Palliative Fixes, Drug Essentiality, and Collateral Effects

Troy Trygstad, PharmD, MBA, PhD, et al, discuss palliative solutions following drug shortages, the critical infrastructure vis-à-vis essential drugs, and dealing with unexpected shortcomings.

Troy Trygstad, PharmD, MBA, PhD: I imagine that, Rich, across 9 states and 48 hospitals, you have some Band-Aid activities from time to time. Can you think of a scenario in which you were putting a finger in the dam because it was an emergency situation, and you had to run with something different?

Richard Montgomery, RPh, MBA: Yes. I think it’s when we had to start making our own morphine syringes from multidose vials. There was no way we were going to get through because taking a dose out of a multidose vial and throwing it away was heresy. So we had to ramp that up and make sure everybody was being managed properly.

Troy Trygstad, PharmD, MBA, PhD: Erin, again, as a national expert, do you envision a scenario in which there is a narrow therapeutic index of drugs that are treated differently? Do you see the same thing where it’s a critical infrastructure of certain types of drugs that get treated and supported differently because they’re the essentials and there’s no substitute? What does that look like going forward in the future?

Erin Fox, PharmD, BCPS, FASHP: That’s a great question. I think that right now, no drug is critical infrastructure because no company has to make a product, no matter how lifesaving it is; however, it is good to think about if we should have some required redundancy or maybe incentivized redundancy for some products that are critical—things like saline, lidocaine, morphine, and hydromorphone.

Troy Trygstad, PharmD, MBA, PhD: Have you ever had one of those Murphy’s Law days, when it’s 8 o’clock, drug shortage came in, and then at 9:30, 11, and 1, other shortages occur, and everything sort of falls apart all at once? Do they stack up on one another just because of randomized effects?

Richard Montgomery, RPh, MBA: If a line gets shut down at a company or a facility gets a warning letter and get shut down, or if somebody decides they’re doing preventive maintenance but doesn’t have enough product in the pipe—yes, it happens. But it’s usually only company specific.

Troy Trygstad, PharmD, MBA, PhD: It doesn’t trickle in all at once.

Richard Montgomery, RPh, MBA: Not to say that it never happens, but usually when it comes in a run like that, it’s a company that’s doing it.

Troy Trygstad, PharmD, MBA, PhD: So Erin, have you ever had a rogue wave hit the University of Utah?

Erin Fox, PharmD, BCPS, FASHP: Sure. I would say a lot of that rogue wave occurs when our informatics team is off at an off-site conference and can’t make the changes that we need to get it done.

Richard Montgomery, RPh, MBA: Or doing an upgrade in the middle of something.

Erin Fox, PharmD, BCPS, FASHP: Or doing it in the middle of an upgrade. Sometimes, though, when you think about alternatives, you might have great clinical alternatives, but you don’t have them built in your system. When Lasix injections are in short supply, it’s really easy to go to bumetanide—or some other products—but you might not have enough, and you might not have those built into your systems or on your order sets.

Troy Trygstad, PharmD, MBA, PhD: It sounds to me like an interesting aspect of your area of work. When I talk to a pharmacist, they like the rush and unpredictability.

Richard Montgomery, RPh, MBA: No.

Erin Fox, PharmD, BCPS, FASHP: No.

Richard Montgomery, RPh, MBA: Yeah. I would say if drug shortages went away tomorrow, I would not shed a tear. I think that we would have plenty of other things to keep us busy and to move forward.

Troy Trygstad, PharmD, MBA, PhD: So how did you get into it? You fell into it? You volunteered? Everybody else stepped back?

Richard Montgomery, RPh, MBA: Everybody stepped back, plus my director and I have the most vision over the whole enterprise and access to vendors. At the local level, you’re going to deal with the local representative who will then have to go to his regional person. I have straight lines to some of the product managers, from whom I can get answers fairly quickly.

Troy Trygstad, PharmD, MBA, PhD: This feels to me like you were in a room at one point and people looked around and said you’re in the best spot to do this; it’s yours.

Richard Montgomery, RPh, MBA: Yes.

Troy Trygstad, PharmD, MBA, PhD: Erin, did you want to get into this? You’re a drug-information expert, and now you’re given a deal with drug shortages. Those things are pretty tied together, right?

Erin Fox, PharmD, BCPS, FASHP: A little bit. I had the opportunity early in my career. Our drug information service was going to provide the shortage content for ASHP [American Society of Health-System Pharmacists], and someone needed to volunteer to lead the project, so I raised my hand when nobody else did. Even though I was the newest person on our team, my boss took a risk on me, and it’s been very interesting. I never intended to spend my career on shortages. I never intended to be an expert. Drug-information specialists are by definition experts in nothing, really. We know how to find the information quickly. I agree with Rich: If drug shortages went away tomorrow and I never talked to another reporter, if I was never on the news again, it would be great. I’d love that.

Troy Trygstad, PharmD, MBA, PhD: It sounds to me as if you’re the jack-of-all-trades—but a master of emergent situations.

Erin Fox, PharmD, BCPS, FASHP: Absolutely—at making a plan. We know how to make a plan for when we switch a drug if we do a therapeutic interchange or bring a new product on hand. I know the nurses and the providers. We know how to get something done with a shortage. We really have to just speed up the process.

Richard Montgomery, RPh, MBA: That’s the key point: knowing the go-to people for the specific service lines. Erin is in an academic institution, so she’s got a little bit more structure—but in the community, you’ve got to grab the key influence stakeholders, people who you know can get it done.