Pandemic creating potential for drug shortages that Canada isn't equipped to deal with
Canada needs to become self-reliant in developing and supplying its own critical drugs, vaccines
This column is an opinion by Dr. AbdulGhani Basith, an emergency physician in Toronto and a faculty member at The Schulich School of Medicine & Dentistry. He is a co-founder of The Critical Drugs Coalition, a group of pharmaceutical experts, physicians and others working to prevent future drug shortages in Canada. For more information about CBC's Opinion section, please see the FAQ.
For months now, Canadians have been sacrificing things we never thought we would have to and giving up more than we ever thought we could. Those sacrifices are paying off — they've helped flatten the curve, and our hospitals are able to keep up with the burden of this terrible virus.
However, while we have survived this leg of the race, we must recognize that COVID-19 is a marathon that will continue to tax our health care system, and that it is creating the potential for drug shortfalls on a level that we may not be prepared to deal with.
This applies to critical medications as well as potential COVID-19 treatments and vaccines. The federal government needs to publicly and openly take action now to secure our supply of critical care drugs, so that front-line health care providers can continue the work of tending to the sickest patients.
Part of taking care of critically ill people depends on medications that are routinely used in emergency departments and intensive care units all over the world. Medications such as norepinephrine can help support a patient's blood pressure, while others such as propofol and fentanyl help sedate patients on ventilators or undergoing painful procedures.
Without these medications in my ER, we would not have been able to save the life of an otherwise healthy female patient recently whose respiratory system could no longer handle the damage done by COVID-19. We also would not have been able to honour the wishes of an 85-year-old grandmother who was not able to be with her family during her final moments from pneumonia, and who wanted to die with dignity and comfort.
Although these medications are not currently in short supply, the long-term situation is tenuous due to issues with global supply chains as the pandemic rages on.
In fact, over the past few months Canada has had numerous supply issues, many of which have been identified on the Tier 3 drug shortages list run by Health Canada that details those which could have serious consequences for the health care system.
Currently, the vast majority of the drugs on the Tier 3 list (24 of 32) are essential for treating COVID-19. Recently, for example, the drug propofol has had to be imported in non-traditional concentrations. The implications for errors are obvious, and have led to alerts from pharmacists to ensure that physicians are taking care with the new concentrations.
We have also been facing shortages of non-injectable drugs — ventolin (the "blue puffer" as it's known to many of our patients) and dexamethasone, a steroid showing tremendous promise for treating the inflammation from COVID-19, being prime examples. Health Canada has been urgently importing ventolin puffers from abroad to fill domestic demand.
Why we face potential shortfalls of these types of drugs is multifaceted. Two of the biggest reasons are the hoarding of drugs by some nations, and the fact that we rely on imported active pharmaceutical ingredients (APIs) with ambiguous supply chains. APIs are the actual precursors for drugs, and their shortage means manufacturers are unable to produce needed drugs in their final form — be it a tablet, an injectable or an inhalable formulary.
Canada relies almost exclusively on imported APIs, and China and India are the leading producers. The supply issues mirror the shortages of personal protective equipment (PPE) that we have all become familiar with over the past few months. We relied heavily on China for vital PPE supplies, and when the COVID-19 pandemic overwhelmed both their own health care and PPE production systems, exports became limited.
Lack of communication
Compounding this is a long-standing lack of information about issues in the global pharmaceutical supply chain.
Drug shortages have been the norm for many years for pharmacists, and they often aren't given advance notice of pending international supply problems. They find out about specific drug shortages only when trying to order more medication from a manufacturer, and are often forced to put together bits and pieces of information as they try to figure out a solution because they aren't privy to the full global supply-chain picture.
This concern has only become worse as COVID-19 limits the export of many drugs from major manufacturers abroad. This is why the Canadian Pharmacist Association recommended 30-day limits in March on prescriptions that normally may have gotten 90-day supplies, to ensure all patients would have the medications they needed on a daily basis. This limit is now being lifted as China's API production picks back up.
The federal government has created a website, drugshortages.ca, to help streamline the communication of this kind of information, but many pharmacists feel it is not user-friendly and it does not provide alerts about pending shortages.
Until we have a reliable domestic supply of these types of drugs, the government could achieve better transparency by instituting public policy that mandates disclosure of all aspects of the logistics of API imports.
However, on a global scale the distribution of medications often goes to the highest bidder. With the advent of novel therapies for COVID-19, we are seeing hoarding of some essential medications. Hydroxychloroquine was an early example, and most recently, the U.S. Government purchased 100 per cent of the world's supply of the antiviral drug Remdesivir from Gilead Pharmaceuticals, a medication that may have some benefit for the treatment of COVID-19.
Ideally, many of these critical-care drugs should be part of Canada's National Strategic Emergency Stockpile, but it's clear that we simply do not have enough medications sequestered to meet the demand during the COVID-19 pandemic. Part of this may be due to funding cuts to the maintenance of this stockpile prior to the pandemic. However, it remains that a stockpile is only a temporary measure in the face of a crisis; we need to put systems in place for self-sufficiency around critical health care resources such as the production of important pharmaceuticals.
Unfortunately, Canada is quite limited when it comes to domestic generic drug production. The Sandoz Pharmaceuticals facility in Quebec is the only one in the country that can make injectable drugs, for example, and it is likely not large enough to meet our domestic requirements. Just as we've started producing PPE in Canada, we need to create a stronger domestic drug manufacturing sector.
As a country, we have the knowledge and the skills required to manufacture our own pharmaceuticals, and the payoff for the health care system is well worth it.- Source
Bringing pharmaceutical production back to Canada is not easy, nor would it be without consequence. We should expect to see drug prices increase. But while this is a complicated process, it's not insurmountable. As a country, we have the knowledge and the skills required to manufacture our own pharmaceuticals, and the payoff for the health care system is well worth it.
The lessons of Connaught Labs, the Toronto-based non-profit maker of Frederick Banting's insulin that also made vaccines, are highly applicable today. Connaught Labs was privatized and sold to Sanofi in the '80s. The tragedy of this was aptly described in a recent Toronto Star op-ed, as we could have used Connaught Labs for our domestic COVID-19 vaccine supply today, if not for our drug supply.
Nonetheless, we do have a chance to restore domestic manufacturing now. Government support is essential to doing this successfully, and the Critical Drugs Coalition, which I am a part of, is advocating for this as well as for better stockpiling and increased transparency about the drug supply chain. Domestic manufacturing is the most definitive long-term solution to ensure Canada is not in a position where we are reliant on other countries for necessary medications.
The need to ensure a domestic drug supply also extends to vaccines. Eventually we will have a vaccine for COVID-19, and its distribution will be crucial to rebuilding our economy and restoring normalcy to our daily lives.
However, when a vaccine comes to market it will strain supply chains to a degree we haven't seen before. This will be a product that every country will need to restart their respective economies. We cannot afford to be without a robust supply of our own.
The federal government has made investments around research and production of a COVID-19 vaccine, but Canada needs to absolutely ensure we will have the ability to produce vaccines at home. Just as domestic production of APIs allows for self-reliance when global drug shortages occur, the ability to produce vaccines in Canada will also afford us a similar safety net.
We have all lost something during this pandemic, through the innumerable sacrifices made or loved ones who we will never hold again, but we will come out of the crisis stronger. That is who we are as a nation. To ensure our losses and sacrifices haven't been in vain, and to prepare for future crises, we must fix the cracks in our health care system and become self-reliant in developing and supplying our own domestic pharmaceuticals and medical technologies — not only for the Canadians of today, but also for those yet to come.