Chemotherapy drugs. Attention deficit-hyperactivity disorder (ADHD) medication. Albuterol. Morphine. Children's fever reducers. Certain antibiotics. All have been in short supply in the United States within the past year or so.
In late July, 243 drugs were on the American Society of Health-System Pharmacists (ASHP) drug shortage list. New drug shortages increased nearly 30% between 2021 and 2022, according to a March report from the U.S. Senate Committee on Homeland Security and Governmental Affairs. And while drug shortages are not a new phenomenon, "the number of active, ongoing shortages is at a 10-year high," says Michael Ganio, PharmD, MS, BCPS, FASHP, senior director of pharmacy practice and quality at the ASHP. "We're edging close to an all-time high, which is very concerning."
Unfortunately, most of these shortages (and the underlying contributing factors) are unlikely to be resolved any time soon. Because it can take years to rebuild supply chains and manufacturing capacity, nurses and patients will likely be grappling with ongoing, rolling drug shortages for the foreseeable future.
CURRENT DRUG SHORTAGES
Generic drugs-particularly generic injectable drugs-are most likely to be in short supply. So, while demand-driven shortages of semaglutide, an antidiabetic medication that's also approved for weight management in certain patient populations, dominate headlines, it's the shortage of bacteriostatic water, sterile saline, injectable epinephrine, lidocaine, and chemotherapy agents that are affecting U.S. nurses and patients. "Name a generic chemotherapy drug, and odds are it's in short supply," Ganio says.
Cisplatin, a chemotherapy drug used to treat many solid tumor and hematologic cancers, including testicular, ovarian, bladder, head and neck, lung, and cervical cancer, is listed on the U.S. Food and Drug Administration (FDA) website as "currently in shortage." So is carboplatin, a chemotherapy drug commonly used to treat ovarian and head and neck cancers. Shortages of platinum-based medications like cisplatin and carboplatin were first reported in February and are expected to persist for "several months and possibly longer," according to an April statement by the Society of Gynecologic Oncology. Given the ongoing shortage, the organization recommends conservation strategies, including increasing the interval between cycles to the longer end of a recommended range, using the lowest appropriate dose, and rounding doses down to the nearest vial size. "If the shortage becomes more critical," according to the statement, "consider reserving carboplatin and cisplatin for curative intent treatment or when prolonged clinical benefit is anticipated."
Common crash cart medications are also in short supply. Nurses who are used to prefilled epinephrine syringes on crash carts may instead find epinephrine vials-and may need to measure and draw an appropriate dose during an emergency.
Fentanyl injection is currently in shortage, as is injectable furosemide, digoxin, hydromorphone, and dozens of other medications. Patients and families continue to report difficulty obtaining the combination oral medication amphetamine and dextroamphetamine (Adderall) and other medications for ADHD. These patients may experience withdrawal symptoms, including nausea, vomiting, insomnia, fatigue, and mood swings, if they suddenly decrease their dosage or abruptly stop their medication.
Economic forces and manufacturing challenges have contributed to the current drug shortages. "Part of the problem is that the health care industry is trying to operate like manufacturing," says Deborah Burger, RN, copresident of National Nurses United (NNU). The shift toward just-in-time manufacturing and inventory means that most manufacturers and health care systems don't have large stocks of medication (or the supplies necessary to make them) on hand. As a result, relatively few manufacturers or health care organizations have sufficient stock to weather minor supply interruptions.
Additionally, company mergers and acquisitions have reduced the number of drug manufacturers. So, when Akorn Pharmaceuticals, a primary producer of concentrated liquid albuterol (and other medications), filed for bankruptcy and ceased operations in February, hospitals nationwide scrambled to get albuterol in appropriate volumes and concentrations for continuous nebulizer treatment. At Lurie Children's Hospital of Chicago, staff had to open 40 smaller albuterol containers and squeeze out the contents to equal 20 mL, the amount in an Akorn bottle of albuterol 5 mg/mL.
"There were a few medications that Akorn made exclusively," Ganio says. "There's no source for them now." And because Akorn is out of business and cannot respond to quality concerns, the company and the FDA recently announced a voluntary recall of most existing Akorn products, so hospitals and pharmacies must discard medications that may not have ready replacements.
HOW SHORTAGES AFFECT NURSES AND PATIENTS
Navigating drug shortages increases stress-and the potential for medication errors.
"When I was doing conscious sedation and we didn't have the fentanyl we typically used, we were doing workarounds," says Burger, who recently retired from clinical practice. These workarounds included using multidose vials and drugs from different manufacturers. That took more time, because nursing staff had to check and recheck doses and drugs to make sure they were administering the prescribed medication.
Despite nurses' care and concern, "there have been medication errors that have resulted from a change in concentration or vial size, or from providers incorrectly converting dosage from morphine to hydromorphone when there was a morphine shortage," Ganio says.
Nurses experience the stress of working with less familiar tools, as well as the emotional stress from knowing that patients may not have access to preferred or necessary medications. In many cases, nurses also become targets for the anger, fear, and frustration that patients and families feel when medications are not available.
"Because nurses are often the ones in the room with the patient, they have the responsibility of explaining why a loved one can't get a medication, and that can be really draining," says Stephanie Au, DNP, MSN, APRN, FNP-C, an assistant clinical professor at the Sue and Bill Gross School of Nursing at the University of California, Irvine.
Patients, of course, may experience delays in treatment or less-than-ideal treatment, which may affect clinical outcomes. "The main predictors of how well a patient with cancer will respond to chemo is getting the right dose on the right schedule," Ganio says. When patients can't get full doses of the recommended medications on time, he notes, it's "heart wrenching."
COPING WITH DRUG SHORTAGES
It's easy for nurses to feel helpless in the face of drug shortages, but there are steps nurses can take to protect patient safety and provide good care, even when medications are in short supply.
Be proactive. Pay attention to news stories and notices from your health care system regarding drug shortages. Take note of those most likely to affect your work and your patients. Learn what alternatives may be available. If you need to use an unfamiliar (or less familiar) medication or dosage, Ganio advises that you educate yourself and "talk to your colleagues and health care team, so you're prepared to talk to patients about what's happening."
Reemphasize medication error prevention strategies. If you must use a multidose vial instead of a more familiar single-use injectable, for example, ask a colleague to double-check the dose.
Educate patients. Help patients and families develop strategies to deal with ongoing drug shortages. Patients who regularly take prescription medication should be instructed to request refills at least a week (perhaps longer) before they run out of medication, as it may take time to find a pharmacy that has (or can get) the drug.
Patients should also be encouraged to work with their NP or physician to determine alternatives should prescription medications become unavailable. "Rarely is there only one medication that will work for a particular diagnosis," Au says.
Document. Burger urges nurses to document instances in which they do not have the necessary medication or supplies to safely provide patient care.
"In all our unionized hospitals, we have assignment despite objection (ADO) forms," she says. The forms include space for nurses to indicate why they believe the assignment poses a threat to the health and safety of patients. Copies of the ADO are shared with management and the union representative, and the nurse should also retain a copy.
Advocate. Nurses cannot solve the drug shortage, but they can educate legislators (and others) on the extent and impact of the problem.
"Start reaching out to your congressperson," Ganio says, noting that bills intended to address drug shortages are under consideration. "There's a lot of attention on the drug shortage issue right now, so it's a good time to engage."