“So, you don’t have it in liquid form?” I asked.
The answer, as usual, was no. I hung up the phone and sighed.
“Playing the amoxicillin game?” my colleague asked.
“Yup. This is the fifth pharmacy I’ve called,” I said.
Asking a patient’s preferred pharmacy is a reflex whenever I electronically prescribe medications for home. But this previously innocuous question has now become the start of a wild goose chase.
I knew something was wrong when our office started to receive a deluge of phone calls from parents in the late fall requesting their prescriptions be sent to another pharmacy because it was not in stock. Tylenol, ibuprofen, Tamiflu, and amoxicillin were all in shortage as the demand for them rose. Similarly, we started to receive more distressed calls from parents whose children were recently discharged from the hospital requesting their prescription be sent elsewhere. Left with no option, desperate parents even brought their children to the emergency room to receive the medications they could not find in pharmacies. In a February survey, Jackson Pharmacy Professionals found 73% of U.S. pharmacists had been negatively affected by the amoxicillin shortage with greater impacts in rural areas.
During last fall’s “tripledemic,” cases of influenza, respiratory syncytial virus (RSV), and Covid-19 in children soared nationally. There was a spike in ED room visits, urgent care appointments, and hospital admissions. Amid the strain on providers and patients, medication shortages were an unwelcome addition to an already challenging viral season.
In October 2022, the Food and Drug Association reported a shortage in a product that is used to make liquid amoxicillin, an antibiotic used to treat pneumonia, ear infections, and strep throat in children. Naively, I did not think too much of this initial report. I wrongly assumed the FDA, along with large pharmaceutical organizations, would increase production before patients were affected. I was wrong.
Pharmaceutical production shortcomings have led to critical inconsistencies in medication supply. Providers, parents, and especially children have all felt the squeeze of this failure. The latest amoxicillin shortage has shown the United States pharmaceutical supply chain and commercial pharmacies are not adequately equipped to respond to increased demand for generic medications.
At the beginning of the tripledemic, the majority of cases in children were viral illnesses, meaning antibiotics would not help their illness. For these children, pediatricians could largely only offer supportive care, such as fluids for hydration and anti-fever medications such as Tylenol or ibuprofen. For influenza infections, Tamiflu can help shorten duration of symptoms.
But we do sometimes need antibiotics — chiefly, when viral infections lay the groundwork for a bacterial infection to build inside their lungs, called a “secondary pneumonia” or “superinfection.” When I started to see more of these cases, the shortage of amoxicillin became impossible to ignore.
This became a daily challenge. It was no longer possible to simply trust that national retail pharmacies would have common medications in supply. There was a new step added to the already strained pediatrician workflow. I had to wait to discharge patients until finding a pharmacy where they could pick up the medications they needed. This process often took at least five phone calls per patient.
When I did find a pharmacy that could fill the prescription, there were long wait times. What shocked me, though, was the lack of an integrated inventory system for large national retail pharmacies. If one retail pharmacy did not have a medication, they often did not know if another nearby might carry that medication. Prescribing the medications children needed turned into a game of whack-a-mole full of electronic wait music and requests to hold. When I was short on time, I conscripted parents to help me call lists of pharmacies.
We did not always succeed. Not every family has access to transport to travel far or drive pharmacy to pharmacy to find amoxicillin. Despite our best intentions, the supply-chain failure from large pharmaceutical companies forced me to change my prescribing practice and select second-line therapies for treating pneumonia or ear infections. These medications could incompletely treat the child’s infection, cost more, and expose children to a different side-effect profile.
While the tripledemic has thankfully waned, the challenge of finding amoxicillin has not. The FDA has shared the shortage will continue into 2023 as primary manufacturers are still catching up on production. My patients’ parents and I are still having to call multiple pharmacies to find the prescriptions they need. Luckily, it’s not as bad as it was, but that’s only because demand is low.
The problem in the fall and winter was that demand spiked for a medication whose production and sale does not financially incentivize keeping surplus mediation production. As of 2019, 80% of the United States’ amoxicillin liquid production was imported. USAntibiotics is currently the only domestic producer. As a generic drug, amoxicillin is not terribly profitable for U.S. manufacturers. Production meets expected demand, with little incentive to creates surplus. The tripledemic prompted an acute surge in demand and left pharmaceutical producers unable to rapidly increase supply. I worry what may happen should we see a repeat of the tripledemic this upcoming winter.
We must learn from the baby formula, Tylenol, ibuprofen, Tamiflu, and amoxicillin shortages that have harmed children this past year. Congress and the Food and Drug Administration should strengthen the Mitigating Emergency Drug Shortages Act passed in 2020. This legislation creates transparency by requiring manufacturers to disclose causes, create contingency plans, and share expected length of medication shortage.
But we also need stronger legislation to incentivize manufacturers to produce drugs in shortage as well as manufacturers for contributing to shortages. Patients should not suffer because pharmaceutical manufacturers fail meet the demand for less profitable generic drugs. Additionally, retail pharmacies must improve their organization to establish inter-pharmacy communication and knowledge of inventory to support their patients. That way, I could just call one pharmacy instead of five, which is a waste of my time and the pharmacists’ time.
The past three years have taught us how acutely health care demands can change, especially from unexpected infectious surges. When demand for medication rises or shortages occur, we should be ready to quickly increase supply. Children should not have to receive second-line treatments.
Nishant Pandya, M.D., MPH, is a pediatrician from New Haven, Conn.
