Fixing the problem of drug shortages in Canada

Drug shortages are a persistent problem in Canada and around the world. They interfere with patients’ ability to consistently take medication to manage chronic diseases. And they disrupt urgent care as critical drugs like epinephrine and propofol face shortages. 

The COVID-19 pandemic led to concerns that the pandemic would exacerbate existing issues with drug shortages in Canada. Canadian policy-makers responded with several important measures in March 2020 in an attempt to ensure a steady supply of medication.

On this episode, Mina Tadrous discusses the impact of those measures as well as the ongoing challenges to Canada’s supply of pharmaceuticals. Mina Tadrous is coauthor of the paper, “COVID-19 in the prevalence of drug shortages in Canada,” published in CMAJ. He's an assistant professor at the University of Toronto. 

Drs. Bigham and Omole also speak with Andrew MacIsaac about the role Canadian manufacturing can play in easing the problem of drug shortages. Andrew Maclsaac is the CEO of Applied Pharmaceutical Innovation, or API. API is partnered with University of Alberta to create the Canadian Critical Drug Initiative. One of its goals is to make Canada less vulnerable to drug shortages. 

Links:

COVID-19 in the prevalence of drug shortages in Canada

Canadian Critical Drug Initiative

Applied Pharmaceutical Innovation

CMAJ

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Transcript

Dr. Blair Bigham:

Hi, I'm Blair Bigham.

Dr. Mojola Omole:

Hi, I'm Mojola Omole. This is a CMAJ Podcast. So today Blair, we're going to be discussing an article that was in the CMAJ titled, “COVID-19 and the prevalence of drug shortages in Canada.” And they were looking at the time before COVID-19 and 2020 and after, just looking at the drug shortage and the issues, what Canada is going through, which is not unique to Canada but that's also been noted worldwide. What for you, Blair is your experience, because you're an ICU doc. So, you work with a lot of drugs. So what's your experience been with drug shortages?

Dr. Blair Bigham:

Yeah, I was really excited to see this topic. I mean, about a decade ago, there was an epinephrine shortage. And epinephrine — if there ever was a quintessential emergency medication, it would be epinephrine. You can't run out of that. And so I think that, it's always sort of been something that's on my mind, and certainly during the pandemic we either had or anticipated having shortages of ICU medications, particularly sedatives, to the point where we actually came up with a randomized controlled trial looking at, can we use other drugs like propranolol, for example, which actually has a sedative effect, if we ran out of propofol or to reduce our doses of propofol? So there were a number of different ideas being floated around about how can we spare ourselves these critical medications when we run out. And certainly that even got down to the point of having conversations about rationing.

Dr. Blair Bigham:

So this is something that every ICU and emergency doctor has thought about before. And family doctors also experience drug shortages, and it can still be really debilitating or impactful for their patients. So I'm really excited to talk about this study today. I'll give a super-brief rundown of it because it took me a little bit of time to digest. There's this big national drug shortage database. Apparently it's pretty unique to Canada. It's only been around since 2017. And so looking at that database, the researchers were able to look at drug shortages, leading up to the pandemic. And at the beginning of that database, there were around 900 drug shortages and that increased to 2300 drug shortages come March 2020.

Dr. Blair Bigham:

And that's when the government enacted a couple of steps federally. They amended the Patent Act to allow emergency shortages to be addressed by manufacturers who didn't have to negotiate with the patent manufacturer. They also allowed for emergency import approvals. And so this study looked at the impact of that pre and post, basically, and found that, during the pandemic, that rising level of critical shortages was greatly diminished. And the authors suggest that these federal changes may have had something to do with that. And we're going to talk to one of the coauthors of that study, Mina Tadrous, an assistant professor of pharmacy at the University of Toronto.

Dr. Mojola Omole:

And then our other guest, Andrew Maclsaac, is to be exploring with us the role of Canadian drug manufacturing and how it can ease the problem of drug shortages. He is a CEO of the Applied Pharmaceutical Innovation, or API, and they've partnered with the University of Alberta to create the Canadian Critical Drug Initiative.

Dr. Blair Bigham:

And hot off the press, Jola, I don't know if you faced this where you worked. There's this huge shortage of contrast media right now for CT scans. And so I'm constantly being asked to either choose a different type of test, like ultrasounding carotid instead of doing a CTA or we've even heard of some hospitals being limited in their ability to accept transfers because of this media shortage. And apparently, it's because almost all iodinated contrast media comes from this one plant near Shanghai, China, which was recently under COVID lockdown. And so it just gives you an idea of how fragile the global supply chain is and how consequential it can be to me in the ER or to you trying to get the right diagnosis for your operative planning. Did I say that right? I'm not a surgeon. Does that make me sound like a surgeon?

Dr. Mojola Omole:

It made sense, but I was like, I just write the order and somehow it gets done.

Dr. Blair Bigham:

All right. Let's jump right into it with Mina Tadrous. Dr. Mina Tadrous is a coauthor of the paper, “COVID and the prevalence of drug shortages in Canada,” published in CMAJ. He's an assistant professor at U of T. Mina, thanks for being here.

Mina Tadrous:

Oh, thanks for having me.

Dr. Blair Bigham:

So Mina, your study looked at the period from before COVID started, but from April, 2017, through to just recently, March ‘22. Let's start there. What type of shortages were happening before COVID came about and how did that change during COVID?

Mina Tadrous:

That's a really great question, because I think that the premise of this question was that the problem existed prior to the pandemic. And prior to the pandemic, what was happening is that there was a series of shortages that were occurring — not just a series, like a large amount of shortages that were occurring — so much so that a recent survey done by the Canadian Pharmacists Association found that one in four Canadians would be impacted or know somebody that was impacted by a drug shortage. And really it affected all drugs. There were certain drugs that were affected a little bit more than others but more importantly, I think the number and prevalence of them was actually going up as well. And we entered the pandemic very much concerned about this problem, not realizing the problem that was about to come our way.

Dr. Blair Bigham:

And tell me, what exactly was the scope of this problem? Like, how many drugs were we short and are there any top drugs that come to mind? Things that everyone would go, oh man, we can't do without that?

Mina Tadrous:

I think with the shortages, there's really no specific drug that wasn't affected, or no drug class, but some of the major ones that we've seen over the years that have hit really closely were there was a really big shortage of IV bags, and even just dextrose, saline was really hard to get at some points, and certain concentrations. A few years ago, there was an epinephrine shortage — not just the injectors, but the actual epinephrine used in hospitals — like in the early two thousands. There was a recall of valsartan and that led to a shortage across all ACEs and ARBs and trickled through the drug system as well. So you could see like there's really nothing that's not affected by this and at many times it feels rather random.

Dr. Blair Bigham:

And epinephrine, I mean like I'm an emergency doctor, how can you live without epinephrine? What were the impacts of the epinephrine shortage?

Mina Tadrous:

Absolutely. There was a paper a few years ago that looked at the impact of the epinephrine shortage in the US, and obviously people switched to norepinephrine just to have some other option, and they found that it actually increased mortality. And so some of these shortages can be impactful on clinical outcomes. Versus others, I think with the valsartan one, because we had so many different options, generally it's been okay to switch to other blood pressure medications. So I think not all shortages are created equal.

Dr. Blair Bigham:

Canada has this big database now through Health Canada. How does Canada compare to other countries, both in terms of the scope of the problem and what we're doing about it?

Mina Tadrous:

So there was a recent OECD report that tried to pinpoint if some countries had more shortages than others, and if there's some protections. Now Canada came up top, but that's because we actually have the best data. So when you think about the number of shortages, since we have the best data it looks like we're reporting the most. I think that likely there is no difference between countries because drug supplies are a global issue and most countries don't actually have varying different policies. Most people are dealing with this on their own. So I think it's really important for people to realize the life of a drug, in a way, if you think about where it's made. So every product has an active pharmaceutical ingredient. We call that an API, and that API is the actual molecule. So that could be made in one factory.

Mina Tadrous:

Now, most APIs are produced in a variety of different countries, and they're rather well distributed, but there's concentrations of certain countries that make them a lot. Now the API is shipped to probably another country where the final dosage form — an FDF — is made. And that's where they combine that API with a bunch of the other stuff, like the stuff that goes into making the capsule, the pill, whatever it may be. And that is the final pill. And then that could be sent somewhere else where it's bottled, and then those bottles have to be specific for each country. And then those are distributed to Canada. And then that goes to the wholesaler, and then the wholesaler will distribute it to pharmacies or the hospitals and then it goes.

Mina Tadrous:

What I'm trying to paint here is this picture of a massive supply chain. And anywhere that that goes wrong, it can go in any different direction. More importantly, this is happening across a multitude of different countries. And because of that, a variety of different factors can impact it. And because we have so many different drugs — 14,000 or whatever it may be — not every country can produce its own drug supply. So we're all dependent on each other. There's a global ecosystem here. And so when one shortage happens, it ripples around the world.

Dr. Mojola Omole:

What's the original, like we know, like for example, with the baby formula shortage, we can pinpoint what started the shortage in the US. What is the original starting point globally of the supply chain issue with drugs across the world?

Mina Tadrous:

That's an amazing question. And there's actually no single reason. It could be every... So as that chain I painted for you, anywhere it could go wrong and it could be everything from a hurricane hitting Puerto Rico, which by the way, produces most IV products for North America and some biologics for the world. I didn't know that till hurricane Maria hit it, and then the world had a shortage of medications.

Mina Tadrous:

It could be a pandemic affecting supply chains, shutting down factories. It can be one factory changing the way that they produce a drug, which produces a suboptimal therapy, which is what happened with valsartan. It could even just be that one country stops shipping its drugs because they felt that it was important to hang onto that drug. For every drug shortage, there's often a different kind of story and there's not any major reason that drives it through. And it could happen at any point in the supply chain.

Dr. Blair Bigham:

So let me take a couple of steps back: 2017, you have all this data, you're looking forward, Health Canada has a data set now and then COVID hits. What happened when COVID hit? And what were some of the changes in supply shortages that were directly linked to the pandemic, and how did Canada get through that?

Mina Tadrous:

Yeah, absolutely. So I think what our paper points to is that some of the policies actually worked out. So what they did and most of this was actually on Health Canada acting towards this. The first thing they did is that they knew that there were certain drugs that needed to be prioritized. And those were drugs that were going to be used for COVID treatments or could be linked with that. And so they created this exemption list. And this is something that we've been pushing for even prior to the pandemic, that not all drugs are created equal, and so we need to figure out which drugs are at the highest risk. And what I mean by risk is supply chain risk and clinical risk. So you need to combine both of those. I think all the conversations before this have always concentrated on either clinical risk or supply chain risk, but you actually need to account for both.

Mina Tadrous:

And so they did that. And they allowed exemptions, and these exemptions were things like importation of drugs from other countries. So for example, because of the pandemic, in the very beginning, everyone started rushing for rescue inhalers, salbutamol inhalers and hospitals started switching to them, because they didn't want to use the nebulized formulation so they didn't spread disease. And then people started showing up to the pharmacies and just stockpiling their inhalers and this led to a shortage.

Mina Tadrous:

So that salbutamol became on that list. And we started being able to ship in drugs, labelled in like Polish. Because they were actually coming in from Poland to be able to meet the demand in Canada. And that wouldn't have been allowed prior. So this exemption list was like, these are urgent needs and we need to be able to meet them. But for me, what was exciting was the actual prioritization of certain drugs.

Mina Tadrous:

It forced us to think through this and it may have changed our lens on which drugs we need to think about most. Within locally, what we found is that a lot of payers and governments started limiting supplies and also limiting distribution. So pharmacies couldn't order a bunch of salbutamol so that they can stockpile to ensure that they had supply over the next guy. And that became really important. And limiting patients going in and getting six months of drugs, limiting it to 30 days, which initially was a really important step because we didn't know what was coming our way.

Dr. Blair Bigham:

Okay. So we had preconceived the idea that we would have to really tightly control how many drugs get shipped out at every stage of that distribution process so that no one place had boxes and boxes of a short drug sitting on the shelves.

Mina Tadrous:

That was an important thing. And then I think other policies that became important was that the federal government started thinking about a stockpile, which is the first time that they've ever done this. So other countries do this where they've national stockpiles of certain drugs. Now you can't stockpile all drugs, but again, like they prioritized and thought through which drugs are important to stockpile and they stockpiled some of them.

Mina Tadrous:

And they were able to distribute these through the hospitals and through the systems to ensure that the supply chain of the most important drugs, especially for COVID treatments, were on hand. So I think what our paper found is that these policies were able to mitigate that sort of rise that was occurring. And at the same time, they were actually able to control the fact that the number of shortages, which we knew globally was going up, didn't actually increase in Canada.

Dr. Blair Bigham:

So what else needs to be done? Sounds like Canada fared better than it could have because it seems you were ahead of the ball on this one. But what else can we be doing in the next couple of years to mitigate drug shortages going forward?

Mina Tadrous:

There's a whole slew of different policies. I think the challenge here, and something that I've been championing, is the challenge is that you've certain policy levers that you can use. And they range from creating your own stockpile, investing in local production, ensuring that you increase competition for certain products, ensuring that products that are really high risk are produced in more than one country. So you minimize your geopolitical risk. You minimize your risk towards natural disasters, especially for really important drugs.

Mina Tadrous:

And I think there's a variety of those, but you can't use them for all drugs. So what we actually need to do is have a very candid system to go through this and calculate what we think are the drugs at highest risk, right? Like an epinephrine. Like we need to make sure that epinephrine risk is low. We need to make sure that we have the ability to locally produce some, and we have mitigation strategies.

Mina Tadrous:

Now the other thing to think about is supply chain risk. So supply chain, things that affect supply chain risk is like how many countries is it produced in? Like if you think you have eight different generic products but they're all produced in the same factory in India or China, which is where 80% of our drugs are produced, you have a supply chain risk. Because if things go sour with one of those countries or if a hurricane hits one of those locations, where, Shanghai or something, then we're out of luck. So if you have an important drug, you need to make sure that your supply chain risk is also low. If not, then you need to use one of these levers. So I think we need to go through an activity where we develop a national at-risk medicine list. And then the ones that float to the top are the ones that we use all these different policy levers to attack.

Dr. Mojola Omole:

Just, what I'm thinking is part of during COVID that was brought up often was that, in Canada we've closed a lot of our manufacturing plants for vaccines, for drugs. And that's why we're in precarious states of not being able to procure vaccines at a certain point. Would Canada having more manufacturing in the pharmaceuticals — how much of a dent would that make in the sense of protecting us, ensuring us up for not having any further drug shortages?

Mina Tadrous:

That's an amazing question because I think you're absolutely right. Even the United States, when I've been at conferences and they talk about this problem, know that they, and their economy being multitudes larger than ours, can't tackle this on their own. And so they can't just manufacture their way out of this. But they have realized, and I think we realize this, that, one, you can invest in some infrastructure and when you do, you pick the drugs that are right for you. And I think the ones that you need that are most important and it may put a dent in things that are highly important and you'd be surprised like that the list can actually be shortened rather dramatically to the ones that are most important.

Mina Tadrous:

The second thing is, you need to look at your supply chain and have insight into where your drugs are coming from. So our regulators are working on this and I think they've had a big wake-up call to realize, I don't need to just know how many drugs I have, I need to know where they're made. And so if you have an important drug and it's only made in one geopolitical area or one country and it's really important to you, then maybe you need to say, I will pay a little extra for a drug to be made in a newer location that's different. So I think to answer your question point blank, I think it's only one lever. We need to figure out which drugs to use it for. But we also need to depend on other, kind of, we need to diversify our risk so that we understand what the problems are. And so we may have to depend on other countries that manufacture, but again, distributing that risk across the world.

Dr. Blair Bigham:

Amazing. Mina, thank you so much for joining us today. This has been terrific.

Mina Tadrous:

Thank you very much. And thanks for the great questions.

Dr. Blair Bigham:

We're now going to dig a little deeper into the role Canadian manufacturing can play in easing the problem of drug shortages. Andrew Maclsaac is the CEO of Applied Pharmaceutical Innovation, or API. API is partnered with University of Alberta to create the Canadian Critical Drug Initiative. One of its goals is to make Canada less vulnerable to drug shortages. Andrew, thanks for joining us.

Andrew MacIsaac:

Thanks for having me on the show.

Dr. Blair Bigham:

Mina did a really good job of explaining just how complex the pharmaceutical supply chain is. And it's beyond even, like even the United States isn’t able to manufacture all of its drugs domestically. Like it just seems like there are so many components, so many pieces coming from all over the world. How can the Canadian pharmaceutical manufacturing industry or community really play a role in reducing drug shortages here at home?

Andrew MacIsaac:

It's a very complex question because it is a very complex industry, and there are a lot of moving pieces and parts. One of the big reasons that we see drug shortages, not only here in Canada, but also around the world, is we've moved to a model where we really are looking to get the best value out of a generic drug. And that means producing it at extremely high volumes so that we can get a low cost. Additionally, there’s some components of producing it in countries that have lower environmental regulations, some of those other pieces as well too but in many cases, it is about the size and scale as well.

Dr. Blair Bigham:

Now, during the last couple of years, we've heard a lot about Canada's ability to manufacture its own vaccines. Relative to our size, how strong is our manufacturing capacity for vaccines or for pharmaceuticals in general? How reliant are we on other countries?

Andrew MacIsaac:

It's a problem around the world. Most medicines come from India as the final sort of manufacturing point. So it's not a challenge that's uniquely Canadian, but we do have a weaker position compared to countries such as the United States and Europe. And there's definitely room for improvement in terms of the sector here. We had a lot of exits from the generic industry over the past 30 years as they moved to that larger-volume production in India and elsewhere around the world to try and lower their margins. And it's something that hopefully we can walk back a bit as we're looking to get a more resilient supply chain.

Dr. Blair Bigham:

And your nonprofit is trying to be part of that resiliency. You guys have partnered with the University of Alberta to create the Canadian Critical Drug Initiative. Tell us more about that. What's the goal of that collaboration?

Andrew MacIsaac:

Yeah, absolutely. So for us, we're a not-for-profit organization that focuses on providing the capacity for innovators with new potential therapies that are looking to commercialize. And so we do, in that course of that, produce clinical trial material here in Edmonton. And one of the first things that happened during the pandemic is we had outreach from a number of different hospital systems, and most importantly AHS here in Alberta, which is the country's largest integrated health care system. And what they were doing is they were looking at the supply chains of a whole bunch of critical drugs that they expected, very drastic fluctuations in demand, thanks to COVID-19. One of them was propofol, which an inpatient in Northern Alberta used the entire Northern supply of propofol in a manner of weeks. And they were looking to figure out how they could ensure that there would be drugs on hand for when they needed and they were doing outreach.

Andrew MacIsaac:

And so for us, this is something that we don't normally enter into commercial manufacturing but we immediately realized that there was a huge challenge here. There are a number of drugs. Most of them on the Health Canada tier three drug shortage list that just don't make market sense to produce in-country. And so we started to think about what we could do ourselves as an organization in terms of building a capacity for us to produce some of these critical drugs. And that over the period of the past two years has evolved into what is the Canadian Critical Drug Initiative.

Dr. Blair Bigham:

Got you. What do you think Canada needs to be better at when it comes to manufacturing? I mean, is it the small molecules for the pharmaceuticals themselves? Is it for like pill casings, IV bags? Is it more around logistics? Where do you see not only your organization but Canada in general leaning into so that we can be less reliant on supply chains globally?

Andrew MacIsaac:

I think the easiest thing is what we're trying to do with the Canadian Critical Drug Initiative, which is to manufacture more active pharmaceutical ingredients, which tend to have shortages, as well as do the fill-finish on them to produce some of the hospital drugs that are the highest potential of causing a catastrophic health care system failure, if there is a shortened supply.

Andrew MacIsaac:

The other aspect that we can do as well too, is focus on building capacity to support innovative companies, because the more of the sort of innovative medicines that we have being developed or produced within Canada, the more robust we become naturally because we've got a lot more activity happening. So people are producing, importing and working on drugs here in-country. And so that naturally builds stronger supply chains.

Dr. Blair Bigham:

We heard from Mina about importing and how there were some regulatory workarounds during the pandemic to make importing easier. How much of that do you think is the solution compared to increasing our production and manufacturing capabilities here?

Andrew MacIsaac:

No, I think with the importation challenges around pharmaceutical products, there are some that we can make it easier to bring in, and that's obviously an easy opportunity, but the big challenge is some of these drugs only have one or two sources in the world, and in some cases they're within the same country. And so without that capacity to produce it locally, you run into a scenario where you just can't get it. If you were allowing it into the borders, it would come through normally, but they just don't have any.

Andrew MacIsaac:

And you look at some of the active ingredients to these compounds that really aren't that expensive but they're a critical step in the manufacture. So I'll take, again, propofol as an example. A kilogram of propofol costs about $210 on the open market. And you probably only need about 500 to 1000 kilograms to supply all of Canada for six months.

Andrew MacIsaac:

So it's not a high-value, high-cost item, but when you don't have it, you can't have surgeries, you can't have people on ventilators and it's a catastrophic issue within the health care system. So it's not always something that a market scenario or an import or even a stockpiling can help because some of these products will be delayed for quite a while, or you'll end up in a scenario where they end up having expiry dates. And just like early in the pandemic, we found that a lot of our stores had gone out of the usage. And so what we're really working to do is build steady-state, small-scale production with the ability to ramp up if there is a shortage, and have that established and the ability to pivot and be responsive to the needs of the health care system.

Dr. Mojola Omole:

Are there some drugs that would be relatively easy to produce domestically?

Andrew MacIsaac:

Yeah. The benefit of Canada is we are a bit of a small market. And so in some cases the infrastructure needed is not too large. So some of the stuff that the Canadian Critical Drug Initiative are working on is a list of about six critical drugs that are used heavily in the hospital system that have tenuous supply chains attached to them, and the ability for us to produce these six drugs for all of Canada. The cost of the facility is only about $60 million.

Dr. Blair Bigham:

Andrew, what's a low-hanging fruit? What would you do tomorrow if you were in charge of Canada's drug supply to ensure that Canadians had the drugs they needed most when they need them?

Andrew MacIsaac:

Well, I'd fund the CCDI. I'm a little bit biased here because that's really what we're working to do is we're trying to find the lowest-hanging fruit and the lowest-cost solutions to at least build a little bit more security in the supply chain. And then the other thing that I would do is I would continue to invest in life sciences sector overall because the more novel compounds we produce here, the more we're involved in the pharma industry broadly, the more likely we are to have, like in the States, of the capacity to manufacture and jump into something like operation war speed pretty quickly. Whereas in Canada, the first investments in COVID-19, such as the biologics manufacturing at the NRC in Montreal is still coming online, because we were so far behind in terms of the industry, whereas if we had a more robust production and innovation space within the life sciences — which we as a country should, because we do have phenomenal expertise within our postsecondary system, and we produce a lot of intellectual property — if we're able to capitalize that to build more industry, we will have an easier time in future pandemics.

Andrew MacIsaac:

And we'll also have a scenario where maybe some of the drugs that are first approved on the Canadian market are from Canada. But I do have a little bit of a quick point to make in terms of some of the wins that we've had in the pandemic. If you folks aren't aware, the first approved treatment for COVID-19 was actually manufactured in Edmonton.

Andrew MacIsaac:

Remdesivir, the antiviral, was produced by a facility that has been running in Edmonton for the past 30 years or so. And it's a facility that produces the active pharmaceutical ingredients for Gilead products on the early clinical trial to late clinical trial to early market stage. The problem is it went down to a foster city in California to get the final fill-finish and packaging. So we didn't have first access to it. But that just shows that we actually do have the capability, even from a market perspective, to play a role in the supply chain, but without government incentives or subsidies, it's just sort of by building that innovation industry.

Dr. Blair Bigham:

Got you. Well, it sounds like there's lots of exciting things coming down the pipeline, and hopefully with initiatives like yours, we'll all be better-prepared — heaven forbid — for the next pandemic.

Andrew MacIsaac:

Heaven forbid.

Dr. Blair Bigham:

Thank you so much for joining us. I know you're having a very busy day and we really appreciate your time.

Andrew MacIsaac:

Oh, it's my pleasure. Always happy to chat. And it's an area that obviously is very near and dear to our hearts and something that we should be able to do as Canadians.

Dr. Blair Bigham:

You bet. Andrew Maclsaac is the CEO of Applied Pharmaceutical Innovation. One of the partners of the Canadian Critical Drug Initiative. 

Dr. Blair Bigham:

So Jola, what do you think?

Dr. Mojola Omole:

This one's a tough one for me, because what I left feeling was that yes, they've implemented some measures but health care — we're always just one step away from like a massive health care disaster. The way health care is run at the province level in Ontario is similar to the way it's being run federally, which is we're always just avoiding disaster and we're always just like razor-thin edge. And no one seems to be incentivized to reimagine health care where we're not always do, do, do, do, do, and then panic. So I kind of left feeling a little bit blah.

Dr. Blair Bigham:

But do you get the sense that we're maybe better off than other countries? Like, it seems like at least we have this database of shortages that seems pretty robust and unique to Canada. At least we had some rules to be able to reduce barriers to import when things got really tricky for certain drugs. I don't know, it seems like we're doing some things right but that just the complexity of it all, the supply chain, the way it's truly globally produced little components all over the globe having to get here. I don't know. It just seems super tricky. And I left just wondering, what are we supposed to do locally? Are we supposed to, like, build more big plants? Are we supposed to just have more agreements to get drugs into the country easier? It's a really tough one.

Dr. Mojola Omole:

I think maybe it's a mixture of all of those. I like, I mean, if they made remdesivir, that was made in Canada, right? So I don't think manufacturing will solve all of the supply chain issue, but I do think that having some manufacturing capability in Canada that's more robust would be helpful.

Dr. Blair Bigham:

And I guess it's up to the front-line doctors just to always have a backup plan when your drug of choice isn't available or is at least on shortage. Are there alternatives that you can think about, at least for the short term, just to help kind of get through those tough periods? And then I guess, at the end of the day, we got to figure out how to communicate all of that to patients because no patient wants to be switched from a drug that's working to what they might view as a backup drug. That would feel awful.

Dr. Mojola Omole:

Yeah. And then for some people, like, it could be like, well, it's the same as when you look at proton pump inhibitors, right? Technically all of them should work the same, but I can say as someone who takes them that some don't work for me and others do. So, I mean, I do think that's a conversation that we need to have with our patients. But I also just think generally we just have to have a much more robust conversation about the state of health care, not just like the deliverables in the hospital but just even when we talk about drugs and the availability of drugs.

Dr. Blair Bigham:

That's it for this week on the CMAJ Podcast. We'll see you again in two weeks. Please remember to share and like our podcast, wherever it is you download your audio. I'm Blair Bigham.

Dr. Mojola Omole:

And I'm Mojola Omole. Until then, be well.