Drug shortages jeopardize access and quality of palliative care

Palliative care providers and patients are having difficulty obtaining medicines due to nationwide drug shortages, threatening quality of care and patient access to palliative care. These include essential medications for pain and symptom management.

The scale of shortages appears to be widening. According to Data of the American Society of Healthcare Pharmacists (ASHP). Injectable drugs accounted for 66% of new shortages identified so far this year, the ASHP reported.

This scarcity complicates the delivery of care and could mean that some patients in need may not receive palliative care, according to John Paglino, vice president of pharmacy services at VITAS Healthcare, a subsidiary of Chemed Corp. (NYSE:CHEM).

“Drug shortages can be a barrier to transitioning into hospice,” Paglino told Hospice News in an email. “Shortages can also hamper our ability to honor certain patient and family wishes. Access to medication is still relevant for end-of-life patients as it supports pain and symptom management.

Shortages have existed for some time, including cardiac drugs and intravenous (IV) artificial nutrition, hydration, and opioids, such as morphine and fentanyl, among others.

Injectable drugs are of particular concern because they have a shorter shelf life, making it harder for palliative care to maintain sufficient back-up supplies.

These factors can make the ever-difficult decision about end-of-life care even more difficult for patients and families.

Managing pain and symptoms is highest priority for patients and families, 2014 study finds study. Patients may be more reluctant to enter palliative care if they have better access to these drugs in another setting, Paglino said.

Drug shortages can also impact patient satisfaction scores, Paglino said. Often, using an alternative pain reliever may not be “quite as effective” and may impact a patient’s quality of life, he said.

This in turn can negatively affect hospice performance on publicly reported quality measures, which are key considerations for referral partners and payers.

“Palliative care providers face challenges that other providers don’t face,” Paglino said. “Palliative care providers can be extremely vulnerable to disruptions in access to medicines and supplies and are not always the first to receive additional supplies. In a palliative care setting, we often need new drugs extremely quickly – sometimes within hours – to better care for very complex and critically ill patients.

Not only are the number of drugs in shortage increasing, but the duration of shortages of certain drugs is getting longer, according to a report by the United States Food & Drug Administration (FDA).

For some drugs, shortages have lasted up to eight years, the FDA said. The agency attributes this largely to logistical and regulatory challenges that are slowing market recovery from a disruption.

High demand and low supply are also driving up drug prices for providers, even as rising fuel and labor costs make shipping and delivery more expensive.

“Many manufacturers compete on cost alone, so prices actually tend to follow inflation,” Marisa Todd, PharmD, clinical pharmacy manager at Enclara Pharmacia, told Hospice News. “Even when there are multiple manufacturers of a particular drug, they can all rely on a handful of suppliers for key ingredients.”

Other factors contributing to the shortage include trends in the pharmaceutical industry itself.

The pharmaceutical space has become more complex and fragmented over the past two decades, in part due to increased overseas production and the growing use of contract drug manufacturers.

This has complicated the ability to both find new sources of active pharmaceutical ingredients in short supply, as well as obtain approvals from various national regulatory agencies, the FDA reported.

Moreover, this scarcity creates fierce competition between health care providers looking to buy drugs for their patients, especially when it comes to generic drugs. These make up about 90% of the drugs in shortage, according to Todd.

According to Joseph Solien, PharmD, vice president of clinical services for OnePoint Patient Care, which is the pharmacy brand of BrightSpring Health Services, the consolidation of generic manufacturers and the resulting lack of redundancy among product options is the primary shortage factor in the field of palliative care.

“Hospices may have had to temporarily order a more expensive competing product,” Solien said. “The best thing hospices can do to offset any increased drug costs is usually to focus on utilization, ideally in conjunction with a hospice clinical pharmacist.”

According to Todd, surviving these shortages will require a collaborative effort to manage costs between hospices and their pharmaceutical suppliers. She recommended that hospices work with a pharmacy benefit manager who can track usage trends.

Pharmacists can also help with conversion to other medications and routes of administration to maintain pain and symptom management, Todd added.

Drug shortages don’t appear to be easing any time soon, and the pandemic has only exacerbated the problem as demand for IV and other drugs in the palliative care space has increased.

However, the pressure of the pandemic has drawn attention to these issues, leading regulators and manufacturers to seek solutions.

“One of the positive outcomes of the COVID-19 pandemic has been increased awareness of supply chain issues as well as concerted efforts by the FDA, drugmakers, and other key players to securing our drug supply. If this continues, we might see improvement,” Todd said. “If people become complacent and we see greater geopolitical instability, we could face greater risk. As hospice professionals, our role is to advocate for the former while preparing for the latter.

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