Drug shortages have become an ongoing issue in the United States — and it’s a problem that did not happen overnight.

A perfect storm of events with many layers of growing complexity has led to drug shortages. The first blow to drug production came long before Hurricane Maria in 2017, which disrupted significant pharmaceutical production in Puerto Rico.

As early as 2014, IV fluid shortage was reported in Baxter’s Puerto Rico facility, according to a 2018 report co-authored by Duke University’s Margolis Center for Health Policy and the FDA.

The report notes that since so few factories produce essential medications, supply-and-demand challenges put healthcare organizations and patients at greater risk of negative outcomes.

Healthcare practitioners must now decide which patients receive drugs and which ones can go without, according to a 2019 JAMA Internal Medicine report.

Hoarding and drug rationing have become a common practice, based on a 2017 national survey sent to members of the American Society of Health System Pharmacists, which reports 226 drugs in short supply. This includes yellow fever vaccines and preventive drugs for cardiac ischemic complications, according to a University of Chicago Medicine report.

Addressing drug shortages

We shared questions about this issue with David K. Tan, MD, EMT-T, FAAEM, FAEMS, president of the National Association of EMS Physicians (NAEMSP). Skilled in patient care and collaborating with agencies capable of solving the drug shortage problem, Tan provided great insight.

NAEMSP works with federal agencies such as the Department of Health & Human Services (HHS), Centers for Medicare & Medicaid Services and the Center for Medicare & Medicaid Innovation to solve issues related to drug shortages.

Recently, NAEMSP has developed a top 10 critical emergency medications list that no provider should ever have to do without.

“Legislatively, we want to empower the secretary of HHS to create legislation and a task force to make sure emergency drugs are always in supply,” Tan said. “We are in the process of refining the list, but this is what we have so far.”

According to Tan, the current top 10 critical emergency medications include:

  1. Epinephrine
  2. Crystalloid solutions (normal saline; lactated Ringer’s)
  3. Midazolam
  4. Nitroglycerin
  5. Albuterol
  6. Lidocaine
  7. Ketamine
  8. Fentanyl
  9. Calcium
  10. Dextrose

Q: What are the biggest risks related to drug shortages?

“The single biggest risk first responders face in light of the drug shortage crisis is the grave potential for medication errors,” Tan said. “As drug X becomes unavailable and they substitute it for drug Y, the obvious risk is that crew members are now faced with drawing up a certain amount of medication that they are less accustomed to for a particular emergency, for any given emergency situation.”

Due to this, Tan reminds first responders to keep dosage and concentration levels in mind, based on medication availability. EMS personnel could have become accustomed to using certain concentrations for certain emergencies, based on their usual protocols.

“Instead of using 1 milligram per milliliter, it may be 10 milligrams per milliliter that is available,” he said

According to Tan, “in the stress of the moment” is when medical mistakes can happen. Such as when first responders are more accustomed to working with 1 milliliter vs. 10 milliliters, or vice versa.

Q: What do you suggest to alleviate the variance in drug concentration availability?

“Every time I issue a new directive, either when we cannot get a drug, or when it’s not available in a specific concentration, either scenario creates potential for medical error,” Tan said. “So, we educate the crews and put brightly colored labels on a bag or box to draw attention that something is different.

Q: What can first responders do to conserve drug supplies?

“We don’t want to suggest that EMS ration medication. They should be good stewards of all medications, not just essential emergency medications,” he said.

“EMS personnel may help conserve medications by knowing their standing orders and protocols to know when certain medications are indicated,” Tan said. “If a paramedic feels a patient needs a drug, they should follow protocol.”

Shortages exist for other supplies too

drug shortagesTim Nowak, AAS, BS, NRP, CCEMTP, SPO, MPO, CADS, is founder and CEO of Emergency Medical Solutions, LLC, an EMS training and consulting company in Colorado Springs, Colo. He’s also an active EMS professional.

Besides drug shortages, Nowak said first responders also deal with saline solution shortages.

“We encourage EMS personnel to be more cautious with the use of saline, which helps lessen the effect of the shortage. Instead, you could use a small pre-package flush, like a 10-milliliter flush. If they did not need a liter of fluid, it’s an alternative to keep the IV open.”

In terms of substituting different drugs, Nowak said fentanyl often comes in short supply.
“We’ve had to switch to morphine, ketamine, or dilaudid to reduce pain,” he said.

When substituting drugs, it’s important first responders understand how different drugs could affect patients.
Fentanyl acts quicker but doesn’t last as long, whereas morphine takes longer to kick in, but seems to make some patients more nauseous,” Nowak said.

He attributes the fentanyl shortage to the national opioid crisis, noting reduced drug production in response to the epidemic and overdose deaths.

“Reduction of fentanyl should have been on the pill form,” Nowak said, not on the formula used by EMS and hospitals. “The drug as a whole got penalized. The likelihood of getting addicted is low when given for a broken ankle. People get addicted when they are prescribed pills.”

When treating a pain-ridden patient, Nowak suggests considering all treatment options. He said it’s dangerous to automatically equate pain management with opioids.

“Use your medications appropriately,” he said. “If someone has pain, it doesn’t always need a pharmacologic. It may be OK to give an NSAID. Appropriately manage your patient and if it means an opioid, OK. But Tylenol is OK, too,” Nowak said.

Take our course on Capnography, Oxygenation & Opioids to learn more about this topic.