When drugs are scarce, reassure patients that you’ll help them navigate this challenge. If you can’t find the medicine after searching, consider rationing when clinically appropriate.
It’s happened to me twice this week. Odds are it will happen to you, too—drug shortages now routinely complicate clinical care.
After receiving the phone call, page, or Epic message, you may feel waves of emotions: denial, anger, bargaining, depression and—eventually—acceptance. Whether you’re the physician or patient, Dr. Kübler-Ross’ stages of grief also apply in miniature when navigating medication shortages.
The denial phase is often directly proportional to the time and effort put into the treatment plan. We strive to find the right medication at just the right dose, pouring over clinical trials data and treatment algorithms to arrive at the perfect balance of tolerability and efficacy for our patient. However, in the shadow of the ivory tower, real world medicine is complicated by supply chain issues, manufacturing problems, safety recalls, and human error.
While few of us are still surprised by initial insurance coverage rejections, medication shortages are less predictable. Fortunately, the FDA provides a helpful database. As a psychiatrist practicing in a well-resourced part of the county, sometimes I learn of shortages in the media weeks before patients start calling the office. The recent Adderall shortage was like that. In those cases, you can be proactive and develop contingency plans.
Unfortunately, sometimes the patient’s condition is fragile and stakes are high. In these cases, the anger/bargaining/depression stages may arrive all at once. Thankfully, that wave of affect can help drive action.
What can you do to help?
1. Talk to your patient immediately.
Ask questions to understand their concerns and preferences. Share any information you’ve gleaned from colleagues, their pharmacy, or the FDA.
2. Offer hope and reassurance.
A little can go a long way when patients are understandably frustrated and overwhelmed.
3. Model cognitive flexibility and optimism.
Let them know that you both may need to adapt to a changing situation.
4. Cast a wide net.
The patient’s pharmacist can search drug availability across sites and query restocking schedules from the supplier. Check with multiple pharmacy chains including local mom-and-pop establishments (they often have excellent customer service). If the medication is branded—and particularly if it’s the only drug in the class—consult with the manufacturer. They will often allocate a customer service rep to track stock.
5. Ration supplies.
If the delay is temporary and it is clinically appropriate, consider lowering the dose or decreasing frequency to make the available medication last longer. Consult the manufacturer’s prescribing information to find out if tablets can be split.
6. Get creative.
You’re the expert, so put that knowledge into action. Since most medications share their mechanism with several others drugs, it may be possible to switch or substitute treatments. Consult dose equivalency charts and insurer formularies PRN. If you’re really stumped, hospital pharmacists are an excellent resource.
And after all that? Prepare for the next shortage by collaborating with your staff and colleagues to set up an efficient clinical work queue to address these issues. Fortunately, it’s much easier to accept what you’ve prepared for.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.