Everyone agrees that medication supply shortages are a pain.
The current shortage of two HRT patch brands will mean plenty of hassle for affected women, more doctor visits, and thousands of extra conversations with pharmacists.
Replacement products may be less suitable clinically, and medication substitution will increase confusion and the likelihood of dosage error.
The problems of shortages are obvious, but it’s not at all clear what can be done to prevent them. In fact, it’s difficult to even pinpoint who is responsible for their prevention — and who should pay.
One way of reducing the potential for shortages is for a buyer to stockpile. In the US, this is increasingly being done by private hospitals and the giant health insurers.
But in Australia, the cost would inevitably fall to the federal government, at the expense of other health budget items.
We do this occasionally with medications prone to running out in extreme circumstances such as infectious epidemics.
Even then, we get it badly wrong: the $200 million Tamiflu stockpile was widely considered wasted when subsequent research revealed the drug shortened symptoms by just half a day, without reducing complications or hospitalisations.
Stockpiling is inefficient, expensive, and impractical in most circumstances.
So should the obligation fall to the manufacturers? Again, we have to be careful what we wish for.
Obliging a private company to produce a product necessarily entails punishing them financially if they get it wrong. For example, making this a condition of PBS listing.
The fine would have to exceed the year-round cost to the company of creating a buffer by continually producing more stock than required.
In essence, this just shifts the stockpiling costs to the manufacturer, which they would pass back to us.
So although running out of two HRT brands wastes time and money, the costs of implementing a system where this never happens are potentially far greater.
Drug safety and return of menopausal symptoms are also concerns, but they can also be put into perspective.
Imagine a world where neither brand of patch had ever been invented. No one would get up in arms and insist that someone had a duty to start manufacturing them. Nor is it anybody’s ‘right’, for example, to have two new patches enter the market in 2018.
If there is any hint of ‘gaming’ by the pharmaceutical company, that should always be exposed. But in most cases, the manufacturer is the one losing the money, and already has incentive enough to rectify the supply-demand mismatch.
Most drug shortages fall into the above category — they are a hassle and expensive and no one wants them — but temporarily we cope.
The lack of slow-release metformin last year was annoying, although removing the PBS subsidy for Panadol Osteo caused more complaints. Extraordinary, given that the 665mg dose was, in my view, merely a marketing concept gone viral.
More concerning, of course, are shortages of drugs with few or no alternatives, such as certain oncologicals or antibiotics. The knowledge that no one in the world had access to the drug until its recent invention is of little comfort. It is a genuinely life-threatening problem.
Unfortunately, I can’t offer an affordable, universal solution and nor, it seems, can anyone else.
*Justin Coleman is a GP at Inala Indigenous Health Service, Brisbane. Medical writer and editor. Medical Observer columnist.