The first wave of critical shortages exposed by the coronavirus was medical masks and gowns. Then it was ventilators. Now, a handful of crucial drugs are in short supply in overrun ICUs throughout northern New Jersey and New York City, many of which are needed to use the ventilators.
At the top of the list is fentanyl, the deadly synthetic painkiller — 100 times more powerful than morphine — the very drug that has become public enemy No. 1 in the nation’s war on opioid addiction. Demand for fentanyl has doubled nationwide and shot up more than 500% in the New York/New Jersey metropolitan region, the current global epicenter of the pandemic.
Fentanyl may have been killing people in record numbers on the streets of New Jersey in recent years, but in our hospitals, it is now saving lives.
New Jersey and New York City currently have about a 10-day supply of fentanyl, according to data collected by Premier Inc, a purchasing group for hospitals. That projection is supported by other industry groups and at least two New Jersey hospitals. Demand for fentanyl is followed by Propofol, a sedative also used with ventilators, according to Soumi Saha, Premier’s senior director of advocacy. (She is a pharmacist, an attorney and a New Jersey native.) Close behind those two is a new category of drugs to face shortages — neuromuscular blockers, which are also being used for ventilator patients because they keep them from involuntarily coughing on the healthcare worker inserting the vent tube.
Extended stays on ventilators
During normal times, patients stay on ventilators for three or four days. Now, not only has the number of ventilated patients spiked, but the time they remain on the device is two to three weeks. Production and replenishment are not keeping up. “Fill rates,” as they are called, have dropped to 56%, according to Premier’s data. Time is becoming critical, according to Premier.
A plea for help was sent to FEMA April 4 by a group of health officials from New York and New Jersey, asking them to dip into the Strategic National Stockpile (SNS).
“Hospitals in New York and northern New Jersey are rapidly exhausting all available supply of critical medications from manufacturers, wholesalers, distributors, and other suppliers,” the letter said. “We greatly appreciate the release of ventilators necessary to keep patients alive. However, these ventilators will be rendered useless without an adequate supply of the medications.”
They were told that their request was being evaluated, Saha said, but no allocation of drugs has occurred yet. The FEMA recipients of the letter did not respond to a request for a response.
“The question becomes: At the end of those 10 days, what’s next?” Saha said. Further, she poses the prospect of what will happen when other hot spots around the country emerge? “We may soon be in the situation where hospitals … will have to make some difficult decisions. “
Task force on drug shortages
Last week, Gov. Phil Murphy announced the formation of a task force, spearheaded by the state Department of Health, to monitor the drug shortages.
“We have asked the (hospital) CEOs to let us know particularly about medication supplies, because there are some shortages,” Health Commissioner Judith Persichilli said Wednesday. “And we did get from one hospital up in the north that some medications that are used to sedate patients, their volume that they have on the shelves is going low.”
Also last week, the U.S. Drug Enforcement Administration approved a 15% annual increase for the amount of fentanyl and other drugs to be made available for sale. Earlier this year, before the coronavirus struck, the DEA had ordered production of the opioid be reduced by 31%. (The announcement was posted on the DEA homepage, just above mug shots of its three most wanted criminals — each of them a fentanyl dealer.)
In addition to fentanyl, the DEA authorized increased amounts of other drugs that may be imported into the United States, including ketamine, diazepam, midazolam, lorazepam and phenobarbital — all of which are also used with ventilators.
Fentanyl usage is up by 300% in the 17 Hackensack Meridian Health hospitals, which includes Hackensack University Medical Center, a hospital spokeswoman said. They report a 10-day supply of fentanyl and related medicines and are expecting a large delivery next week. Nonetheless, “the manufacturers have to increase their production,” she said.
Pfizer, the New York-based drug giant that manufactures fentanyl, issued this statement Monday, when asked about its fentanyl production:
“We’ve identified a list of medicines that are critical to treating patients with COVID-19 during this time. For many of these critical medicines, we have ample supply. For some, the unprecedented surge in demand for these products is limiting our ability to fully satisfy customer orders in the short-term. We are making every effort to advance the ordering of additional materials, increase our production of the most essential products, and expedite orders to customers, especially those in high-impact areas.”
Why ventilators demand painkillers
Inserting a tube down a patient’s airway to his lungs is an extremely painful procedure. It cannot be done without a cocktail of drugs, including pain relievers, muscle relaxers and sedatives. The patient must be placed in a coma.
“I’ve seen patients tear out their tubes without these medications,” said Dr. Shereef Elnahal, president and CEO of University Hospital in Newark, one of New Jersey’s hardest-hit acute care facilities. “We have an adequate supply of drugs now,” he said Saturday, noting the recent arrival of a shipment of fentanyl and midazolam last week.
Elnahal said University’s drug supply is adequate for the moment — “a week or two.” But he is concerned about how long the surge in patients will last and how high it will go. The number of critical care beds has already doubled, along with ventilator use, he said, and “we keep looking for other places in the hospital to expand.”
Predictions vary on just when New Jersey hospitalizations will stop rising. It could be this week; it could be mid-May. Then, there is also the possibility of a second wave of infections.
Elnahal finds it “extremely concerning that it appears the national stockpile does not have the meds we need, particularly those needed for ventilators … We are in a compromised situation. We were not prepared.”
The depletion of supply, as well as no ability to track it in both drug companies and the federal government, has become an area of concern for U.S. Sen Bob Menendez, who confirmed that “the federal stockpile is extremely low.”
A month ago, Menendez, a Democrat, teamed up with Tennessee Republican Sen. Marsha Blackburn and introduced a bill to encourage the manufacture of active pharmaceutical ingredients in America. “If we are going to have the supply chain we need, we’re going to need continuous manufacturing here,” he said in an interview Saturday. He fears we have become too dependent on foreign production.
It is not lost on Menendez that China is the world’s largest manufacturer of fentanyl, according to the DEA, as well as many other drugs and items suddenly in great demand — like masks, gowns and ventilators. According to the Council on Foreign Relations, about 80% of the world’s active pharmaceutical ingredients are thought to come from China and India. While the FDA tracks drug shortages domestically, the agency is mainly responsible for their safety and efficacy, not their supply. No one knows how much of any given drug is being made because this information is regarded as a trade secret.
Dubious of our shifting, sometimes volatile, relationship with China, Menendez wants to see the United States put out a decisive, clear message. “We are the biggest marketplace in the world. We can use that leverage with China,” he said. “I wouldn’t wait for our law to pass. I would instruct the FDA to increase manufacturing right now.”
Asked if he believes that will happen, he said, “Who knows what this president will do.”
Xian Huang, a political science professor at Rutgers University, agrees that for China there is just too much money to be made from the U.S.
“It does not make sense for China to use the supply-chain position as a leverage over the U.S.,” she said. “In the age of globalization like this, no country can survive by itself. This is one of the lessons China and the U.S. should learn better than before from the COVID-19 pandemic.”