Dr. Mina Tadrous is a scientist at Women’s College Hospital and an assistant professor at the Leslie Dan Faculty of Pharmacy at the University of Toronto.
In the Prime Minister’s 2019 mandate letter to Minister of Health Patty Hajdu, she was asked to “ensure that Canadians have access to the medicines they need by taking action with manufacturers, provinces and territories and other stakeholders to address drug shortages.” This was in response to drug shortages over the previous decade that had been getting worse.
Drug shortages are broadly defined as any time the drug supply cannot meet the demand – basically when a patient is prescribed a drug and cannot get it. These shortages can occur for a variety of reasons, ranging from product recalls to hurricanes striking major manufacturing hubs. It is a global problem – what happens in one place in the world often ripples out.
A great example of this was the July, 2018, recall by Health Canada of a blood pressure medication called valsartan from a single manufacturer. When this notice came across my desk, I thought it was similar to the many notices I had recently been receiving around potential shortages. At that point, there had been close to 1,000 drug shortages in the previous few years. And since valsartan is made by multiple manufacturers, I wasn’t worried about my patients not being able to get this commonly used drug.
A few weeks later Health Canada announced that more valsartan products were recalled – it appears that although we had many generic products, most of them sourced their active ingredient from the same factory in China. This caused a cascade of drug shortages for other blood pressure medications and affected tens of thousands of Canadians. Patients were extremely anxious about the potential harms involved in switching treatments.
While we are aware of shifting drug utilization patterns, the extent and effect on patients and health system costs in Canada remains unexplored. We have no idea how many people are affected by drug shortages in Canada.
By early 2020, no major solutions for shortages had been presented and it was clear the problem was getting worse. Then came COVID. As with toilet paper, the supply chain for prescription drugs was taxed because of surges in demand associated with panic shopping, exacerbating existing drug shortages and causing new ones. This was made worse by geopolitical actions, with many countries limiting the exportation of some drugs. My fellow researchers at the Ontario Drug Policy Research Network and I were so concerned, we launched a tool to monitor Ontario’s drug supply through the pandemic.
When the pandemic was declared in early March, we saw a spike in the demand of asthma inhalers as people worried that they would need these drugs to battle a respiratory infection. At the same time hospitals switched to using inhalers instead of nebulized mist to limit the spread of disease. While Health Canada acted quickly to meet the demand by allowing the importation of inhalers from other countries and introduced a number of other policies, we need more permanent solutions.
So how do we tackle this growing problem? First, we need more information to better understand the risks of a drug shortage and our capacity to respond. Most striking, we have little idea how much drug supply we have inside the country at any time. We need to improve our data infrastructure to track the supply and use of drugs actively and in real-time. Additionally, we need better insight into where our drugs are manufactured so that we can assess the vulnerabilities of the drug supply.
Second, we need to ensure there are redundancies in place for critical drugs. Unfortunately, no country in the world can realistically produce all drugs in a financially viable manner – there are more than 4,500 different drugs covered by public insurance and 13,000 different products. Governments can safeguard supply by developing risk categories for all drugs they pay for that would categorize the potential effect of shortages and the risk in the drug supply chain.
Imagine a risk-based tier system. Green would indicate drugs that are okay to be manufactured anywhere. Yellow would be for drugs that require production in more than one country to mitigate risk. Red would be for drugs where ensuring Canadian production capacity is key. For example, an allergy medication, although important, may not have the same urgency as an antibiotic. This will require investment in our own manufacturing capacity but will ensure we have the capacity to make critical medications and optimize our current capacity.
This problem will not vanish after the pandemic. Similar to food and personal protective equipment stockpiles, other countries such as the U.S. have begun framing drug supply as a national security issue – it’s likely time we did the same.
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