Position Statement on Prescription Drug Shortages in Canada
The escalation in shortages of prescription drugs in the past few years and the ongoing disruptions to supply experienced in Canada and globally are matters of grave concern to the Canadian Medical Association (CMA) and its members. Drug shortages are having a detrimental impact on the delivery of patient care and treatment and the availability of health care services across the country.
CMA has advocated for a thorough examination of the drug supply system to identify points where we in Canada can influence supply problems. Solutions will have to involve the various players in the drug supply chain, from manufacturers through to healthcare providers and levels of government.
Drug shortages are not a problem confined to Canada. In the United States the number of drug shortages from 2006 to 2010 grew by more than 200 per cent.1 In 2011, 251 shortages were reported to the FDA. 2 Canada has not had an accurate record of the number of drugs in short supply over past years but in April 2013 253 drugs were listed on the industry sponsored Canadian Drug Shortage Website.3
Factors that influence the occurrence of a drug shortage can occur at any stage of the drug supply chain and any disruptions can ripple through the system.
Figure 1 Drug supply chain in Canada4 [See PDF]
There are many causes that can lead to a drug shortage. Disruptions in the supply of an active or key ingredient contribute to drug shortages and this is exacerbated when the active ingredient is produced by a single raw material supplier. If the supplier is unable to meet demand than all manufacturers relying on that supply become vulnerable to disruptions. The sourcing of raw materials from outside of North America, primarily China and India, whose safety and regulatory standards may not be stringently enforced can result in regulatory authorities closing down facilities thereby impacting supply of active ingredients or necessitating a lengthy search for a new supplier.
Additional manufacturing issues contributing to shortages can include complex manufacturing processes like those used to make sterile injectables, changes in product formulations, problems in the production process or regulatory enforcement of good manufacturing processes, limited capacity, an unexpected surge in demand, regulatory delays in product approvals and business decisions. 5
Shortages may also be due to factors outside the manufacturers control such as various interruptions in the normal delivery of medicines through the pharmacy supply chain and distribution network6. Just in time inventory management practices can lead to a reduction of available drug inventories. In addition procurement strategies that lead to sole source contracts for bulk purchases has been identified as the single most avoidable cause of drug shortages. 7
Disruptions in the supply of medications have the potential to impact patient care, patient health and the efficiency of the overall health care system.
Among the impacts of drug shortages are:
- delays in access to needed medication;
- delays or disruptions to clinical treatment;
- delayed or cancelled surgeries,
- loss of therapeutic effectiveness when an appropriate alternate therapy is not available;
- increased risk of side effects;
- increased non-compliance when changes in medication make it confusing and harder to comply with a new medication regime particularly for those on long term therapy.8
Any and all of these situations can result in a disruption to clinical stability and deterioration, particularly in patients with complex problems. Drug substitution can also result in unintended consequences. In 2010 an Institute of Safe Medication Practices survey of 1800 US health professionals revealed that in one year drug shortages caused over 1000 incidents involving negative side effects or medical errors. 9 In many instances shortages can lead to an increase in the use of the health care system, be it in physician or emergency room visits or treatments.
A CMA survey of physicians in September 2012 found that 66% of respondents indicated that drug shortages have gotten worse since 2010 and 64% stated that the shortages have had consequences for their patients or practice. Similarly, the results of the 2012 Canadian Pharmacists Association (CPhA) survey of pharmacists found that over 91% of pharmacists indicated that patients had been inconvenienced by shortages and 51% indicated that patients' care had been compromised.10
Drug shortages also have an impact on the practices of physicians and pharmacists. Sixty seven percent of the respondents to the CMA survey stated that drug shortages do have an impact on their practice most notably by increasing time spent on research or consultation with health professional colleagues to source alternative medicine, increase in length of patient visits due to medication substitution concerns, and increase in time spent on forms such as insurance claims. Seventy six percent of hospital pharmacists and 76 percent of community pharmacists also report an impact on their workload and practice.11
Since as early as 2005, the CMA has supported a comprehensive strategy and adequately resourced system for monitoring domestic drug supply. In response to a Health Canada consultation in October 2005 on a report entitled "Developing a Drug Supply Network" CMA recommended that Canada needs such a system to identify shortages and respond quickly to remedy them, and to ensure that policy and regulatory decisions are founded on accurate and reliable knowledge.
In March 2011 this position was reinforced in communication with the Government of Canada stating that Canada needs a sustainable, adequately resourced process to identify shortages, rapidly communicate them to health professionals and respond quickly to resolve them.
1. The Canadian Medical Association supports an investigation into the underlying causes of prescription drug shortages in Canada.
2. The Canadian Medical Association recommends the creation of a monitoring unit to track drug production disruptions in Canada and abroad.
The communication of information to health professionals once a shortage occurs, or is expected, is critical to their ability to make patient centered decisions and provide continuity of optimum care. CMA has participated on a Multi Stakeholder Working Group on Drug Shortages that has had the pharmaceutical industry and health professional organizations working together to establish a national drug shortage reporting website. CMA provided key input on the needs of needs of physicians to ensure that information required to provide optimum care when managing a drug shortage such as product information including name, manufacturer, formulation, strength, package size, expected duration of shortage, notification that shortage is resolved as well as automatic alerts and search and sort functionality was included on the website.
The establishment of the Canadian drug shortage website marks an improvement in the management of drug shortages but significant issues remain. Of great concern are drugs that are 'single sourced'. When there are shortages of single sourced medications there are no clear substitutes. Related to this are the unintended consequences of sole sourcing products from one manufacturer to secure a lower price. This introduces a vulnerability to the marketplace if the sole supplier experiences production disruptions. The 2011 production stoppage at a Sandoz facility in Quebec due to regulatory compliance issues and a subsequent fire in the plant resulted in a scramble to find alternate sources of many essential medications. The CMA supports the development of strategies at the provincial/territorial and federal level to discourage single source purchasing decisions. The inclusion of incentives or penalties for guaranteed supplies, or a contingency plan for supply disruptions should be inserted into purchase contracts. We must be extremely careful not to exacerbate supply problems while trying to address cost issues.
3. The Canadian Medical Association calls for a review of the supply processes in place for drugs and equipment considered essential for medical practice.
4. The Canadian Medical Association supports strategies to discourage single-source purchasing decisions for prescription medications.
Advance notice, by manufacturers to Health Canada, of expected drug shortages can provide a window of opportunity for the manufacturer and regulators to work together to resolve production problems or identify alternate supply. We are encouraged by recent initiatives by Health Canada to collect information on planned discontinuances from manufacturers.
5. The Canadian Medical Association calls for the establishment of a legislative framework requiring pharmaceutical companies to provide advance notice of production stoppages and any forecast disruptions in the drug supply.
Because of the complexity of the drug supply system, to effectively identify the situations that lead to drug shortages and find Canadian based solutions that can decrease the incidence of shortages or mitigate their impact requires the involvement and cooperation of all players in the process. CMA has consistently asked the government of Canada to work with the provinces and territories, the private sector and health professionals to address this potentially dangerous threat to the lives of Canadian patients.
6. The CMA supports the provinces and territories in their efforts to prevent drug shortages.
We are heartened by actions of Health Canada in 2012 to bring together representatives of industry, federal, provincial and territorial governments and health professional associations in a Multi Stakeholder Steering Committee on Drug Shortages to respond to the need for the mitigation of drug shortages. We trust that processes can be put in place and supported by key players to allow Canada to respond in a coordinated, transparent and accountable fashion to future or actual drug shortages.
Drug Shortages represent an ongoing worry for physicians. The impact on patients, health professionals and the health care system can be significant. Substantial progress has been made since 2011 in terms of gathering and sharing drug shortage information and improving our understanding of the drug supply processes but much still remains to be done. Although complex and challenging, ongoing attention to the issue is required to ensure that Canadians can count on a secure supply of medication into the future.
The CMA will continue to represent the best interests of patients and physicians to ensure that Canada's health care system delivers on patient-centered care.
1 DRUG SHORTAGES FDA's Ability to Respond Should be Strengthened, Statement of Marcie Cross, Director, Health Care, United States Government Accountability Office, Testimony before the Committee on Health, Education, Labor, and Pensions, U.S. Senate, December 15, 2011.
2 FDA is asking the public to send in ideas for combatting drug shortages, FDA Voice, Feb. 13, 2013, U.S. Food and Drug Administration, available at http://blogs.fda.gov/fdavoice/index.php/tag/drug-shortages/ (accessed 2013 April 2).
3 Canadian Drug Shortages Database available at http://www.drugshortages.ca/drugshortages.asp (accessed 2013 April 5).
4 Drug Supply In Canada: A Multi-stakeholder Responsibility, Report of the Standing Committee on Health, 41st Parliament, First session, June 2012.
5 Drug Supply Disruptions, Environmental Scan, Canadian Agency for Drugs and Technologies in Health, Issue 17, March 2011.
6 Canadian Drug Shortages Database available at http://www.drugshortages.ca/drugshortages.asp (accessed 2013April 5).
7 Drug Supply In Canada: A Multi-stakeholder Responsibility, Report of the Standing Committee on Health, 41st Parliament, First session, June 2012.
8 Prescription Drug Shortages, E Panel Survey, Canadian Medical Association, December 2010.
9 Drug Shortages, Recommendations of the Working Group on Drug Shortages, Ordre des Pharmaciens du Québec, March 2012.
10 Impact of Drug Shortages, Member survey, Canadian Pharmacists Association, October 2012.
11 BACKGROUNDER - DRUG SHORTAGES SURVEY, Canadian Pharmacists Association, Canadian Society of Hospital Pharmacists, Canadian Medical Association, January 2013, available at http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/2013/Backgrounder-Drug-shortages_en.pdf ( assessed 2013 April 2).
Dear Premier Ford and Minister Elliott:
We write to you as organizations concerned about the health and welfare of some of the most vulnerable Ontarians, following reports that your government plans to undertake an unnecessary review of the evidence on supervised consumption sites (SCS),1 and the even more troubling announcement that you are imposing a moratorium on the approval of new overdose prevention sites (OPS).2
All the available evidence, including substantial peer-reviewed scientific literature, demonstrates conclusively that these health services save lives and promote the health of people who use drugs. This includes opening doors to treatment. Rather than conduct an unnecessary review and delay expansion of these services, the Ontario government should work with community organizations and health providers to rapidly scale up these services. Delays mean more preventable overdose deaths and new infections of HIV, hepatitis C and other illnesses that could be averted.
Multiple reviews of the evidence have already been done, and have established that SCS and OPS:
provide a needed health service, reducing overdose deaths and the sharing of drug-injection equipment (and the associated risk of transmission of blood-borne infections);
increase access to addiction treatment and other necessary health services; and
benefit public order by reducing public injecting.3
As you know, Canada is experiencing a large-scale opioid overdose crisis. In Ontario alone, overdose deaths related to opioids increased by 45 per cent in 2017, with more than three people dying every day during that year.4 The opioid overdose epidemic has been called “the worst drug safety crisis in Canadian history.”5 HIV, hepatitis C and other infections, as well as overdose deaths, are preventable if the right measures are taken. These include increasing voluntary access to treatment for problematic drug use (where Ontario must do better), and also simultaneously scaling up evidence-based harm reduction services such as SCS and OPS.
We urge you to heed the recommendations of experts in public health, front-line clinicians, harm reduction staff, and people with lived experience of drug use. Rather than impeding access to life-saving health services, we urge you to work with community organizations and other health services providers to ensure greater, equitable access to SCS and OPS for the people of Ontario.
Aboriginal Legal Services
ACAS—Asian Community AIDS Services
Action Canada for Sexual Health and Rights
Addiction Services of Thames Valley
Addictions and Mental Health Ontario
Africans in Partnership Against AIDS
AIDS Coalition of Nova Scotia
AIDS Committee of North Bay and Area
AIDS Committee of Toronto
AIDS Committee of Windsor
AIDS Committee of York Region
AIDS Vancouver Island
Alliance for Healthier Communities
Atlantic Interdisciplinary Research Network on Hepatitis C and HIV
Black Coalition for AIDS Prevention
Breakaway Addiction Services
Butterfly (Asian and Migrant Sex Workers Support Network)
Canadian Aboriginal AIDS Network
Canadian AIDS Society
Canadian Association of Community Health Centres
Canadian HIV/AIDS Legal Network
Canadian Medical Association
Canadian Mental Health Association—Thunder Bay Branch
Canadian Nurses Association
Canadian Positive People Network
Canadian Public Health Association
Canadian Research Initiative on Substance Misuse—Prairie Node
Canadian Students for Sensible Drug Policy
Canadian Treatment Action Council
Centre for Addiction and Mental Health (CAMH)
Centre for Social Innovation
Centre on Drug Policy Evaluation
Chinese and Southeast Asian Legal Clinic
Community Legal Assistance Sarnia
Community Legal Services of Ottawa / Services juridiques communautaires d’Ottawa
Community YWCA Muskoka
Courage Co-Lab Inc.
Dr. Peter AIDS Foundation
Elgin-Oxford Legal Clinic
Four Counties Addiction Services Team
Gerstein Crisis Centre
Guelph Community Health Centre
Haliburton, Kawartha, Pine Ridge Drug Strategy
Halifax Area Network of Drug Using People (HANDUP)
Harm Reduction Nurses Association
Health Providers Against Poverty
HIV & AIDS Legal Clinic Ontario
HIV/AIDS Regional Services
HIV/AIDS Resources and Community Health
Houselink Community Homes
Housing Action Now!
Huron Perth Community Legal Clinic
Income Security Advocacy Centre (ISAC)
Injured Workers Community Legal Clinic
Inner City Health and Wellness Program
Interagency Coalition on AIDS and Development (ICAD)
Kensington-Bellwoods Community Legal Services
Lake Country Community Legal Clinic
Lakeside HOPE House
Lanark County Interval House
Legal Clinic of Guelph and Wellington County
Maggie’s Toronto Sexwork Action Project
Mission Services of Hamilton Inc.
Mississauga Community Legal Services
MODIFY: Drug Insight From Youth
Moms Stop the Harm
mumsDU - moms united and mandated to saving the lives of Drug Users
Native Youth Sexual Health Network
Neighbourhood Legal Services London & Middlesex
Nipissing Community Legal Clinic
OHIP for All
Ontario AIDS Network (OAN)
Ontario Nurses’ Association
Ontario Positive Asians (OPA+)
Overdose Prevention Ottawa
Parkdale Activity Recreation Centre
Parkdale Community Legal Services
Parkdale Queen West Community Health Centre
PHS Community Services Society
Planned Parenthood Toronto
Racial Health Equity Network
Reelout Arts Project
Regent Park Community Health Centre
Regional HIV/AIDS Connection
Registered Nurses’ Association of Ontario (RNAO)
Rideauwood Addiction and Family Services
Sandy Hill Community Health Centre
South Riverdale Community Health Centre
Stonegate Community Health Centre
Students for Sensible Drug Policy, Ryerson Chapter
Superior North Emergency Medical Service
Syme Woolner Neighbourhood and Family Centre
Tanner Steffler Foundation
The AIDS Committee of Cambridge, Kitchener, Waterloo and Area
The Children’s Aid Society of the District of Thunder Bay
The Interfaith Coalition to Fight Homelessness
The Mental Health Consumer Survivor Project for Simcoe County
Thunder Bay Catholic District School Board
Thunder Bay Drug Strategy
Timmins-Temiskaming Community Legal Clinic
Toronto Overdose Prevention Society
Toronto People With AIDS Foundation
Waterloo Region Community Legal Services
WellFort Community Health Services
West Neighbourhood House
West Toronto Community Legal Services
Women & HIV/AIDS Initiative, Ontario
YWCA Niagara Region
1 F. Merali, “PCs ‘playing politics with people’s lives’ on injection sites, drug policy expert warns,” CBC News, August 4, 2018. Available at: www.cbc.ca/news/canada/toronto/supervised-injection-sites-waiting-1.4771143.
2 K. Bueckert, “Ontario puts new overdose prevention sites approvals on hold,” CBC News, August 11, 2018. Available at: www.cbc.ca/news/canada/kitchener-waterloo/ontario-overdose-prevention-sites-approval-hold-1.4782132.
3 E.g., M. Kennedy, M. Karamouzian & T. Kerr. “Public Health and Public Order Outcomes Associated with Supervised Drug Consumption Facilities: A Systematic Review,” Current HIV/AIDS Reports, 2017; 14(5): 161-183, doi: 10.1007/s11904-017-0363-y. Available at: www.salledeconsommation.fr/_media/public-health-and-public-order-outcomes-associated-with-supervised-drug-consumption-facilities-a-systematic-review.pdf.
4 Public Health Ontario, “Opioid-related morbidity and mortality in Ontario,” May 23, 2018. Available at: www.publichealthontario.ca/en/dataandanalytics/pages/opioid.aspx#/trends.
5 Municipal Drug Strategy Coordinators’ Network of Ontario, “Opioid Epidemic: Call for Urgent Action That Can Save Lives Now,” December 9, 2015.