Pharmacists want more flexibility to help manage drug shortages

Critical drugs such as the breast cancer treatment letrozole and epi-pens have been in short supply.

Pharmacist Aila Aitamurto Image: Timo Nykyri / Yle

Most Finnish pharmacists want more rights to substitute drugs when filling prescriptions to help manage a shortage of pharmaceutical products, according to a survey by the Association of Finnish Pharmacies (AFP).

Around 65 percent of respondents said that supply problems had worsened over the autumn, with just four percent saying the problems had eased.

There have been supply problems with painkillers, birth control pills, blood pressure medication, epi-pens, adrenaline pens and cancer drugs in Finland, according to the survey.

Some 95 percent of respondents agreed either completely or to some extent with the idea that they should be able to swap out unavailable medicines for ones they can get hold of, and adjust the dosage to account for the replacement medicines' strength.

Currently, it is possible for pharmacies to substitute prescription meds with a cheaper generic. The right to exchange is package-specific — the strength of the medicine or dosage cannot be changed.

By the end of September, pharmaceutical companies had made 1,151 notifications about medicine supply problems.

The drug availability problem is exceptionally widespread, said Aila Aitamurto, who runs two pharmacies in Oulu and has been working in the industry for 35 years.

"The situation has never been this bad," said Aitamurto, who added that pharmacies have to work extra hard to find replacement.

"Pharmacy workers need to call the prescribing doctor to switch the prescription drug to one that is available," she said.

Of the 386 pharmacies that responded to the survey, 65 percent reported that the problem had worsened during the fall. Pharmacies estimate that disruptions in supply cause pharmacists to work an extra 6.5 hours per week on average, most of which is spent on customer service.

Health centres burdened

Hannu Halila, deputy CEO at the Finnish Medical Association, says more flexibility in the rules would be a good idea. He hopes that Fimea and the Ministry of Social Affairs and Health could provide guidelines to pharmacies.

"For instance, it would make sense to replace a two-milligram pill with two pills of one-milligram each without changing the medicine. It should be allowed to use common sense," said Halila.

However he added that the drug should not be changed if the patient does not approve.

Halila observed that the shortage of drugs is embarrassing for doctors, and the constant calls from pharmacies can burden health practitioners, who may already be suffering from burnout.

"It would be ideal for a doctor to check what kind of medicine is not available when writing an electronic prescription," Halila said.

While a nearly daily list of unavailable drugs is available on Fimea's website, it is not always possible for doctors to go through the list every time they prescribe drugs, said Halila.

No substitutes for some drugs

While the Finnish Medicines Agency Fimea’s list of interchangeable drugs is extensive, there are still a lot of drugs that don’t have accepted substitutes.

Aitamurto said that one such drug is penicillin, which has been in short supply worldwide for years.

"With temporary permissions, substitutes are sometimes brought to Finland based on availability. However, medicines cannot be switched to another one containing the same active ingredient if they are not on the list of interchangeable medicines," he added.

Since 2003, pharmacies have been allowed to substitute prescription meds with cheaper generic drugs.

This has resulted in savings of more than one billion euros, revealed Erkki Kostiainen, director of communications at AFP.

Granting pharmacies more rights to switch medication in the event of a supply disruption would reduce unnecessary contacts with doctors, said Kostiainen, who added that a similar practice exists in neighbouring Norway.

"The risk of errors while making a switch is low. Of course, explaining the change to the customer could add to the work of pharmacies, especially in the case of a memory-impaired, older patient," he said.

Shortage of birth control pills, pysch meds, cancer drugs

According to statistics from Fimea, this year the shortage has most affected pain and psychiatric meds and drugs for cardiovascular disease. There has also been a scarcity of drugs for sexual and urinary disorders, as well as birth control pills.

Johanna Linnolahti, a senior pharmaceutical inspector at Fimea, adds that the most critical drugs that have been in short supply are the breast cancer drug letrozole and epi-pens.

“The cancer drug is needed for a very vulnerable group of patients. Epi-pens are used to treat severe allergic reactions and it has been difficult to find a replacement for them,” Linnolahti said.

According to Linnolahti, it has been difficult to find substitutes for drugs in fewer than ten cases each year.

In addition to prescription drugs, there is also a shortage of over-the-counter medicines.

Global supply problem

The drug shortage has been increasing since 2016 and 2017. The problem is not limited to Finland, as shortages have affected markets across the globe.

Finland is dependent on imported medicines — up to 80-90 percent of medicines are imported from outside Finland. A lot of drug manufacturing is now concentrated in plants located in India and China. However, production problems have been observed in the manufacturing of several generic drugs. Factories in China have even been closed due to the environmental issues that they cause, according to Kostiainen.