By Stephen Spotswood
WASHINGTON — As government agencies struggle with an ever-increasing number of drug shortages on a national level, pharmacists at VA hospitals deal with the problem — usually very successfully — on a day-to-day basis.
Terrill Washington, PharmD, is the chief of pharmacy services at the Washington DC VA Medical Center (DCVAMC), where he has worked for 22 years and is the person ultimately responsible for making sure the hospital’s 50,000 veteran patients have access to all of the pharmaceuticals they need.
“There are a number of processes in place for when a shortage happens,” Washington explained. “And we normally get multiple notifications when there is an outage or there are back orders.”
If there’s a shortage of a drug, Washington will receive word through the hospital’s procurement process from their prime vendor or the drug wholesaler. They also are notified by the FDA and by VA Pharmacy Benefits Management.
Washington said he also finds the website of the American Society of Health-System Pharmacists very useful. The site gives an up-to-date tally of shortages and what the alternatives are, as well as when the drug is expected to be available again.
“Once we identify the problem, depending on the nature of the shortage, we see what we have in stock,” Washington said.
Sometimes a shortage is isolated to a particular strength of medication. While supplies of the 50 mg version of a drug may be low, there might be 25 mg versions or 100 mg versions which are easily accessible.
“We’ll determine if there’s another strength of the drug that’s available. We can make changes in the computer to use less of the higher strength medication or to cut the higher strength medication,” Washington said.
Pharmacy Workload Increases
Even shortages requiring simple fixes increase the pharmacy’s workload, however. With changes in strength, for example, patients nevertheless must be educated to take two pills instead of one.
Sometimes the shortage is not so easy to fix.
“If there’s something that’s totally not available in any strength, we notify the specialists in the area the drug is used and tell them it’s not available and for how long, if we know,” Washington said. “And then we would look for a reasonable alternative for our patients.”
Washington described one workaround that VA pharmacies across the country had to deal with — a shortage that, eventually, was handled successfully.
“About a year or so ago, we had a shortage on a product that we would use for respiratory complications like asthma or COPD (chronic obstructive pulmonary disease). It was a combination inhaler product with a bronchodilator component and a steroid component. This was a nationwide shortage,” Washington recounted. “We were able to identify a similar product. We got guidance from our national formulary committee and were able to make the switch over for our patients and provide the same level of effectiveness.”
When the switch occurred, the DCVAMC sent notices out to patients to ensure no confusions. While the process might have appeared smooth to patients, it was strenuous due to the additional workload involved.
“It was quite arduous, because we had so many patients using the drug,” who need to be educated and monitored, Washington said.
The DCVAMC also frequently partners with neighboring hospitals and other VA facilities to ensure the facility has the drugs it needs.
“If it’s something they have available, we work together quite closely,” Washington said.
To date, Washington has been able to work around all of the shortages DCVAMC has faced.
“We’ve been really fortunate, because we’ve been able to meet the needs of our patients. We haven’t had to cancel any surgeries or anything of that nature,” he said. “But it does cause some heartburn, to say the least.”
That stress is not expected to subside anytime soon, as shortages are occurring with greater frequency and in greater numbers.
“Over the last two years, we’ve been experiencing some level of drug shortage or outage almost every day,” Washington said. “The problem has increased steadily. We’ve always had shortages or manufacturer delays — but not to the point we’re seeing right now. It’s almost every day that we get a notification about medication shortages.”
It is a much more common occurrence now for manufacturers to tell the hospital that they can provide only so much of a particular medication, based on reduced allocation. “We may put in an order and not know how much we’re going to get,” Washington said.
Currently, DCVAMC has between 150 and 200 medications on back order.
Still, Washington said he is confident that, by teaming with physicians and nurses, he and his pharmacy staff can handle most shortages that come their way. “We develop a strategy, determine how long the shortage will be for, see what its status is and then make a determination to see what needs to be done.”