hall said.
Drug shortages are typically caused by problems at the manufacturing level, Ganio of the ASHP said. They also tend to affect generic versions of medications more than the brand-name drugs that are bigger money-makers for pharmaceutical companies.
“If it was an easy problem to solve, we would have done it … two decades ago,” Ganio said.
A spike in demand rarely causes a supply-side issue, but he said it was a factor in recent shortages of Adderall and Ozempic. A recent report from the U.S. Centers for Disease Control and Prevention shows prescriptions for ADHD meds like Adderall rose in recent years, while various news reports say Ozempic has been talked up on social media as a weight-loss drug.
The latest report from the Senate’s Homeland Security and Governmental Affairs committee pegged the problem to a number of factors, “including economic drivers, insufficient supply chain visibility, and a continued U.S. overreliance on both foreign and geographically concentrated sources for medications and their raw materials.”
The report pointed to the fact that nearly 80 percent of manufacturing facilities that produce active pharmaceutical ingredients — the key ingredients that give a drug its intended effect — are located outside of the U.S.
Ganio said there’s a lack of transparency about manufacturers’ supply chains.
“There could be five manufacturers of a blood pressure medication, for example, and all five are sourcing from the same producer of the active pharmaceutical ingredient,” which can make the system vulnerable to shortages if something goes wrong with this one supplier, Ganio explained. But the government might not know that because of the opaque supply chains of drugmakers.
The U.S. Food and Drug Administration already does a lot to address drug shortages, he said, but there’s more that could be done at the federal level. He hopes increased public awareness of these shortages as they spill over to the pharmacy counters and affect patients, would put “more pressure on Congress to enact change.”
How patients are affected – and what they can do
The currently limited supply of cancer treatments like cisplatin has been a scare for Hope Maniyar, University of Louisville Health pharmacy manager.
“We’re not having to ration care,” she said. “But we are starting to have that conversation of: ‘If we get to dire straits, how are we going to ration cancer care to patients?’”
UofL Health spokesperson David McArthur said, so far, the staff has managed the chemotherapy drug supplies so that patients can complete their prescribed regimens.
If supplies of a certain chemo drug run out, doctors can shift patients to a different treatment, Ganio said. But that’s far from ideal.
“That’s really hard to tell a patient, ‘We can’t give you your first-line treatment because it’s not available,’” he said.
If a person is concerned about the drug shortage affecting them, Sandlin of Baptist Health said they should call their pharmacy and talk to the staff about their needs.
“Please, please don’t wait till you are completely out [of meds],” she said. “Then something urgent becomes emergent.”
Louisville-based Family Health Centers runs four pharmacies in Louisville. Their director of pharmacy services, Mike Lin, said they “have probably a page worth of ‘outs,’” referring to drugs they’re struggling to acquire. He estimates over 90 percent of those "outs" are generics.
It’s common for there to be multiple generic versions of the same medication on the market, though, which gives patients options. When one generic goes into shortage, Lin said, a common solution is to switch to one of the other generics.
“And that's the beauty of generics … they are interchangeable,” he said.
However, Lin would rather avoid swapping the generic meds a patient gets.
Different versions of the same medication may contain varied levels of a particular ingredient because the manufacturing standards for generics aren’t as stringent as the standards for brand-name drugs.
The pills also might look different, even though they contain the same ingredients, he said. That can confuse people. So, he encourages patients to be mindful of these variations if their medications are switched.
Another common way to help patients during a shortage is to connect them with other pharmacies that still have their medication in stock, said Ben Mudd, executive director of the Kentucky Pharmacists Association.
But sometimes pharmacies may not be able to accept new prescriptions if they’re already struggling to cover their current patients due to limited shipments of a particular drug, Mudd said.
“This is one of those times when it’s important to have a kind of a personal relationship with your pharmacist,” he said. “At the end of the day, pharmacists are just trying to help their patients navigate this.”
This story comes from a partnership between Louisville Public Media and Side Effects Public Media, a health reporting collaboration based at WFYI. Side Effects is a collaboration of NPR stations across the Midwest and surrounding areas, including KBIA, Iowa Public Radio, Louisville Public Media, KCUR and Ideastream Public Media.