A new drug war

When pharmacist Heather Christ arrived for her afternoon shift at Shoppers Drug Mart in New Brunswick, Canada, she noticed a tower of empty pharmacy trays stacked nearly 2 feet high. The reason, Christ said: shortages. Patients with high blood pressure request a 90-day supply of medicine, but the pharmacist may only give them enough for 10 days. A mom comes to pick up an anti-convulsant for her epileptic child, only to find the drug isn’t available.

When drugstores run out of drugs, “people just get panicky,” says Christ. But that’s nothing new in Canada: Christ sighed heavily and said, “It’s been part of the scenery for so long.” Christ, a 30-year veteran of Canada’s pharmaceutical industry, says the country’s drug shortage has worsened in recent years. More than 1,800 drugs are on Canada’s needed list, according to the official Drug Shortages Canada website.

Last month U.S. President Donald Trump announced plans to allow the import of cheaper prescription drugs from Canada. But Canada doesn’t have enough drugs to share with the massive U.S. market, and the Canadian Health Minister’s office said, “While we’re aware of ongoing state-led initiatives to import Canadian drugs, we weren’t consulted on specifics.”

Given Canada’s preexisting drug shortages, Christ says expanding the market is “alarming from Canada’s point of view.” If the United States drills a hole in the already leaking Canadian drug pipeline, and then tries to fill a tank 10 times the size of Canada’s, the drug supply will run dry. A 2018 study published in the journal Health Economics & Outcome Research: Open Access found that if one-fifth of U.S. prescriptions are filled in Canada, Canada’s drug supply will be exhausted in six months.

Christ says Canadian pharmacists sometimes work around drug shortages by adapting prescriptions. They work from scratch to create alternative compounds. The process takes extra time and keeps patients waiting, but shortages leave them no choice.

Christ is allergic to bees, so she carries an EpiPen. When an EpiPen shortage struck Canada last summer, she didn’t feel right getting a new one. She and many other Canadians kept their expired EpiPens. A drug’s expiration date is the time after which the drug could have lost 10 percent of its potency, so an expired EpiPen might still work. But it might not work, and a severe allergic reaction would be the consequence. Thankfully, Christ didn’t have to find out because the shortage ended.

One year later, Canada is running out of EpiPens again. Pfizer, until recently the only company authorized to provide injectors to Canadians, continued to have manufacturing problems. Ginette Petitpas Taylor, the Canadian health minister, has signed an emergency interim order to allow U.S.-based provider Kaléo to send epinephrine auto-injectors to Canada.

That may sound like an easy solution, but it was complicated. The new injectors didn’t have instructions in French for distribution in Quebec. They operated differently than EpiPens, so pharmacists had to spend extra time teaching patients how to use them. The injectors came in packages of two, so pharmacists had to open the packages to redistribute them one per patient. And Kaléo had to rebuild trust, since it suffered a product recall in 2015.

Why the recurring shortages of other drugs? Opinions abound. Manufacturing and shipping problems. Disruptions in international supply. Discontinued generics in favor of newer, brand-name drugs with greater profits. Lack of suppliers. Government price caps imposed by Canada’s nationalized healthcare system. And the future of Canada’s drug supply? Christ said, “I’m discouraged.” She sees the recurring problems as the new normal: a normal that could be worsened if the United States comes looking for a share.