Story 51 – Methotrimeprazine in Palliative Care

A resident physician working in palliative care in Alberta writes…
[We] have been unable to get Nozinan SQ [injectable methotrimeprazine] in the community in the past week (to be fair, I just switched to home care this week and the impression I got is that this shortage has been going on for quite a while this year). According to home care here and the local pharmacists, it is on backorder. This has been a recurring problem.
This is a relatively critical drug for patients at end of life for comfort (it is often used for agitation when some component of sedation is beneficial – for example haldol can address agitation but does not have the sedation property) and when patients cannot take PO medications we turn to the SQ form. Have you heard anything about this medication experiencing a shortage?
Webmaster’s reply:
Thank you for remembering my endless quest. I had not heard about this particular shortage.There are usually 700 to 1000 shortages going on at any given time. We hear only when someone speaks up.
 
The shortage is reported here at Health Canada’s site
 
Apparently it began 4 Jan and should end 28 Feb 2019. “Delay in manufacturing” is the vague “cause” given.  You will note that the first report came on the very day that the shortage began — despite a “rule” that shortages should be reported in advance.
 
But why might it be recurring?
 
From checking the Health Products Database we learn that it is also the only injectable format left after Sanofi appears to have cancelled all its other formats:
 
However the Drug Product Database also shows that some oral versions are still available from AA Pharma:
 
At the same time — it reveals that several other companies have just stopped making it, one by one since 2003— Aventis, Pro Doc, Pharmascience, Riva, Novopharm.
Why? Usually it is for business reasons — not enough profit from low prices and few sales.
 
This, then, is the perfect set up for a shortage — a single maker with a problem and no back up.
 

Story 50 – Bupropion

A woman in rural BC writes :

You’ve asked for stories, and I’m needing to vent, so here goes…

I finally landed on the right drug at the right dosage after decades of struggling with depression. Bupropion XL 300mg turned my life around, and with my 60th birthday looming, I was actually looking forward to the rest of my life. I had given up on antidepressants because they just seemed to make things worse.

I’ve also struggled most of my life with my weight and have been growing increasingly desperate about it. I heard about a new weight-loss drug called Contrave, a combination of the generic drugs bupropion (an antidepressant) and naltrexone (used in drug rehab), which sounded both promising and safe. While Contrave had been available in the US for a few years, it was not yet available in Canada, but my doctor was willing to prescribe these two generic drugs in dosages that approximated Contrave.

As it turned out, this didn’t help a whole lot with my weight, but what a difference it made to my energy and mood! I was ME again!

I had tried bupropion before, but only 150mg, and I had given up on it because I experienced mild side effects and no real therapeutic effects. Just add it to the long list of antidepressants I’ve tried. But at 300mg (and perhaps in combination with the naltrexone), it was life-saving. I just needed to take more of it.
So, I was pretty upset when I went for a refill at the end of October to find that this drug that I was stable on wasn’t available. That is, the extended release (XL) form wasn’t, so instead the pharmacist gave me the sustained release (SR) form with the instructions to take 150mg twice a day instead of a single dose of 300mg. Well, twice a day for me is in the morning when I get up and then just before bed.

It took me several weeks before I figured out that the onset of severe sleep problems coincided with this change in drug regimen. I called my pharmacist, who said it definitely was the drug and that he should have told me not to take it before bed.

Well, the doses are supposed to be at a minimum 8 hours apart, but even taking the second dose in the afternoon affected my sleep – it was still too late. So I am only able to take 150mg in the morning, half the dose I need. If I take the second dose, I don’t sleep.

I lost the entire month of November to lack of sleep because I was literally up all night most days of the month. So now I’m on half the dose of bupropion that I need, and while my sleep is better, I can feel my energy and mood slipping downward. I AM SO ANGRY! Finally, I was getting my life together, and now this? And no explanation? And will it EVER be available again?? I need a refill, and it looks like I’ll be getting the SR again.

So that’s my story. Do the pharmaceutical companies have no ethical standards???

—-

Update, Christmas Day:

In consultation with my pharmacist, I am now taking the second dose of bupropion 5 or 6 hours (i.e., less than 8 hours) after the first dose and have not experienced any adverse effects. I need to take the first dose as soon as I get up in the morning, and as long as I remember to take the second dose on time (cell phone reminders are very helpful!), I’m managing. I’ve now been on the full therapeutic dose for a couple of weeks and am beginning to feel decent again. But I feel like I’ve lost two months of my life, and I really resent having to be so vigilant about the timing of my meds when it shouldn’t be necessary.

Story 49 Acebutolol – again!

Well, it has happened again. See Story 27 from 2012 and Story 48 below from June 2018.

My 3-month supply of beta blocker for blood pressure (Teva’s acebutolol)  can’t be filled. On 1 October, the pharmacist gave me a one-week supply — and now I am almost out.

Stopping suddenly is dangerous (heart attacks).

I just called. It’s still “on back order,” and no new orders can be placed. The pharmacist says he will call around to other pharmacies.

But get this! —

I just checked the government’s official website about drug shortages again. https://www.drugshortagescanada.ca

While my problem started 1 October, the company did not report this shortage until 11 October (it had another shortage last July, as per Story 48 below). Other companies that make it also have shortages–Sanis, Apotex, Pro Doc. But two other companies have discontinued it completely: Mylan and Sanofi-Aventis.

So much for advance reporting.

What is going on?

This is a very old drug. Beta-blockers (among other drugs) won the Nobel Prize in 1988.

If I die, blame drug shortage and tell someone.

 

Update 23 October…problem continues!

No Acebutolol is available till December.

My poor pharmacist has spent a LOT of time phoning around, and twice I have been back to pick up sufficient medication for 1 week each time.

My doctor has decided to switch me to a different beta blocker, which I will start today.

Will we ever see acebutolol again? Stay tuned.

 

Update 8 December

So the pharmacist phoned to say the rest of my prescription was “in,” bought and paid for more than two months ago, although the Health Canada website suggests that the problem was resolved a month ago (5 November for Apotex and 16 November for ProDoc. Teva is still in short supply.)

In other words, “resolved” does not mean available.

Now I have TWO beta blocker prescriptions. Which one should I take? Another visit to the doctor. More time and expense for me and the system.

Does the shortage of a beta-blocker come with a warning to patients or their doctors? Certainly none was given to me.

Does providing prescription for TWO beta blockers not generate a warning – or cause the pharmacist to question the medics about what should be done?  Nothing was said about that in the phone call.

I’m lucky that I have an MD — and although I don’t know what to do, I do know that I should not take two at the same time, nor should I just quit.

Worse it would be for someone who just “went without” for two months, letting their blood pressure get out of control…risking heart attack and stroke.

 

Same thing is happening everywhere — see this May 2019 story from USA

Ivan Oransky, when drug shortages hit home for a doctor journalist, Medscape blog, 1 May 2019.

 

 

Story 48 Acebutolol (Sectral) — again!

A woman in Ontario writes….

I have been taking Sectral, a Beta Blocker, since the late 90s and it has worked very well for me. I recently had quite an experience getting my prescription filled. I started with the [local] Costco where I usually fill my prescriptions and the associate said that they are having a problem getting the medicine and suggested I try another pharmacy chain. I went to Rexall where I had the same problem – Sectral is not available. I ended up at a … Shoppers Drug Mart which happened to have a bottle in stock. I filled out paper work, Costco faxed over my prescription, and two hours later I was home with the bottle of pills in my hand.

I have googled the pharmaceutical company who makes Sectral (Aventis) and will call them next week to see if I can get more information about the
shortage.

I am upset that I may have to switch to a new Beta Blocker as this will create a host of issues for me. I have tried other versions of Sectral which do not work for me. I can’t understand why there is a shortage of this medicine after all these years – end of patent? or lack of clientele?

My story is just one in the overall drug shortage problems that you have encountered, but I would appreciate your letting me know if you reach any conclusion, or if you have any other person whom I should write to.

Webmaster comment: we’ve seen this problem before (See Story 27). She should write to her MP and her MPP!! and send them the link to our recent study.

https://www.cdhowe.org/public-policy-research/assessing-canada’s-drug-shortage-problem

Story 47 Fluvoxamine (Luvox)

I’d been on the full therapeutic dose of “luvox” for many years and was shocked to learn in December of 2017 it was discontinued.  I then learned after some minor internet research that this has occurred with other medications–including those for epilepsy.

Since the loss of this medication I have suffered many desperate bouts of suicidal thinking despite utilizing my tools for relief which include singing with a choir, artwork, and many walks.  I feel shame and guilt constantly and ruminate constantly and am not surprised to learn that the more a person tries to push away intrusive thoughts they return with a vengeance.

Two drugs were attempted as replacements, serataline and mirtazapine  bring with them intolerable side-effects.  I suspect there must be many other Canadians dealing with this sudden withdrawal and the shock of learning about the capricious behaviour of pharmaceutical companies.

I just wanted to advise you of my specific experience and hope to learn more about other citizens suffering the consequences of the above-mentioned experience.

Story 46 Nabilone

A reader in British Columbia writes….
I have complex PTSD and chronic pain from Fibromyalgia. I also have insomnia and tinnitus, among other symptoms. For many years I self-medicated with whole plant Cannabis that I grew myself. I have also tried a few antidepressants and other medications, but those failed to help me. Because I could no longer grow my own Cannabis, and can’t afford to pay for it on either the black, gray or legal markets, I have been using Nabilone daily since 2014. I am on disability benefits so the BC government pays for the Nabilone.
If I had a choice, I prefer whole plant cannabis that I turn into edibles, because Nabilone is pure THC, so it has unwanted cognitive side-effects. But Nabilone is the next best option, certainly better than opioids, which my doctor probably wouldn’t prescribe for chronic pain anyway.
In the last few years, there have been regular shortages of Nabilone, which appears to be getting worse. Most months when I got a refill, they could only give me part of my prescription because they were short. Until now, I could go back a week later and get the rest of the month’s supply. But last time, at the beginning of June, they told me they had no stock and the drug company told them they could not resupply them until maybe July. In other words, I could not get Nabilone for this month, and it is uncertain when I can get more.
Fortunately, because of this recurring shortage I have slowly built up a bit of a surplus supply.  As an experiment to see how I would feel without taking it, I stopped taking Nabilone for a couple months, but still filled the prescription and kept the pills. But my pain got too bad so I restarted the Nabilone, but at half the dose I was prescribed, also keeping those extra pills. So now I have a surplus of about a three month supply, which will get me through short, temporary shortages.
The pharmacist told me to tell my doctor about the shortage and ask for an alternative. But I have spent over 10 years, with different doctors and specialists trying different medications, and there is no alternative as effective or safe as Nabilone or Cannabis.  I recently started to use acetaminophen on a daily basis. It’s below the maximum daily dose and my doctor knows, but it does concern me taking it daily on a long term basis. I just don’t have many options.
It’s a dilemma for me, because on one hand, the government is willing to pay for artificial THC, but if I can no longer get Nabilone, the government will not similarly pay for the real thing. In that case, I would return to growing my own plants, but because I need large amounts, I would have to grow more than the four plants that will be allowed under the new law. In other words, I will become a criminal again, risking arrest and conviction, to treat myself if Nabilone is no longer available.
I’m puzzled by this particular shortage. Perhaps it is because there is growing acceptance of Cannabis as medicine so more people are using Nabilone, or maybe some of the reasons you give on your website for shortages explains this one. Thanks for raising public awareness about this problem.

Story 45 Clonazepam

A woman from the Ottawa area writes:
I wish to report my own story about a medication that I have relied on for over twenty years and that, about two months ago or more, it was reported to me that this medication is backordered.
The medication is APOTEX clonazepam of which I take .25 mg twice daily.  Through trial and error over the years, my doctors and I have learned that ONLY the APOTEX clonazepam is effective for me.  Yes, I realize that there should be NO difference between companies on the same medication; however, in my case, that is how it is.
So, the medication is backordered and my pharmacist has said that clonazepam in general is beginning to run low.
I absolutely must have this medication in order to function.  I am quite convinced that if I cannot have this medication that I would become suicidal and would possibly even commit suicide without it.  The dosage is very, very low but the little bit of it that I need is life-saving to me.
So, given that the medication is no longer available at the moment, what am I doing?  Well, the pharmacy has the 2 mg tablets made by APOTEX.  So, the best that could be done is to cut the tablets into four which means that each quarter tablet is .5 mg.  It is impossible to cut the tablet into eighths without having it crumble.  So, initially I tried taking it once a day but that didn’t work as at the near end of the 24 hour cycle, the effects of the drug were too thinned out (and I begin to have serious anxiety symptoms).  Then, I tried taking it twice daily (double the proper dosage) and what happened was that I found myself sleeping hours upon hours throughout the daytime when I should have been awake and alert.  So, that was unacceptable.  Finally, what happened is that my husband suggested that I take the .5 mg tablet ONCE every 18 hours. Obviously, this is awkward but it turned out to be the only workable solution.  I was able to become properly functional.  HOWEVER, as my daughter (who is a student nurse) pointed out to my doctor during a recent visit, this solution is probably NOT sustainable in the long run!!  And, I must keep a diary all the time in doing this.  I tried to program the clock on my smartphone to remind me but that was simply a no-go technologically for some reason. So, I keep track with paper and pen. So far, so good.
So, that is my story at the moment.  I am patiently waiting for the .5 mg APOTEX clonazepam tablets to become re-stocked at my pharmacy so that I can once again cut them in half and take .25 mg twice daily.  The way it works at present is that I take one at 6:00 pm on one day, then at noon the next day, then at 6:00 am the day after that, and finally I take it at midnight and 6:00 pm the final day; then the cycle repeats every 3 days.  It means I MUST wake up at midnight twice during the week.  It means I must be extra, extra diligent in watching that I do not miss a dosage.
Please record my story. One day it may be very much needed.  Thank you.

Story 44 Valproic Acid, Fluvoxamine, Topiramate

A woman from Calgary writes:

I personally have been impacted by a prescription drug shortage. In 2010, I was diagnosed with vestibular migraines, characterized by 24/7 severe and chronic vertigo. When the vertigo was most acute I could not go into stores or areas that were visually complex, I had trouble walking, and I had to rely upon others to do many tasks. I was diagnosed by a neurologist, and we tried several medications to treat the disorder without any success.

Finally, in 2011, valproic acid (an anticonvulsant) produced by Mylan helped partially control the symptoms – at least I got some relief and I could finally stand up and walk without falling over. But in 2012, my pharmacist informed me that Mylan would not be producing valproic acid and this shortage could last a year.

I had difficulty switching between brands (I got ill) so I had to remain on the Mylan brand that I was initially started on. The supply of valproic acid made by other pharmaceutical companies at that time was also very low so I had to consult with my neurologist and find a replacement medication. As I had a partial response with an anticonvulsant, he selected topiramate.

Switching medications was extremely difficult but the response to topiramate was worth it. It truly has been a life saving medication for me. I have had a 100 percent response to the medication. Given the severity of my symptoms I will need to be on this medication for life.

I never thought about drug shortages again until recently. My brother had been taking fluvoxamine that was prescribed by a psychiatrist to treat social anxiety disorder and obsessive compulsive disorder. Presently there is no fluvoxamine available in our city (Calgary). So his doctor had to decide on a different medication. I learned that there is also a shortage of Lithium.

The other day I was discussing my brother’s situation with my pharmacist and asked him if I should be worried about topiramate availability in Canada. I was quite surprised and rather upset when he answered “yes” – that topiramate is expected to be in short supply in the future. Without that medication I will be not be able to function. I am extremely worried about this situation and angry that it is happening and we don’t know why.

Story 43 Repeated & baffling shortages of specific painkiller

A 70 year-old reader from Toronto area writes:

I have been disabled by spinal cord injury and Multiple Sclerosis pain since 2006 and have Multiple Chemical Sensitivity.  I retired early because of this pain from the national office of a large health charity where I worked for over 25 years in senior positions in education and research. I also participated in consultations and collaborations with the federal government and other health charities and health professional organizations.

For years, I’ve been a patient at St Michael’s Hospital’s Pain and MS Clinics in Toronto under whose direction I’ve tried all available other pain control options.  They either don’t work for me, I have allergic reactions, or the side effects outweigh the value. The only pain medication I can tolerate for my severe MS and spinal cord injury pain contains nabilone and I take a high dose.  Luckily for me, it is non-addictive and unlike many medications, appears to have no dangerous side effects. Frankly, if I don’t have this medication, the pain will be unbearable.

However, it’s been in short supply since June 2017.  I assumed at first this was a glitch in the system but then realized the system is the glitch.

In June, 2017, my local independent pharmacist told me he could not fill my prescription because his supplier was out-of-stock but he knew Shopper’s Drug Mart had a supply. So I take my new 3 month prescription from St Mike’s Pain Clinic to Shopper’s.  My drug plan only permits one month supply at a time but for two months, Shopper supplies.  Then, when I need the third month in August, consternation from Shopper’s – their distributor cannot supply either the brand name or generic form of the drug until January, 2018.  However, that same local independent drug store I normally use now can get a quantity of the drug from its supplier so I had to get a brand new prescription from St. Mike’s.  The local drug store was able to provide the medication for three months, but then their distributor ran out of stock.  Meanwhile, through family members (not health professionals), I’d learned of another drug store that had a supply and St Mike’s sent a prescription there – however, they were now out-of-stock so they could only give me less than 2 weeks of supply.  I didn’t have enough to last until January so I reduced my daily dose to make them last longer but reverted back to my usual dose when I realized my savings only last a few days and meanwhile the pain increase was significant and my stress was affecting my family.

A new just-opened pharmacy we found had some inventory and was able to get me more when the Ontario government released a limited inventory of a small dose previously delisted.

The message from all of the drugstore staff I spoke to from June to December 2017 was that their suppliers said that the shortage would last until January, 2018 and their only advice was to call every drug store in Toronto to see if they have any stock left.  Unfortunately, most of the stores I found who had any at all were holding back supplies for their regular patients.

All of these pharmacists had no idea why the specific drug was in short supply but eventually I learned that there was a worldwide shortage of the active ingredient. By the end of December, 2017, various manufacturers had received approval from Health Canada for a substitute source (email communications) but one respondent honestly commented that no one could guarantee future shortages would not occur.

Story 42 Cancer chemo cancelled due to drug shortage

A woman in Ontario writes….
On Friday March 3rd, I was informed that my chemotherapy was cancelled because the drugs that are used in my treatment were not available. I was not told which drug.  I take four: Irinotecan, Leucovorin, Fluorouracil, and Avastin. I understand that some drugs were held because there was leakage, and that they have now been made available. But I have not been rescheduled for chemotherapy as yet. I am worried as it is important for me to receive this treatment. When I learn what is happening I will inform you.
 One week later: chemo found, and given.
Webmaster:
Thanks for the story!
Health Canada indicated that the affected drug was 5-Fluorouracil. Some vials had been found to be leaking and a batch had been held up. The ‘quarantined’ batch is now released and hopefully your treatment will be re-scheduled soon.
However some important points.
1. when one drug is unavailable usually the whole treatment must wait. It does not mean all the drugs are in shortage.
2. the drugshortages.ca tracking site indicates that Canada has experienced shortages in all 4 of these drugs since 2012–more frequently with the off-patent older drugs, than with the one on still patent (Avastin).
3. Cancer drug shortages are not new.