Oh, Gosh, We're Also Running Out Of Drugs Needed To Keep People On Ventilators

This might be bad.

As we bumble through a worldwide pandemic with the supply chain for medical supplies looking like a game of Hungry Hungry Hippos without enough marbles, it's worth keeping in mind that it's not just personal protective equipment and ventilators that could soon be in short supply. Hospitals all across the country could soon face a shortage of the sedatives, pain medications, and other pharmaceuticals that are necessary to keep people in respiratory distress on ventilators. That could quickly become the next big shortage in this medical crisis, according to experts in the pharma supply chain, and there are a whole bunch of reasons it will be difficult to ramp up production and distribution of the needed meds in time to meet the needs.

So please, look at the kittens and take some deep, regular breaths, because this is some scary stuff.

When someone's put on a ventilator, the machine does the breathing for them, and they need to be heavily medicated, because our bodies would much rather breathe on their own, thanks. A breathing tube has to go down the patient's airway to their lungs, and you just can't do that without a bunch of meds:  

Our gag reflexes are so strong that it is impossible to properly place the tube without sedating the patient, and muscle relaxers are often necessary to relax the windpipe, said Marcus Schabacker, CEO of ECRI Institute, a nonprofit in Montgomery County [Pennsylvania] that studies health-care quality, safety, and efficiency.

Once connected to the ventilator, patients must remain in a medical coma, with sedation and pain medications, he said.

"The ventilation process itself is so intolerable that an awake patient would not tolerate it," said Schabacker, an anesthesiologist and intensive care specialist. "The reversal of lung function is so counter to anything your physiology would allow, we need to put the patient in an artificial coma."

And demand for those drugs is already starting to become a problem. In March, orders were up by 50 percent above normal, while "fill rates" — the percentage of orders actually filled by suppliers — had dropped by 25 percent nationwide. And we aren't even seeing the peak of hospitalizations yet. According to Daniel Kistner, the pharma manager for Vizient, America's biggest supplier of drugs and equipment to nonprofit hospitals, it's an "unprecedented" surge in demand. And while the country is trying to ramp up ventilator production, it also needs to be getting more of the drugs that make using those ventilators possible: "We're gonna build all these cars, but if we don't have the gas, they can't go anywhere." (Kistner is cited in articles at NPR , Vox , and the  Philadelphia Inquirer , and he uses that analogy each time.)

And just as it's difficult to convert a car assembly line to start churning out ventilators, there are several factors complicating increased production of sedatives, painkillers, muscle relaxers, and other necessary go-juice for patients on ventilators. For one thing, all IV-injectable drugs need to pass a 21-day sterility period to make sure they're free of contamination; in total, Kistner says, a new batch of meds that started being made today would take about five weeks to get to an emergency room.

For another thing, virtually all the drugs are generics, which you might think would make them plentiful, but hooray for the profit motive, that actually means they only bring in enough revenue that most pharma companies concentrate on patented meds that make profits, leaving gaps in the supply chain, according to Erin Fox, a pharma honcho at University of Utah Health.

"Most of drug manufacturing is on a just-in-time schedule," Fox says. "It's pretty rare for companies to have more than a three-month supply, six-month supply on hand. And with the [COVID-19] surge, we are going to just burn through that at an incredible rate. A three-month supply could go in a week" [...]

"Thesehospital drugs are very, very cheap. It's just not a big profit-making arm for these companies," Fox explains.

And to complicate matters even more, Fox says, pharma wholesalers are sticking to anti-hoarding procedures that limit new purchases based on their prior order history, even though past usage rates have suddenly been made irrelevant. She adds that because many of the meds are controlled substances, "the Drug Enforcement Administration has rules about how much a hospital is allowed to buy [...] You can't just order double." (We are not A Expert, but isn't that one of those bureaucratic bottlenecks a National Emergency order is supposed to help prevent?)

And while many experts have been calling on Donald Trump to act like he has executive authority even when it won't pressure Ukraine, it's not even clear whether the looming drug shortage could be addressed by invoking the Defense Production Act, says Fox, even though the FDA has already asked pharma companies to increase production.

"They may literally be limited by the total amount the factory can make in a certain amount of time." In normal times, a solution could have been importing critical medications from other countries, but in a global pandemic, we don't have that luxury. "Europe is having their own shortages of the same medications," Fox says. "It's not like there's empty factories we can just turn on and start cranking out drugs."

With increased ventilator use, hospitals are already seeing shortages. In Albany, Georgia, Phoebe Putney Hospital has gone from a typical 12 to 15 patients on ventilators to a high of 46 at once.

"At present we're running through anywhere up to 134 bags of fentanyl," says Dr. Shanti Akers, pulmonary and critical care physician at Phoebe Putney. "Pre-COVID that would have lasted us two to three weeks. And now we're running through that quantity in simply a day."

Worse, COVID-19 patients often need to be on a ventilator for two weeks or even longer, compared to an average of a few days in the Before Times.

"The nightmare really is that I won't have enough ventilators to treat them all at the same time," Akers says. "And even if I get them on a ventilator, I won't be adequately able to sedate them to know that they're safe. And my real worry is that a lot of people will die as a result of that."

Ordinary Americans can't cook up bags of fentanyl for hospitals (at least outside the sketchier neighborhoods), but we can all do one thing to help the meds and ventilators go as far as possible: Stay the fuck home and keep the infection rate down. Watch TV and read books, secure in the knowledge that you're helping. We should start selling stickers with a picture of a TV that says "I Helped Flatten The Curve."

[ Vox / NPR / Philadelphia Inquirer / Photo:  Paul Schadler, Creative Commons license 2.0 ]

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