Patients regularly face medicine shortages as New Zealand struggles to secure supply
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At any given time, New Zealand is running low on someone's medicine. Ben Heather reports on why you can't always get what the doctor ordered.
Coming into Christmas, Simon Rillstone found himself in the uncomfortable position of turning away patients looking for their medicine.
Dexamfetamine, a registered Government-funded drug for treating ADHD, was running out everywhere. The Wellington pharmacist had only 100 pills left and no idea when more would be available.
"It really created some anxiety among our patients. For the month we had 100 tablets that we had to share between five patients, we just had to give them drib and drabs. We were turning scripts away."
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Rillstone and other pharmacists say medicine shortages are getting worse and more frequent, with one drug or another being rationed to prevent panic buying constantly.
"There have alway been shortages, but they are starting to happen more often and occurring with drugs that affect more patients," Lee Hohaia, Pharmacy Guild chief executive, says.
The guild lists 10 medicines currently in short supply, treating everything from acne to heart disease.
A shortage of Metoprolol, a blood pressure and angina drug that is among the most prescribed medicines in the country, is forcing tens of thousands of patients to cut their three months supply to a monthly prescription.
In January, the nation completely ran out of the BCG vaccination, which is used to immunise newborns at risk of tuberculosis. Th
is is not the first time New Zealand has run out of BCG, with the entire global supply recalled in 2012, amid safety concerns.
Dr Craig Thornley,Wellingto Regional Public Health medical officer of health, says only a small group of children are affected but it is still concerning.
"It does create issues for us, because you are meant to give BCG when they are newborn."
Some blame shortages on the Pharmac model that often relies on just the one supplier.
Hohaia says the Government-owned drug buying agency does its best, but when that one supplier can't deliver, it leaves the country scrambling for an alternative.
"Pharmac has all these undertakings and agreements with manufacturers, but that doesn't stop the shortages."
But New Zealand is not alone in increasingly rationing drugs, with fewer drug manufacturers making fewer drugs already forcing health services in Europe and the United States to make tough decisions about who gets what.
The US Federal Drug Administration currently lists 66 medicines that are in short supply. While this number has dropped, there are still regular shortages in everything from cancer drugs to painkillers.
The FDA says quality and manufacturing issues are to blame for most of shortages. In other words, FDA inspectors find a factory in the US is not quite up to standard, shut it down, and suddenly a retiree in Dunedin has to switch her heart pills, if there is another brand available.
Other drugs, sometimes important drugs, are scrapped because they are deemed not profitable enough to keep manufacturing.
Pharmac is unable to say how many times New Zealand had run short, or run out, of medicine in the past year but operations director Sarah Fitt agrees there was nearly always a shortage in something.
"It is pretty ongoing, really."
She says there is a global trend towards drug shortages and, as a 0.1 per cent sliver of the market in a far corner of the world, New Zealand faces an uphill battle from the start to secure supply when stocks were running low.
"If they are rationing stock in America we are not going to be very high on the priority list."
However, she disputes pharmacists' claims that the Pharmac model was to blame for shortages. The agency's tight contracts with manufacturers are actually helping the country avoid some of the life-and-death rationing decisions being made the US and Europe, she says.
No district health boards, which run our public hospitals, contacted for this story reported the sort of shortages that leave US and European doctors facing ethical dilemma such as, "which child gets the life-saving drugs and which one misses out?"
Pharmac offers drug companies a virtual monopoly in New Zealand, selling the drugs to patients and hospitals at a subsidised price that shuts competitors out of the market.
Most medicines consumed in New Zealand come under one of these agreements, with patients trading choice for cheaper prices.
If stocks in a drug do run low, the manufacturers are contractually obliged to find an alternative and foot the bill for any extra costs.
"They get a guaranteed market, but they have to deliver," Fitt says.
And while stock shortages were ongoing an alternative is usually found before patients miss out.
"It's very rare that we have to get patients to change their medicine."
Pharmacists spoken to for this story disagreed with this assessment, claiming juggling patients' prescriptions around what was available is becoming frustratingly routine.
Several suggested that it is precisely the cheapness of the drugs that is responsible for the shortages.
"When you're the lowest bidder on a medicine and there is a supply issue they you are going to drop down the pecking order," Palmerston North pharmacist Anthony Roberts says.
He also questions whether shortages, which often arise from quality and manufacturing defects, are a function of the drugs we choose.
"If you having all these quality issues then perhaps you need to look at the quality of the medicine you are getting."
Roberts says he often feels "like an idiot" when patients asked why their prescription had changed and he often had no answer.
"Often we don't know what's going on either."
Even if a medicine had not run out completely, patients are unsettled when asked to shorten their prescription, change the combination of doses, or switch to another brand for reasons that had nothing to do with their health, he says.
The shortage of dexamfetamine is particularly tough as many patients are horrified at the prospect of running out.
"These people need dexamfetamine to have a functional life."
Hohaia says getting patients to take their medicine as directed was hard enough, switching dose and brands in response to supply shortages just added to the confusion and potential for mistakes.
"It undermines the patients' confidence in their medicine."
And if nothing else, Wellington pharmacist Ann Privett says shortages soak up time that should be spent checking up patients.
"The conversation becomes about how they are going to get their medicine, not about their health."
Medicine shortages in New Zealand
* Metoprolol - treats angina and high blood pressure (since December)
* Sumatriptan - for treating migraines (since December)
* Potassium chloride - can be used for low potassium (since November)
* Cefaclor - an antibiotic used for treating bacterial infections (since November)
* Sertraline - treats depression and many other mental disorders (since September)
* Dexamfetamine - treats attention-deficit hyperactivity disorder (ADHD) (since November)
* Isotretinoin - treats acne
* HealthE - cream for treating skin inflammation
* Formoterol fumarate – used for asthma prevention
* Midazolam - a sedative
Source: Pharmacy Guild, note some shortages are only for particular doses.
HOW NEW ZEALAND GETS ITS MEDICINE
The Government-owned Pharmac decides which medicines, and medical devices, will be subsidised and ultimately make up the bulk of what is stocked in pharmacies, medical clinics and hospitals around the country.
To secure the medicine we need, Pharmac will often enter into contracts with manufacturers, in which Pharmac agrees to subsidise the medicine - and often provide a New Zealand monopoly - in return for continuity of supply and cheap prices.
These medicines, there are roughly 3500 of them, are then available for pharmacists and hospitals at the subsidised rate.
When a particular medicine runs low, Pharmac can require a manufacturer to find an alternative source.
If they can't, Pharmac will look another manufacturer and, in urgent cases, even import a substitute medicine that is unregistered in New Zealand.
Often Pharmac asks pharmacies to ration medicine in short supply to prevent panic buying.
Many Pharmac contracts require the manufacturer to meet any cost of sourcing alternatives.