If you’ve got a dog with skin disease you’ve probably heard of a new drug called Apoquel. Manufactured and marketed by behemoth veterinary drug manufacturer, Zoetis, this drug has been a frequent source of frustration for veterinarians. Ever since the spring of the year it debuted (2014), it’s been on short supply. What’s more, it shows no signs of meeting demand anytime soon (for years, possibly).
You might’ve also heard of atropine. And barium, bupivicaine, cefazolin, chloramphenicol, clindamycin, dexamethasone, dextrose, doxorubicin, ephedrine, epinephrine, famotidine, and fentanyl … And these are just a few of the drugs I think you might recognize, listed alphabetically through the letter F. All these are in short supply, too.
In fact, as of today, the FDA’s list of current and resolved shortages includes 97 medications. Ask ASHP (American Society of Health-System Pharmacists), however, and they include approximately double that number on their list of drugs currently in short supply.
Why the discrepancy? According to the ASHP’s more practical definition of a drug shortage, a drug makes the short supply list when your pharmacist or provider has to make changes to medications or choose alternative drugs on the basis of a supply issue. The FDA considers it a shortage only when you can’t get the one drug you need that can be used to save your life.
According to the FDA, my patients and I have suffered quite a few shortages this year. Some irreplaceable drugs I absolutely cannot locate. But the ASHP’s definition describes the extent of my problem more accurately. Here’s why: While I’ve technically retained access to many drugs, their reduced supply has increased their prices to unaffordable heights.
$150 for a seven-day course of doxycycline? Compared to $4 a year ago … that’s effectively a shortage. Whether I can get my hands on it or not, a diminished supply means more competition for the available supply and, consequently, prices that will undeniably affect my patients’ care –– and not in a good way.
Drug shortages can adversely affect patient care in several different ways –– anything from less-than-adequate substitutions, delayed treatment, held up medical procedures and medication errors. What’s more, they place an undue burden on both human and animal healthcare providers, which unfortunately leads to higher prices.
Worse than the recent shortages themselves, however, may be the fact that they’ve become more frequent over the past decade. And no one really knows why.
Though manufacturers attribute drug shortages to trouble securing raw materials, manufacturing difficulties, “business decisions,” and regulatory pressures, they classify more than 55% of the shortages as the result of “unknown” causes.
Consumer advocates, however, have criticized the pharmaceutical industry for its patient-blind, profiteering ways. They cite decreased competition in the pharmaceutical industry (the result of a flurry of recent mergers and acquisitions) as a primary driver of manufacturing shutdowns. The companies are too big to care, they say, and there are too few of them to offer sufficient redundancy in case there’s even the tiniest hitch in their supply of critical drugs.
For their part, drug companies say their expanded sizes means they’re more capable of offering lower prices. Consumer advocates say that’s hard to believe since prices keep climbing and the drug supply is increasingly insecure. What’s more, it’s the lower-priced drugs that drug companies seem to have the most trouble keeping up with. (Lower priced generics appear most affected, probably due to their low profitability.)
Since the inception of this escalating crisis, hospitals, doctors, patients and patient advocates have been up in arms. Fingers have been pointed, lawsuits have been filed, congressional committees have been convened … and there’s still no end in sight for what appears to be an accelerating problem.
It’s a serious problem. But not everyone suffers equally. Those most at risk include one of two categories of patients: a) those with the most sudden and severe drug needs, and b) those who exert the lowest amount of economic pressure on pharmaceutical companies. In other words, those who feel it worst are those who either have the most to lose –– their lives –– or those who have the least to offer, financially.
To those of us who work with animals, this makes a whole lot of sense. Pets may be attached to people –– and their economic impact on the drug market may be growing –– but they still suffer disproportionately when it comes to drug shortages. Here are a few reasons why:
#1 Percentage-wise, pets use more generic medications than people do.
Pets tend to use lots of generic drugs. That’s because generics are less expensive and have a longer track record (so they’re more likely to have been tested on pets). They’re also the least expensive. Which is important to pet owners (who tend not to carry health insurance for their pets).
Unfortunately, of the drugs affected by shortages, generics are the most commonly affected. That’s because generic drugs are the least profitable medications they produce. As such, generics are often made by the oldest, most outdated manufacturing plants and fewer resources are expended when their manufacturing facilities go off line. What’s more, their low profitability means drug companies are more likely to discontinue their production for any reason.
#2 Pets comprise a smaller market than people –– or even agricultural animals –– do.
There are over a hundred and fifty million dogs and cats in the US. But that’s still a drop in the bucket compared to the human population, or even the population of animals involved in agriculture. Though humans are increasingly willing to spend whatever it takes to keep their pets healthy, their spending tends to be limited by their disposable incomes. Overall, then, pets are not likely to make pharmaceutical companies sit up and take notice.
That explains why Apoquel, designed as a niche product for dogs, hasn’t edged out more profitable animal agriculture products in its bid for greater resources from its parent company. And why our itchy dogs won’t be seeing a steady supply of it anytime soon.
#3 People have more moral and political capital.
Which most of us agree is as it should be. Because when a child can’t get a leukemia drug, it’s a tragedy that makes waves way faster than the shortage of any anti-itch medication for dogs. Hospitals get angry. Parents cry on TV. Politicians get involved.
That’s why, given the choice, drug companies are way more likely to focus their limited resources (scarce ingredients, elusive manpower, dwindling production lines, modern manufacturing facilities, etc.) on drugs that would help humans over animals. To do otherwise would be to buy bad PR and court increased government oversight … along with diminished profits.
What’s a veterinarian to do?
A crafty veterinarian will find ways around shortages by coming up with alternatives. This includes talking to local pharmacists by telephone, communing with colleagues online, employing creative compounding pharmacists, and generally being willing to explore a variety of options. But that only helps if there’s time and money to spare. Because in most cases, shortages will deplete both.
What’s a concerned pet owner to do?
Apart from purchasing a pet insurance that covers prescription drugs, consider writing to your congressional representatives. Let them know you worry about drug shortages. But when you do, please keep #3 in mind and refrain from indulging your impulse to talk about the risk shortages pose to your pets.
Since politicians tend to be compelled more by people problems than by pet problems, you’re better off referring to your pets as children … which is probably the truth of it anyway.