Drug supply chain could still be interrupted because of COVID-19

New Brunswick pharmacists say there are still potential drug shortages on the horizon because of the global COVID-19 pandemic.

That's why they're asking New Brunswickers to voluntarily limit themselves to a 30-day supply rather than the usual 90 days, says Sam Lanctin, the registrar of the New Brunswick College of Pharmacists.

As a result of production problems with some of the world's largest pharmaceutical manufacturers, "we could still see disruptions for up to three to six months," said Lanctin.

"It hasn't fully trickled through yet. So not only do we have challenges with our local Canadian supply what's happening in India and China is creating an extra layer of challenges."

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"So I think a voluntary limit might be a good approach, if people are willing and able to do that."

But, he adds,it won't be as effective as an across-the-board limit.

In March, the province implemented a 30-day cap on prescription refills to help address concerns over shortages and people stockpiling drugs.

It lifted that directive on April 23 much to the dismay of the college, which accused the government of ignoring the advice and concerns of pharmacists.

Lanctin said Canada already has "a fragile drug supply chain" and the pandemic has created even more challenges.

The federal government keeps track of the number of drug shortages nationwide on their Drug Shortages Canada website and that number has been hovering around 2,000 "actual" and "anticipated" shortages.

Lanctin said pharmacists in New Brunswick have been seeing shortages of diabetes drugs, asthma inhalers and blood pressure and heart medications and worries that things could get worse in the coming months.

But rationing all medications to prevent shortages of specific drugs "is akin to using a sledgehammer to deal with a mosquito," says Dr. Milton Tenenbein, a professor in the department of pharmacology and therapeutics at the University of Manitoba.

Tenenbein, an academic physician, said the system has been dealing with drug shortages for years. He said governments have "sophisticated mechanisms for identifying these shortages ahead of time."

"They can forecast it and take mitigation strategies for that particular drug."

He said there is no need to restrict all drugs.

"We can identify specific shortages well in advance, so why would we ration every single drug because one might get short?"

In an editorial printed in his local newspaper, Tenenbein said the original decision to limit refills was "self-emulating and disingenuous."

"It is cartel-like behaviour. In principle it is no different than well-documented incidents of industry collusion on the price of bread or the price of gasoline. What makes this more odious is that it is foisted upon us under the mirage of altruism prevention of hoarding and shortages."

If pharmacists really wanted to be altruistic, he says they should forgo their extra dispensing fees.

Tenenbein doesn't buy the argument from pharmacists that their costs also triple.

He said their fixed costs remain relatively stable rent, heat, lights, licensing fees, insurance and certainly don't triple because customers are refilling their prescriptions three times as often.

Rationing all medications to prevent shortages of specific drugs is akin to using a sledgehammer to deal with a mosquito.- Dr. Milton Tenenbein

"If they were a profitable business and certainly they are they were making money when they had one prescription fee for 90 pills, so why should they now have three? They don't have triple the costs of rent, insurance, lights, licensing that's all paid for."

While he acknowledges the extra costs of Plexiglasand other mitigation strategies, he points out that grocery stores and gas stations also have those added costs and haven't tripled their fees.

"The cost for deliveringthe second and third [refills]is not the same as the first," said Tenenbein.

He also doesn't buy the hoarding argument.

"Hoarding means you're acquiring more of a commodity than you need or are entitled to, but prescriptions naturally cap the amount you can get, so there can't be hoarding. You just get what you're entitled to. So the hoarding was essentially a non-issue."

Are prescriptions self-regulating?

While Tenenbein believes doctors' prescriptions are a built-in barrier to hoarding, an assistant professor in the department of pharmacy at the University of Toronto doesn't agree.

"Prescriptions are often written a year in advance and they're not written with shortages in mind," said Mina Tadrous.

Plus, Canada doesn't do a very good job at monitoring the drug supply line, said Tadrous, whose research focuses on evaluating drug policies and post-marketing surveillance of medications.

"We don't have any deep understanding of the drug supply across this country ... It's a national issue that we should be all teaming up and trying to do together."

Tadrous said the lack of understanding extends beyond supplies in Canada. He said we also don't keep track of things further up the supply chain.

"It's important to realize that a drug supply isn't just what's on the pharmacy shelves behind that, there's a wholesaler that has a warehouse filled with drugs."

Then comes the distributor and the manufacturer, who has to source all of the components that are used to make the drug, he explained.

"So if anything in that chain starts to deplete, then you slowly start to see it, but when a shortage happens or say something happens at a factory or if the demand suddenly goes out, it doesn't happen instantly."

It could take weeks or months "before you're not able to give a patient a drug that they need."

Tadrous says "we don't actually have a good idea of how much of a drug is in the pipeline."

It's also not clear how far in advance shortages can be predicted.

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He says it really depends on the reason for the shortage. For example, if people start filling their prescriptions for inhalers in an effort to stockpile, the spike in demand is very quickly felt in Canada. But a quick spike in sales like that can usually be sorted out further up the supply chain.

Tadrous says there may be shortages of drugs coming out of China, which is one of the world's largest manufacturers of pharmaceuticals, as a result of that country's effort to combat COVID-19.

He said it could be "a few months before things started to trickle down into Canada."

And of course, people's buying habits could also have an effect on supplies.

He said the toilet paper hoarding at the beginning of the pandemic illustrates that even if government officials had a good handle on the supply chain, there's no accounting for panic buying.

"So you can plan and model all the demand you want, but the moment that people start shifting their actions, you have to quicklyand nimbly be able to respond."

He thinks Canada should do a better job keeping track of prescription drugs.

"We need to be able to monitor how much is coming into the country and then compare that to the demand," said Tadrous.

He said itwould be a challenging undertaking at the best of times, and virtually impossiblein the midst of a pandemic.

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That's why it's easier to ask people to limit their refills to 30 days, said Tadrous.

But he also understands who is impacted the most older and sicker patients who are on a number of medications.

"I completely understand that that's not fair. And so I think that there needs to be a balance," said Tadrous.

He said it's important to "ensure that the financial burden is not placed on the patients who are doing their part by splitting up their pills. They're taking a bit of a risk ... that they have enough medications and so I don't think it's fair to put that burden on them, if they're doing their part."

Health Canada

Health Canada did not have an expert available for comment, explained spokesperson Anna Maddison, a senior media relations advisor, on Monday.

The department's website says it is "aware that there may be supply disruptions related to COVID-19 and are monitoring the situation closely.

"Companies that market prescription drugs for human use in Canada must report anticipated or actual drug shortages on Drug Shortages Canada and we have contacted companies to remind them of this requirement," Maddison wrote in an emailed response.

"We will continue to use all available tools to help manage critical national shortages when they happen, and work with partners so that Canadians have access to the medications they need."

New Brunswick's decision

When the government first lifted the 30-day ban, the New Brunswick College of Pharmacists was very critical of the decision.

On Tuesday, Lanctin said New Brunswickers have been receptive to a 30-day cap, even if it increases their costs.

"There are a lot of New Brunswickers that are responding positively once they really understand what the issue is," he said.

The New Brunswick Pharmacists' Association was asked specifically about waiving or reducing fees for people who voluntarily limitthemselves to a 30-day supply, but an emailed response from Janet MacDonnell, the group's interim executive director, didn't address the issue.

"Pharmacists have a responsibility to ensure medications are safe and appropriate every time they dispense," she wrote.

"There are costs incurred and additional work required by pharmacists and their teams to dispense all prescriptions, new and refills. That professional service and supplies are covered by the dispensing fee. Pharmacists and their staff must be paid for the work they perform so they can continue to provide service to the citizens of New Brunswick."