Tuesday, October 19, 2010

Why Do Anesthesiologists Use Cheap Drugs?

Got another email from our hospital pharmacy. Succinylcholine is currently in critically short supply. Therefore they are going to stock only one 10 ml bottle of sux in each anesthesia cart. Any leftovers at the end of the day will be collected by pharmacy, even if there is only one ml of drug in the bottle. Sigh. This is just the latest in a series of drug shortages that has afflicted anesthesiologists.

So far this year we've faced an ongoing scarcity of propofol, especially after Teva pulled out of the market following the bone-headed $500 million jury verdict against the company in Las Vegas. We've been discouraged from using TIVA if gas will do. We are also facing a shortage of morphine. If we order morphine for our patients, the pharmacy will kindly substitute a dilaudid equivalent dose. Last year there was a deficit of protamine. They were only stocked in the vascular and heart rooms unless requested from pharmacy.

Why do these problems keep recurring in anesthesia? I suspect it is because we anesthesiologists seem determined to undermine our own self interests by using the cheapest drug available. The aforementioned drugs are all generics, costing just pennies per dose. There really is little incentive for drug companies to stay in that sort of market. As Teva demonstrated, one adverse event can devastate the cost structure of generic drugs and cause these companies to withdraw their products.

You certainly don't see other specialists racing to be the most cost efficient provider. Pharmaceutical companies spend billions every year trying to persuade internists to prescribe their latest treatments for hypertension and hyperlipidemia with great success. Orthopedic surgeons are feted by the hardware manufacturers to use their newest implants. General surgeons frequently demand to use the latest and most expensive laparoscopic equipment. They never seem to run short of those in the OR.

Newer drugs like Precedex and Lusedra are just subjects I read about in anesthesia journals. Our pharmacy refuses to stock them because of the price. We don't have patients coming into preop to demand that we give them fospropofol for their anesthesia. Anesthesiologists, in their attempts to appease the hospital administration, try to keep costs low by using generic drugs whenever possible. But this discourages drug companies from conducting research on the latest anesthetics. There aren't twenty pharmas in competition to develop an alternative to succinylcholine the way there are for the next ACE inhibitors.

So maybe we can do ourselves a favor and start administering the newest drugs on the market instead of one that have been generic for a decade or two, or four. This will show the drug companies our commitment to make sure their drug research pays off and we can finally stop having these regular drug shortages.  And maybe we'll get a few free dinners and golf games along the way.


  1. "Any leftovers at the end of the day will be collected by pharmacy, even if there is only one ml of drug in the bottle."

    This seems to be an unsafe practice. Can they guarantee the sterility of the bottles' contents from one day to the next? Or even guarantee that a bottle labeled succs still has succs in it?

    I seem to recall a clinic spreading hepatitis B (maybe C) using similar methods. http://bit.ly/br8mhT

  2. The difference is that the clinic was using the same bottle of propofol for multiple patients. Propofol is clearly labeled for single use only. Sux comes in a multidose bottle. We assume the bottle is still safe to use the same way we assume other multidose bottles of other drugs like labetalol or atropine are safe to use between patients. Of course, nothing is perfect and you can't assume anything in this world.

  3. Speaking of propofol, even though it is generic, how can it not be profitable ? Now that TEVA has fled the market, APP Pharmaceutical (Fresenius) is the dominant manufacturer in Europe and US. When the propofol shortage began, APP was trading at 13 cents a share (yes 13 pennies), now that propofol supplies has stabilized, APP is trading at less than 4 cents a share ! I still don't get it.