Changing how pharmacists can resolve drug shortages

Today’s status quo of drug shortages, preventing vs. reacting, building a startup to make a change

In-Woo Park
6 min readSep 22, 2024
Photo by Tbel Abuseridze on Unsplash

TLDR:

  • Drug shortages are continuing to become more prevalent over time with a 180% increase in prescription drug shortages in the last 5 years
  • Prevention is macroeconomic and is not a feasible place to start in terms of solving
  • 70% of drugs that are more frequently in shortage are actually able to be substituted
  • On average, pharmacists only perform half of the possible therapeutic substitutions
  • I’m building Rx Assist, a clinical decision-support tool designed to help pharmacists with making therapeutic substitutions

1/4 Canadians have personally experienced a drug shortage or know someone who has

Drug shortages occur when the drug manufacturer is unable to meet the demands of orders on time. It can be caused by difficulty obtaining raw ingredients, a manufacturing problem, a sudden increase in demand, a drug discontinuation in the same therapeutic class, or a natural disaster. The problem is nothing new and pharmacists constantly deal with them.

One might imagine that by now, pharmacists would have developed a framework to follow in the event of a shortage; however, that is certainly not the case.

In the last 5 years, there has been a 180% increase in prescription drug shortages. This is felt among most pharmacists in Canada, with 79% of 1,743 pharmacists in a survey reporting that they feel shortages have greatly increased over the last 3–5 years.

Combined with the recent changes to pharmacists’ scope of practice, knowing how exactly to resolve a drug shortage has become even more of a gray area for pharmacists. For example, in British Columbia, therapeutic substitutions were originally limited to 5 therapeutic classes. Now, substitutions are allowed for almost all drugs as long as its within the same therapeutic class.

So it’s clear that there is a real problem here that’s currently on a trajectory of getting worse. Where do we even begin if we want to start solving it?

The bottom layer of drug shortages: a macroeconomic issue

Many complex problems in our world benefit from doing a root cause analysis in order to identify the causes or faults at the very bottom layer. Surprisingly for drug shortages, the very root cause might not be the best place to start in terms of solving.

In Canada, we are especially vulnerable to shortages because of several macroeconomic factors. Canada represents a small part of the global market and relies on imported products. As much as 60% of active pharmaceutical ingredients (API) are produced in China while 70% of finished pharmaceuticals (such as tablets) are produced in India.

Canada also has a relatively low-cost drug regime due to federal price controls that regulate the maximum price a manufacturer can charge. While this is beneficial for consumers, it has led some manufacturers to exit the Canadian market because the profit margins are insufficient. This creates supply gaps, especially for low-cost, high-volume generic drugs.

For example, in 2023, Canada experienced a significant shortage of Adderall and other drugs used to treat ADHD. One of the main reasons was a combination of manufacturing delays and the fact that companies were prioritizing markets with higher profit margins over Canada.

This heavy dependency on global supply chains combined with federal pricing pressures are what makes the country vulnerable to drug shortages; both matters that are out of control for the common pharmacist.

Unless there are drastic changes to how we manufacture and regulate the maximum price of drugs in Canada, this layer of the problem is not the best to pinpoint and solve. Let’s take a look at a different layer.

A layer above: how pharmacists react to drug shortages

By the time a drug shortage reaches the pharmacist level, we label this layer of the problem as the reaction layer. Typically, when a pharmacist discovers that their pharmacy does not carry the patient’s prescribed drug, they have 4 different approaches that they could take, each with their own inefficiencies:

  1. Contact the original prescriber for changes to the prescription - this approach is notoriously known as a nightmare process for both physicians and pharmacists due to poor communication and the fact that physicians aren’t aware of the availabilities of alternative drugs
  2. Order the drug from the manufacturer - this approach involves making the patient wait anywhere from 1 to 4 business days (only if the drug isn’t already on backorder), which is not ideal especially for time-sensitive treatments (e.g., antibiotics or anticoagulants)
  3. Call other pharmacies + send the patient to another pharmacy - this approach results in a decrease in productivity for both patients and the pharmacists involved (+ no patient wants to travel around to 5–15 pharmacies, nor do pharmacists want to call around 5–15 pharmacies)
  4. Perform a therapeutic substitution/ a drug adaptation - this approach is the preferred method considering the decrease in treatment delays and customer retention for pharmacies; however, the time it takes to make clinical decisions and document them make this approach inefficient

Yet, of these 4 approaches, I see an opportunity to drastically improve one of them: the process of performing a therapeutic substitution.

A frequently asked question is “aren’t there limitations to which drugs can be substituted?” and the answer is yes; however, 70% of the drugs that are more frequently in shortage are actually able to be substituted, so I say let’s give it a shot.

I’m building Rx Assist to help pharmacists with the process of making therapeutic substitutions

After speaking with pharmacy business owners and executives at the head offices of the largest pharmacy chains in Canada, I learned that pharmacies want to prioritize therapeutic substitutions for 3 reasons:

  1. Patients can receive their treatment in a timely manner
  2. Pharmacy businesses can reduce customer churn
  3. Pharmacies can claim government subsidized service fees ranging anywhere from $10.00 to $53.68 per substitution

However, despite the additional benefits of capitalizing on this opportunity, pharmacists on average only perform half of the possible substitutions.

To figure out why, I interviewed over 40 pharmacists and found:

  1. 60% of pharmacists are not confident in performing substitutions - there are no guidelines to follow in the event of a specific shortage (or none developed early enough), evidence-based drug information is scattered, additional patient counseling is required
  2. 65% of pharmacists say that substitutions take too much time - whether it’s the decision-making process, documentation process, or notification process, it takes pharmacists on average 17 mins to perform a substitution, making it difficult to prioritize during busy workflows.

Using these 2 pain points, I am now building Rx Assist, a clinical decision-support tool designed to help pharmacists make therapeutic substitutions.

Image by Author

This application is soon to be beta-tested by a small group of pharmacies in British Columbia and Yukon (as of 2024/09/21). Currently, I am working with a few pharmacists to develop and review the substitution algorithms, starting with the most recent/ongoing drug shortages.

The first launch will consist of the following features:

  • Early notification of drug shortages in Canada (including anticipated drug shortages)
  • Therapeutic substitution decision trees (with auto-dosage conversions)
  • Documentation/notification auto-generation

Eventually, the goal is for this platform to become the central hub that pharmacists visit when resolving drug shortages. With time, additional features such as decision trees for compounds, interprofessional collaboration, pharmacy school training, and more (visit rx-assist.ca for more info) will be available.

Until then, feel free to join the waitlist and we will contact you once the tool is available to you!

References

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In-Woo Park

17yo | Bio-Researcher | TKS Innovator | Pharmacy Assistant | Human Longevity