What These 5 Drug Shortages Say About Pandemic Life
The sobering lessons behind spikes in steroids, insomnia drugs, and more
In early March, Eli Sklarsky, a private school admissions professional in New York City, started building a pharmaceutical stockpile. Sklarsky has an autoimmune disorder that requires him to take eight different medications a day, and as the Covid-19 pandemic spread, he was preparing to enter a lockdown-style quarantine.
“I requested a three-month supply of almost everything,” Sklarsky says. He was trying to be proactive: He didn’t want to have to make another trip to the pharmacy, and he wasn’t sure what the impending shutdown would mean for drug manufacturing and the pharmaceutical supply chain.
Sklarsky’s concerns were well-founded. At the end of 2019, there were already 270 drugs on the Food and Drug Administration’s (FDA) shortage list. As pandemic closures affected manufacturing and the demand for specific drugs rose, the FDA reported nearly 50 new shortages, bringing the total number of medications in short supply to more than 300. The list spanned the diagnostic spectrum, from sedatives and paralytics commonly used for intubated patients to anti-inflammatories that treat conditions as routine as hemorrhoids. The shortage list is part of a broader picture that pharmacy data — including which prescriptions are rising and falling — paints about America’s health.
One of the first prescription spikes, which pharmacy benefits company Express Scripts documented in its America’s State of Mind Report as early as mid-February, was in anti-insomnia meds. Between February 16 and March 15, Express Scripts reported that prescriptions for sleep disorders rose nearly 15% over the same period in 2019.
“I don’t usually prescribe [the sleep aids] Ambien or Lunesta, but in recent months I’m doing a lot of that,” says Carlene MacMillan, MD, the psychiatrist founder of Brooklyn Minds, a mental health treatment center in New York. “Derangement in sleep cycles is so much higher.”
A review paper published in April in the Journal of Sleep Research enumerated the pandemic-related factors that could have a negative effect on sleep quality. In addition to stress and uncertainty, the authors wrote, “Some citizens in strict confinement will be exposed to less daylight than usual, particularly those living in homes with small windows and without an outside area. Many may exercise less due to cancellation of regular sporting activities.”
Less sun exposure can affect circadian rhythm, and abrupt changes to an exercise regimen can make it more difficult to fall asleep, MacMillan says. “When you suddenly don’t have to be up for your morning commute or you’re not going to the gym, that lack of structure makes a big difference. People start to experience sleep creep, where you’re staying up later and later and suddenly it’s 3 a.m.”
Anxiety and depression medications
When the first shelter-in-place orders were issued in March, pharmacies experienced a significant spike in fills for antidepressant and anti-anxiety medications. A report from SingleCare, a pharmacy discount service owned by health technology company RxSense, found that antidepressant prescriptions increased by 50% in the third week of March. In another survey the company completed of 1,000 people, more than half said the pandemic had affected their mental health.
MacMillan says that under normal circumstances, medication isn’t her first course of action, especially for new patients. “We usually preach ‘skills, not pills,’” she says. But under quarantine, typical coping methods have become difficult or impossible for many people, and MacMillan’s prescribing rate has gone up.
“Someone might normally cope by going to their art studio, playing team sports, playing in a band,” she says. “These are the things people seek out when we say you should make some friends, the things we tell people to do to enhance their environment. But then all of a sudden we couldn’t tell people to do those things.”
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The spike in prescriptions may also have other drivers, MacMillan says, including the temporary loosening of restrictions around telehealth and controlled substances. “The government changed the rules that kept doctors from prescribing to people they’d never met in person, which allowed people to see a therapist from the comfort of their home. A good number of those people are getting help for the first time.”
Add to that the fact that many people who might otherwise be getting off their anxiety or depression medications continued to fill prescriptions. “I had a number of patients who were planning to taper their meds who didn’t, because the pandemic didn’t seem like the right time to be doing that,” MacMillan says. “At any given time, there are people who are going off those medications as other people are starting them, which usually keeps the average pretty constant, but for the last four months that hasn’t been happening.”
Numbers fell in April and May, but Ramzi Yacoub, PharmD, chief pharmacy officer of RxSense, says the company tracked another, even bigger spike — a 60% increase — in June. “It somewhat tapered off and there was a bit of a lull, but now we’re seeing another rise in antidepressants,” he says.
At the beginning of June, the FDA listed the popular antidepressant Zoloft and its generic counterparts among the medications in shortage. MacMillan attributes the second wave to the uncertainty of reopening. “I think in the late spring, people were actually getting used to pandemic life,” she says. “Now things are even more uncertain—not knowing if we’re going back to school, back into quarantine, if the unemployment benefit is going to get extended. It’s almost the end of July, and we have no control.”
“I think because health insurance is so tied to people’s jobs, we’re going to see a lot of situations where people suddenly can’t afford their medications anymore.”
Flu vaccinations and allergy medications
The start of the pandemic coincided with flu season, and in an effort to avoid getting sick, large numbers of Americans sought out flu shots. “I don’t know if maybe people felt, ‘Hey, there’s something going on, let me get my flu shot and get myself protected,’ but we did see those spikes,” Yacoub says. Between February 24 and March 9, SingleCare saw demand for the Flucelvax Quad and Fluzone Quad vaccinations increase by close to 500% over last year.
There were also increases in “Albuterol inhalers, commonly used for asthma and shortness of breath, and [the allergy medication] Zyrtec and its generics, all of which do help with similar symptoms to those that can be caused by Covid-19,” Yacoub says.
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But while allergy meds and flu shots spiked, there were decreases of around 20% in prescriptions for common cough medicine and the generic version of Tamiflu, usually administered within a few days of a flu diagnosis.
“We saw a couple different drops in that same data set,” Yacoub says. That could mean that the flu didn’t spread the way it typically does as a result of social distancing, or it could indicate “people not going to physician’s offices,” he adds. The SingleCare survey found, for example, that more than half of Americans had skipped or rescheduled appointments or elective procedures to avoid being exposed to the virus.
Hydroxychloroquine and steroids
Eli Sklarsky’s autoimmune condition, antiphospholipid syndrome, manifests itself as a clotting disorder. For several years, he dealt with recurrences of diffuse alveolar hemorrhage — essentially, bleeding into the lungs.
“It’s a fairly uncommon but serious complication,” he says. “I was hospitalized quite a few times, and we tried many different medications, but none were really effective.” Finally, a rheumatology specialist put Sklarsky on hydroxychloroquine, an immunosuppressant that now keeps his lungs clear of blood and keeps him out of the hospital.
In March, reports began to emerge that hydroxychloroquine might be an effective treatment for the coronavirus, and President Donald Trump called it a “game changer” in a televised briefing. Sklarsky heard that and panicked. While he’d stocked up on his other medications, he only had about a two-week supply of the drug that, as he puts it, “keeps him alive.”
“The first thing I did was call the pharmacy, and they were already saying they didn’t have it in stock and it was on backorder,” he says. Within a few days, the FDA had added the drug to the shortage list, and some physicians were even found to be hoarding hydroxychloroquine. “It was anxiety-inducing. I was mad, I was frustrated, I was worried,” Sklarsky says.
Ultimately, his rheumatologist was able to secure him a month’s worth of the medication. Before that month was up, studies were published refuting the drug’s effectiveness against Covid-19, and demand returned to normal. Though continued misinformation about the drug and its effectiveness for Covid-19, including messages from the U.S. president, remains a threat.
Another medication being used with more apparent success by people with Covid-19 is the steroid dexamethasone, which is used for a wide range of conditions to tamp down inflammation. Since 2019, 16 different dosages of the routinely used steroid have been on the FDA shortage list (even pre-pandemic, its major manufacturers were reporting difficulty keeping up with demand), but a University of Oxford study published in mid-June found that dexamethasone reduced intubated coronavirus patients’ risk of death by a third. Vizient, a company that negotiates wholesale drug contracts on behalf of hospitals, reported a 610% increase in demand in the weeks following the study’s release.
“Dexamethasone is the first drug to be shown to improve survival in Covid-19,” said Peter Horby, MD, PhD, one of the lead investigators of the Oxford study, in a statement. “Dexamethasone should now become standard of care in these patients.”
Shortage or not, the promising results mean demand for the drug will almost certainly keep increasing as long as doctors are treating Covid-19.
Chronic condition medications
From the first days of the pandemic, concerns about supply chain breakdowns saw people stocking up on everything from toilet paper to dog food, and the urge to build a reserve extended to daily medications.
“We saw spikes in chronic medications in the early part of the year, as people stocked up on things like cardiovascular medications and diabetes medications,” Yacoub says. “There was a lot of concern about shortages early on because a lot of these medications or their active ingredients are coming from other countries.”
MacMillan says there was a surge of requests in the early spring for 90-day prescriptions tied to supply chain concerns, but that the medical community is now seeing another spike in those requests for a different reason.
“I think because health insurance is so tied to people’s jobs, we’re going to see a lot of situations where people suddenly can’t afford their medications anymore,” she says. An estimated 40 million Americans have been rendered jobless by the pandemic, and more than half of them are likely to lose their insurance coverage. The SimpleCare survey found that a third of people expect to pay hundreds of dollars out of pocket for prescriptions before the end of the year.
MacMillan says it’s likely those people are trying to stock up before their insurance ends and the price tag becomes prohibitive. “I’ve had a lot of people be like, ‘Write the prescription now, because I need to get it while I still have coverage.’”