Are Medication Shortages Widespread? How Nurses Handle This Issue
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“My worry is that if patients aren’t going to be able to obtain their medications in the commercial market and the legal market, then they’re going to turn to the streets, just like they did in the opioid crisis. Street dealers never seem to have a supply shortage issue.”Dr. Laura G. Leahy, Co-Chair of the Addictions Council of the American Psychiatric Nurses Association (APNA)
A medication shortage is when the projected demand for a certain drug exceeds its supply. Local shortages are common, taking place at a single pharmacy or hospital, and can be resolved relatively easily. National shortages are comparatively rarer, but they do exist, and they can take much longer to resolve.
According to the University of Utah Drug Information Service (UUDIS), there were 112 new drug shortages between January and September of 2022, fewer than the total for any year since 2006. However, those shortages are not resolving quickly: there have been over 200 active shortages since 2018. Further challenges with supply chain logistics and economic inflation mean the problem could worsen before it gets better.
The Food and Drug Administration (FDA) attributes the main reason for drug shortages to manufacturing quality issues, but there are many other potentially contributing factors. The UUDIS found that 27 percent of shortages in 2021 were due to broader supply and demand issues. Notably, sterile injectable drugs are more susceptible to shortages than non-injectable ones, as fewer firms are making them, and raw materials are more of a concern.
Over the last few years, shortages of psychotropic medications, specifically those for anti-anxiety and ADHD treatments, have been particularly challenging for providers and patients. The most active medication shortages since 2018 have been central nervous system (CNS) medications, which include anticonvulsants, anxiolytics, and stimulants. Patients suddenly faced with trouble filling their prescriptions for these medications can suffer several deleterious effects, and nurse practitioners (NPs) have an important role in helping patients adjust to and navigate medication shortages.
Meet the Expert: Laura G. Leahy, DNP, APRN, PMH-FNP, CARN-AP, FAANP
Dr. Laura G. Leahy is a board-certified child, adolescent, and adult psychiatric and addictions advanced practice nurse and master clinician in psychopharmacology. She is an honors graduate of Duke University (BS), the University of Pennsylvania (BSN/MSN), and Drexel University (DNP). She founded her private practice, APNSolutions, LLC, in Sewell, NJ in January 2011.
As a clinician-educator with expertise in psychopharmacology and substance use disorders, Dr. Leahy has served as psychiatric NP program director and taught psychopharmacology at the university level.
Dr. Leahy is the current co-chair of the Addictions Council of the American Psychiatric Nurses Association (APNA) and represents nursing as a lead mentor for SAMHSA’s Providers Clinical Support System. She was inducted as a fellow in the American Association of Nurse Practitioners (AANO) in 2017 and in the American Academy of Nursing (AAN) in 2020.
The Origins of the Current Adderall Shortage
In October, the FDA announced a nationwide shortage of Adderall, a mixture of amphetamine salts used to treat ADHD. Teva, an Israeli pharmaceutical company and a major manufacturer of a generic formulation of the drug, cited worker shortages causing significant ongoing delays. While other companies have continued to make amphetamine salts, their total output is not nearly enough to match the demand.
The number of Adderall prescriptions doubled between 2006 and 2016. Data suggests it’s grown even faster in the last two years, as regulations relaxed during the Covid-19 pandemic allowed the drug to be prescribed via telehealth visits. Startups advertising on TikTok and Instagram have been accused of grossly overprescribing the drug.
Since Adderall is a controlled substance, the Drug Enforcement Administration (DEA) has strict rules on how the drug is produced (and in what quantities) to deter its abuse. That makes it difficult for pharmacies to increase their supplies quickly. Teva said in November that they believed shortages would continue for at least another 30 to 60 days; the FDA believes shortages could persist into 2023.
“Every single year we go through a brief period in which there is a shortage,” Dr. Leahy says. “The DEA has to estimate how many patients might be on such substances, and then distribute the bioavailable ingredient to the manufacturers. If they estimate incorrectly, there might be a shortage.”
How Nurses Handle Medication Shortages
The sudden cessation of what’s been daily use of a powerful medication like Adderall can have significant side effects.
Psychiatric-mental health nurse practitioners (PMHNPs) help their patients navigate those side effects and endure medication shortages safely. They consider alternative dosages, as shortages tend to occur in particular dosage levels first. However, that requires getting insurance companies to approve larger quantities of lower doses when they may have guidelines against doing so. It’s not paranoia: higher quantities have a greater chance of being diverted to different end users.
“If a prescription was for 20 milligrams twice a day, for a quantity of 60 for a month’s supply, dispensing that prescription in five-milligram pills suddenly turns it into a quantity of 240,” Dr. Leahy says. “We don’t want 240 of those out on the street.”
For the current Adderall shortage, the FDA recommends switching some patients to an extended-release form of the drug. This requires careful negotiation, too. Brand-name drugs can be up to 20 percent stronger than generic ones, and insurance companies are less eager to reimburse for their higher price tag. Alternative medications are also an option, but they’re a drastic one. Other common ADHD medications work differently and have their own side effects.
“I try to exhaust my resources within the bioavailable relative equivalent, if you will, of the same agent, as opposed to switching,” Dr. Leahy says. “Because methylphenidate (Ritalin) is not the same as a dextroamphetamine amphetamine salt (Adderall), and certainly neither of those are the same as an atomoxetine (Strattera).”
Switching medications isn’t an immediate process, either. Finding the right dosage takes time, as does adjusting to the medication’s side effects. The adjustment requires more one-on-one time between the patient and provider.
The Importance of Collaboration in Handling Medication Shortages
This cuts to the core of the broader issue: there is no easy solution to medication shortages, and NPs often need to spend more time with their patients for education, counseling, and alternative therapies to help them through. NPs will also need to collaborate with other healthcare professionals in shepherding patients safely through periods of shortage.
“In terms of collaboration, it’s really prudent if you know the local pharmacies that your patients might be using,” Dr. Leahy says. “Go in and introduce yourself to the pharmacist. They’re going to know your prescribing habits, they’re going to know your patients.”
Collaboration is also important in managing side effects and overlapping conditions. Propranolol, for example, which is used off-label for anticipatory anxiety, is also an anti-hypertensive, a medication used for blood pressure; a PMHNP can work with a patient’s primary care provider or cardiologist to possibly cover two issues with one prescriptive intervention.
“Something advanced practice nurses do extremely well is collaborate with other practitioners to help minimize the number of medications our patients are taking, and the frequency with which our patients are taking them,” Dr. Leahy says. “If we can get down to a once-a-day dosing as opposed to a three-times-a-day dosing, it helps with adherence, and it helps our patient stability across the board.”
Predicting and Handling Future Medication Shortages
Predicting medication shortages isn’t impossible. As Dr. Leahy points out, the traditional beginning of the school year tends to coincide with a noticeable increase in demand pressure on medications like Adderall.
The most effective strategies an NP can employ to prepare for medication shortages are educating their patients and maintaining clear documentation regarding their prescriptive practice.
But they can’t manufacture more medications themselves. Addressing shortages themselves would require a more compassionate or at least more accurate estimate by the DEA regarding the natural ebb and flow of demand for drugs like Adderall. Consulting with NPs and other healthcare providers could help the DEA see what providers like Dr. Leahy have seen for years. There’s a lot at stake.
“My worry is that if patients aren’t going to be able to obtain their medications in the commercial market and the legal market, then they’re going to turn to the streets, just like they did in the opioid crisis,” Dr. Leahy says. “Street dealers never seem to have a supply shortage issue.”