No drugs…! Three active pharmacists talk about the current state of “desperate pharmacies

In April 2001, the Abe administration formulated a “roadmap for further promoting the use of generic drugs. It promoted the expansion of the use of generic drugs. In December last year, the Ministry of Health, Labor and Welfare announced that the use rate of generic drugs had reached about 78% as of September of the previous year.

However, this policy has completely backfired. Starting with the revelation of quality irregularities at Nichi-Iko, one of the major generic drug manufacturers, in March last year, the supply of generic drugs was halted due to a series of problems, including contamination by foreign substances at Kobayashi Kako and the suspension of production at Nipro due to the earthquake. Dispensing pharmacies across the country are screaming, “We have no drugs! FRIDAY held an emergency roundtable discussion with three active pharmacists. FRIDAY held an emergency roundtable discussion with three pharmacists, who spoke frankly about the “life-threatening” Covid-19 disaster.

Pharmac ist A, who runs a dispensing pharmacy: “It’s no joke. Even if I place an order, the medicine doesn’t come in. ……”

Pharmacist B, who works at a university hospital: “In December last year, the Ministry of Health, Labour and Welfare issued a notice to the Japan Federation of Pharmaceutical Manufacturers’ Associations (JPMA) asking for cooperation in increasing production of 22 products for which the supply is particularly low, but it has had little effect.

Freelance pharmacist C: “It’s too late to move. There have been signs of shortages of generic drugs since around ’20.

A “It’s the acne treatment drug Duac, isn’t it?　Around the summer of ’20, we were puzzled when we couldn’t get it in stock at all, weren’t we?

B “At that time, all the pharmacists became anxious, wondering what would happen if there were a series of generic drug shortages. And our fears came true. Shortages began to appear one by one, and accelerated in 2009.

C: “In the summer of 2009, when there was a shortage of the osteoporosis drug alfacalcidol, the Ministry of Health, Labor and Welfare (MHLW) issued a notice to stop using the drug and avoid new prescriptions, but the shortages did not stop. Especially after last fall, we started receiving a large number of phone calls and faxes from drug wholesalers every day about the shortage. The number of shortages increased to the extent that we couldn’t keep track of which drugs were not coming in.

A: “Monday mornings are almost over for dealing with shortages. …… How about university hospitals?”

B “Shortages are becoming more noticeable at hospitals as well. Some intravenous medicines have been affected, and some oral medicines are not coming in. However, compared to dispensing pharmacies in town, university hospitals have more and thicker routes with pharmaceutical wholesalers, so it’s easier for them to get drugs from manufacturers they don’t normally deal with.

A and C: “How do you deal with medicines that are out of stock?

B “For example, the situation where we can’t get any of the medicine for hypertension and angina pectoris, ‘Amlodipine 10mg’, continues, but ‘Amlodipine 5mg’ is in stock, so we supply two pills to deal with it. When the same drug is not available – most recently, “Sepamit”, a drug for high blood pressure and angina pectoris, was not in stock at all, but in such a case, we provide the doctor with the information on the shortage and discuss which drug to change to. In such a case, we would provide the doctor with information on the shortage and discuss with him which drug to change to. Sometimes, the doctor would consult with the DI office, a department that provides drug information, and discuss alternative drugs. In the case of a university hospital, team-based medical care is established, so I think we are able to manage to deal with this situation.

A: “University hospitals are the last bastion for emergency and intractable disease patients. We can’t afford to run out of medicine, right? Compared to that, the dispensing pharmacies in town are miserable.

C: “We dispensing pharmacies in towns don’t have the same team-based medical care as university hospitals, so we have no choice but to ask doctors to change prescriptions. Most of the time, it doesn’t go smoothly. The other day, we had a situation where the hypertension and angina pectoris drug “Nifedipine CR20mg” did not come in for a while, and the brand-name drug “Adalat CR20mg” was also out of stock. I asked the prescribing physician to change the medicine, but he said, “There is no way I can change my prescription just because the pharmacy doesn’t have the medicine!　The pharmacy in front of our university hospital has the drug in stock. Isn’t that a lack of effort on your part? He scolded me. I hung up the phone and said, ‘Please share the fact that drug shortages are occurring at pharmacies all over the country.

A: “It is a matter of course that ‘front-door pharmacies,’ which are located near university hospitals and other large hospitals, are given priority in receiving medicines. Because these pharmacies issue more prescriptions than other pharmacies, they receive more drugs, and from the wholesaler’s point of view, they become “big customers” and are given priority. The inventory imbalance should also be corrected.

B: “If there is one patient who needs a special medicine, we have to stock up just for that patient. So the sales themselves do not increase. It’s a problem for the pharmacies in town that are working hard to serve all kinds of patients, but they can’t keep enough stock.

A “There is an aspect that the distribution of medicines depends on the MS (pharmaceutical wholesaler’s sales representative), isn’t there?

C “Even after all this time, I still feel like I should have gotten along with them on a regular basis.

A “However, such background has nothing to do with the patients, so they won’t be convinced even if I tell them that there is no medicine. A “But that background doesn’t matter to them, so they won’t be convinced if I say, ‘We don’t have any medicine. Your job is just to collect and dispense medicines, right?　Can’t you even do that? You can’t even do that!” I had no words to reply.

C “Even when we suggest alternative medicines, many patients are resistant to switching drug manufacturers. The hurdle is quite high. It’s quite a hurdle. Or, ‘My blood pressure is no longer stable. What are you going to do about it? What are you going to do about it?

B: “The definition of a generic drug is ‘one that is therapeutically equivalent to the brand-name drug. The additives vary from manufacturer to manufacturer, so there is a possibility of causing an allergic reaction due to the change in additives.

A “If anaphylactic shock occurs, it can lead to breathing difficulties and even death.

C “When the supply of the standard heart failure drug ‘bisoprolol’ was reduced, it was a serious situation for the Japanese Heart Failure Society to recommend measures for heart failure patients. Switching to other drugs requires attention to the presence of bronchial asthma and liver damage, and there is a risk of unexpectedly worsening symptoms.

A “Many doctors are concerned about the declining supply of psychotropic drugs.

A psychiatrist, Dr. Kina Takagi, adds.

Psychiatrists are having a hard time prescribing sodium valproate drugs such as Depakene. This is because there are no alternative drugs with the same efficacy. There is a risk involved in changing the medication of patients with stable symptoms. In fact, I have heard that in some cases, such as patients with bipolar disorder, their condition becomes unstable or worsens when their medication is changed.

In the case of bipolar disorder, the instability can lead to severe depression and strong “thoughts of death.

“You have to pay the difference!

B “Earlier, I introduced the measures such as ‘prescribing 2 tablets of 5mg because 10mg is not available’ or ‘switching to the brand-name drug’, but this would increase the price of the drug several times.

C: “I was once told, ‘Since you are changing the prescription for your own reasons, I hope you will pay the difference! C: “I’ve had people say to me, ‘You’re changing it for your convenience, so I hope you’ll pay the difference!

A: “No matter how much the patient yells at you, if the drug manufacturer says it’s a ‘shipment adjustment,’ there’s nothing the pharmacist can do. If several manufacturers adjust their shipments at the same time, as in this case, orders will be concentrated on other manufacturers and the decline in supply will be accelerated. If the demand for brand-name drugs increases rapidly, there is a possibility that shipment adjustments will occur for brand-name drugs as well. It is true that I have been recommending generics to my patients, and I and my family have been using them as a matter of course, but I am hesitant to recommend them in the future.

C “To be honest, I’m also not comfortable recommending generics.

B “It is expected that the decline in the supply of generics will become more serious in the next two to three years.

A “The fact that ‘Nichi-Iko’ has been shipping non-compliant products for more than 10 years triggered the MHLW to declare that it will strengthen its unannounced on-site inspections of generic drug manufacturers. If other companies are found to be cheating, there will be new drugs that will be discontinued, which will cause a further decline in supply.

C “In my 20-year career as a pharmacist, I have never experienced such a shortage of medicines.

A “We were walking on a tightrope at the end of the year, but pharmacies will be pushed even harder toward the end of the fiscal year. I think that some pharmacies will go under. This is because there will be a revision of medical fees in April, and drug prices will drop. Normally, we would like to reduce our inventory and start receiving drugs at the new, lower prices in April, but we have no choice but to buy drugs that are in the process of shipment adjustment if we have a chance to receive them. From April onward, we will have to sell drugs that we bought at a high price at a low price, which will directly affect our business.

C “If the inventory purchased at the beginning of the month is 10, it would be ideal to reduce it to 4 by the end of the month, but considering the patients, we have no choice but to prioritize avoiding shortages.

A “What do you think should be done to solve the declining supply of generics?”

B “I think it is unreasonable to try to reduce medical costs by suppressing drug prices.”

A “I agree with you. A “I agree with you. In order to lower the NHI price and still meet the increasing demand, NHI has committed fraud, which means that the field has gone beyond its limits. In order to reduce medical costs, self-medication should be promoted so that minor illnesses such as a cold can be treated without going to the hospital.

The cost of mismanagement is too great.

From the January 28, 2022 issue of FRIDAY