This editorial by Dr. Charles S. Shaver was published in The Hamilton Spectator on August 11, 2019. Dr. Shaver i a practicing physician in Ottawa. He is a graduate of Princeton University and Johns Hopkins School of Medicine. Dr. Shaver is also past chair of the section on general internal medicine of the Ontario Medical Association.
Drug shortages are putting patients at risk in Canada
"Of the roughly 7,000 prescription drug products available in Canada, more than 1,800 are shorted." — Kelly Grindrod, University of Waterloo (Hamilton Spectator, Aug 7)
The possible consequences of Canadian drug shortages are just beginning to be appreciated.
In recent months, local pharmacies have sent notifications to my office (often several per day) that certain drugs were suddenly on "back-order" for unknown reasons and for an unknown period of time.
These included Adalat and Olmetec and their generics. Now nifedipine (Adalat) was patented in 1967 and approved for use in the United States in 1981. It is a calcium-blocker used for hypertension, angina pectoris, and even Raynaud's disease. Olmesartan (Olmetec) is an ARB (angiotensin-receptor blocker) used for hypertension and congestive heart failure. It was patented in 1991 and has been in widespread use since 2002.
So why are these drugs, as well as dozens of others, now temporarily unavailable? Is it increased global demand, a sudden lack of active ingredients, or vague manufacturing problems? No one can provide an answer.
The Canadian Pharmaceutical Survey, conducted from Nov. 14 to Dec. 3, 2018, revealed that in the past three to four years, according to respondents, drug shortages had greatly increased by 79 per cent; and somewhat increased by 16 per cent.
In 45 per cent of cases, this required definite action multiple times per day. Some 32 per cent of pharmacists never received any advance notice of these shortages, and 43 per cent did infrequently. One in four adults in Canada has been personally affected in the past three years, or knows someone who has. The situation is worsening. Three drugs used in cancer therapy — vinorelbine, leucovorin, and etoposide — are in short supply.
We recognize that name brand and generics of the same drug have different efficacies and potential side effects. Switching patients to a substitute, similar drug, in the same family is even more likely to lead to unpredictable outcomes. Therefore, most physicians, would likely request that a patient return to the office within a month or so in order to ascertain whether the change to the new drug has caused any adverse effects or loss of efficacy. Obviously, these extra visits cost our health system additional dollars.
A possible unforeseen consequence of these shortages is on "snowbirds" and others planning to leave Canada on vacation. Travel insurance forms are complicated. As Dr. John D. Allingham recently wrote: "It is only when clients make claims, that they know that they have been covered." Most companies will disallow a claim if they deem persons to be unstable. This can be when the dose of a medication is changed; it could certainly occur when patients were forced to switch to a "close-cousin" substitute drug because of the back-order of a medication that they had been taking for years.
Our already frail drug supply system now faces an additional threat. Busloads of diabetics are obtaining their insulin in Canada at 10 per cent of the cost in the United States. Already ten states — including Florida (the third most populous state), Vermont, and Colorado — are passing legislation legalizing the importation of Canadian drugs. This has the blessing of President Donald Trump. It would mainly affect name-brand drugs.
However, generics may be affected if Canada's Dr. Eric Hoskins' national pharmacare plan is implemented. At present, most generics are more expensive in Canada than in the United States. However, if we were to consolidate existing private and public drug plans so as to increase "bulk purchasing" and negotiate Canadian prices downward, there is no guarantee that a sufficient quantity of drugs would remain for Canadians.
Certainly, Federal Health Minister Ginette Petitpas Taylor should express our strongest reservations about helping Americans solve their problem by permitting them free access to our very limited drug supply. A coalition of 15 groups of hospitals, health professionals, and patients has already conveyed this message to Ottawa. Innovative Medicines Canada warned, "Reliance on reactive measures after shortages occur may pose a risk to Canadian patients."
Future legislation may be needed to restrict the amount of Canadian pharmaceuticals being exported. Perhaps those purchasing more than a week or so of medications, such as insulin, should be required to show ID that they are residents of Canada.
The next Canadian prime minister must also firmly state to Donald Trump that even a trickle of drugs from this country will be totally cut off, if he threatens to reimpose tariffs on Canadian steel, aluminum, or other goods.