Critical conditions

A national drug shortage epidemic is brewing in the heartland, where Iowa hospitals are working together to find patients the treatments they need.

There are more than 200 medications on a national watch list for shortages, 60 of which are considered critical to patient health. Shortages are happening in a broad range of injectable drugs, from chemotherapy cancer treatments to anesthetics and pain medications to antibiotics.

"We've been low on drugs that we absolutely didn't want to run out of," said Pete Carrillo, director of pharmacy at Mercy Iowa City.

When Carrillo ran out of diltiazem, a heart drug a patient needed several months ago, he drove to a hospital in the Quad Cities that was willing to share its supply. "It seems that we always find what we need in the nick of time," he said.

Tom Moore, spokesman for University of Iowa Hospitals and Clinics in Iowa City, said the hospital is "experiencing the same problems that hospitals are dealing with across the nation."

The hospital treats patients with more pressing needs first in cases of severe shortages, Moore said.

According to an American Hospital Association survey of its members in June, drug shortages have begun to harm patient care. The survey revealed that 82 percent of hospitals reported delaying treatment due to a shortage and they often couldn't give the recommended treatment. Shortages caused 69 percent of hospitals to give patients a less effective treatment, the survey said.

Working together has sometimes made the difference between sink or swim for Iowa hospitals.

"We've been able to keep our heads above water," said Pat Thies, director of pharmacy at St. Luke's Hospital in Cedar Rapids, "but we're tired from treading."

St. Luke's and Mercy Medical Center in Cedar Rapids are using a long-standing joint committee to track regional shortages and to explore alternative medications.

"It's nice to take our competitive hats off and work for solutions," said Desmond Waters, the pharmacy director at Mercy Medical Center. "Patients in Cedar Rapids get the meds they need regardless of where they're getting their care."

Iowa pharmacists say they've noticed a concentration of shortages in older generic drugs, which tend to be less expensive.

An October health department report analyzed data showing the price of drugs before they went into short supply.

"Shortages have been concentrated in drugs where the volume of sales and drug prices were declining in the years preceding the shortage, suggesting that manufacturers are diverting capacity from shrinking lines of business to growing ones," the department said.

The Federal Drug Administration has cited other causes, such as quality problems, increase in demand, shortages in raw materials, limited manufacturing capacity and market concentration.

Jillian Grund, a senior studying anesthetics in University of Iowa nursing program who specializes in drug shortages, said practitioners and the government should have more say in what drugs are produced.

"The thing that is most troubling to me and other practitioners is that ... even if a drug is labeled critical, the FDA cannot force a company to produce it," said Grund.

Although drug shortages are not new, pharmacists report that in the past six months they have doubled the time they must spend stocking drugs. And pharmacists reported spending more money, saying alternative treatments can cost more.

"So far, we've absorbed the efforts," said Waters.

The hospital pharmacies reported following similar steps in dealing with shortages.

First, they look for the same product with another manufacturer or wholesaler. They look for the same drug in a different package size or different strength. And before they turn to alternatives, they will contact other Iowa hospitals to see if they have a supply to share.

If that fails they will check to see if the drug has a reasonable alternative. All Johnson and Linn county hospitals say they have only used alternatives with significant research showing its effectiveness.

However, Debra Ratchford, the pharmacist for the oncology department at Mercy Medical Center, said it's hard to calculate outcomes in the short term of cancer patients, and physicians may not be as familiar with the product.

"You don't know at the time of the treatment if it is working or not working," said Ratchford.

Dr. Wendy Woods-Swafford, pediatric oncologist at Blank Children's Hospital in Des Moines, has had to use alternative drugs in five cases, which she said is not ideal.

"You're utilizing a drug because it's proven to be the most effective," said Woods-Swafford. "We know that interfering with therapy the way it was designed will affect the outcome of kids."

President Barack Obama signed an executive order in October in response to the worsening drug crisis. It called for faster FDA approval of expansion in drug manufacturers and increased notice of drug shortages as well as giving the FDA the authority to investigate suspected price gouging.

Grund believes the FDA must go further to guarantee a supply of drugs needed by practitioners.

"It seems like a conflict of interest that companies that can profit from manufacturing or not manufacturing a certain drug also get to decide if that drug is medically necessary," said Grund.