Unexpected Benefits and Personal Responses to Drug Shortages

Doctors discuss the positives of drug shortages, including unexpectedly beneficial treatment regimens, and provide personal instances of initial responses to shortages.

Troy Trygstad, PharmD, MBA, PhD: Can you think of an example where there’s a positive outcome from a drug shortage?

Richard Montgomery, RPh, MBA: We had a couple of unintended consequences with IV intravenous hydration. We couldn’t get saline or lactated ringers, so we used Gatorade to hydrate the patients. For multimodal pain relief, we couldn’t get narcotics, so now we started using muscle relaxants and steroidal anti-inflammatories. These alternatives actually had good outcomes.

Erin Fox, PharmD, BCPS, FASHP: A shortage is always a great opportunity to make sure you’re using a product in the most evidence-based way. Sometimes you find things that aren’t being used correctly, or maybe it’s something like giving diphenhydramine before blood infusion. There’s no evidence that it actually helps, so you stop and save the diphenhydramine for allergic reactions.

Troy Trygstad, PharmD, MBA, PhD: And a month later with your staff, you’d say, “Look, we survived.”

Erin Fox, PharmD, BCPS, FASHP: Sure. And it is sometimes a way to move towards a better level of evidence.

Troy Trygstad, PharmD, MBA, PhD: So there are some opportunities to change the standard of practice.

Erin Fox, PharmD, BCPS, FASHP: Or you’re forced to.

Troy Trygstad, PharmD, MBA, PhD: You don’t have to be a bad guy. You’re just saying, 'Well, we’re going to make this change,' and off we go. Let’s say you get back to work this afternoon, Erin, and all of a sudden, you hear that there’s going to be a drug shortage. What’s the first thing that happens on your team?

Erin Fox, PharmD, BCPS, FASHP: The first thing that happens is we gather our team and figure out how much of the product we have on hand, where it is, where we use it most frequently, and who our key stakeholders are—whether it’s nursing, providers, or pharmacists. We make a very quick plan.

Troy Trygstad, PharmD, MBA, PhD: Would the plan possibly include an alternative?

Erin Fox, PharmD, BCPS, FASHP: It’s going to depend on the shortage. I remember when our sodium bicarbonate was recalled, and we went from being okay on supplies to having almost none. Our first priority was patients on high-dose methotrexate and how we continue those regimens. We sequestered a small amount for those patients, and then went and talked to our critical care, transplant, and cardiologist folks about who may need the bicarbonate. It really does vary on the shortage; it can be stressful but rewarding to work as a team to make a good plan and keep patients safe.

Troy Trygstad, PharmD, MBA, PhD: At Adventist, who’s responsible for drug shortages?

Richard Montgomery, RPh, MBA: The director of pharmacy. And then it goes to my boss, the director of the system, who says, 'Hey, what are you guys doing?' Because you have the 1 squeaky-wheel physician that just doesn’t get it, or is just uninformed and can’t understand why he doesn’t have the drug he’s had for the past 20 years.

Troy Trygstad, PharmD, MBA, PhD: Well, in defense of that physician, if I go to a steakhouse and order a steak and they say, 'Well, we’re out of beef tonight,' that’s going to stimulate some frustration, right? So how do you communicate better? Can you give us an example of a touchy situation where somebody says, 'Hey, why can’t you provide this to me? You’re responsible for this?' What’s that like?

Richard Montgomery, RPh, MBA: We ran into that with oncologists a couple years ago. We had a drug shortage of Doxil [doxorubicin], which was used for patients with breast cancer. They were writing orders for it and were like, 'Hey, we have 2 left across our whole system. What do you want us to do in this type of situation?' That was 1 of the responses I got. It’s situational, and some people are more than cooperative, and understand what’s going on and want to help you. Then there’s those who don’t care, and don’t understand—that’s when we have problems.

Troy Trygstad, PharmD, MBA, PhD: Erin, can you think of a time when you had a touchy situation? You had a vocal employee or a patient, or something in the news where you had to be the engineer, the pharmacist, the drug information expert, but also the public relations expert for the team?

Erin Fox, PharmD, BCPS, FASHP: Sure. We often have to reassure folks. When they hear about a shortage, they automatically think they shouldn’t go to your hospital. It’s a concern.

Troy Trygstad, PharmD, MBA, PhD: Sure.

Erin Fox, PharmD, BCPS, FASHP: I speak a lot about the work we do behind the scenes to make sure patients are being treated effectively. We’ve had sticky situations with some of these more recent shortages of local anesthetics and narcotics. People think they wouldn’t receive good pain control—we try to really reassure our patients.