Injectable drugs are so scarce in Canada that doctors across the country are being forced to restrict their use and depart from standard hospital practices.
Some hospitals are urging physicians to hold onto vials containing leftover medicine, instead of throwing them out after a single use. Cancer patients in Alberta have been switched from faster-acting injectable anti-nausea drugs to oral alternatives, and, in Ontario, at least one hospital has suggested staff consider low doses of more potent painkillers as supplies of commonly used drugs like morphine run low.
While doctors say these short-term solutions aren't compromising patient safety, they point to the larger and more critical issue of getting a handle on a simmering drug-supply problem that has been years in the making.
Sandoz Canada, which manufactures most of the generic, injectable drugs used in the country, warned hospitals last month that it was cutting production following a citation by the U.S. Food and Drug Administration, which flagged the company for sterility concerns at its Boucherville, Que. factory. That shortage was exacerbated last week after a fire broke out at the facility, halting production entirely.
Now, hospitals across the country are "on allocation," which means they are receiving only a fraction of the quantity of the injectable drugs – which include morphine, codeine and other common painkillers – they would normally get.
Sandoz says it plans to partially resume production on Monday, once its factory has been cleaned up. A spokesman for the company said it has aimed to be pro-active in communicating with hospitals over the shortage. But amid continued uncertainty about supply levels, doctors and pharmacists are already implementing the stopgap measures to conserve as much as they can.
Dr. James Silvius, medical director for pharmacy services at Alberta Health Services, said the oral anti-nausea medication now being given to cancer patients in the province takes longer to work, so patients are often prescribed an extra dose to take before chemotherapy. The injectable anti-nausea drugs are being kept for patients for whom it's the only option, including those who have had throat surgery.
Alberta pharmacies are also repacking drugs to eliminate waste. "Instead of a vial that would be single use and opened and used, in a procedure, for example, we may repackage that in pharmacy so that there's actually two doses that come out of it and we don't throw the second one out," he said.
Rick Chisholm, president of the Canadian Anesthesiologists' Society, said hospitals are managing their supplies well, but the shortage has put them in a difficult position. He said some hospitals are holding on to vials of leftover medication to be used again.
"Most hospitals play it pretty tight, and if they used x amount last year, they're probably going to use x plus some this year," he said. "There's not a lot of leeway."
Halifax hospitals have set new guidelines dictating when the drugs should be used to ensure they're available for patients who need them most.
"Any patient that is on injectables, if there's any way at all possible that we can switch them to the oral, we are switching them as soon as possible," said Anne Hiltz, who directs the pharmacy at Capital Health in Halifax.
Doctors say they've faced drug shortages before, for a wide variety of medications. The problem, many say, is that manufacturers aren't required to notify hospitals of pending shortages – as they are in other countries, including the United States and France.
Earlier this week, the federal government signalled that it may consider alternatives to the current, voluntary notification system in light of the problems with Sandoz's supplies.
Deborah Dunn-Roy, of Health Shared Services BC, said the province's hospitals have been actively swapping oral drugs for injectable ones since they heard about the latest drug shortage last month.
"I think that's one of the reasons we've been able to manage the supply as well as we have," Ms. Dunn-Roy said, adding that the doctors are well-versed in finding drug alternatives.
"Substituting drugs does occur on a fairly regular basis, it's just not normally on this scale."
With a report from Carys Mills in Toronto