Crozet Annals of Medicine: Pill Problems

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On Thursday President Trump declared the opioid epidemic to be a National Public Health Emergency. On that same Thursday we ran out of morphine in the hospital. We are likely to be out of morphine for months if not longer. These are strange times we live in. We are flooded with opioids in the streets and out of most of them in the hospital.

Morphine is on the World Health Organization’s list of essential medicines. Morphine has been in widespread clinical use for over two centuries and this is the first time in history that we have run out of it. We are also critically low on other opioid pain medicines like dilaudid and fentanyl.

The reason for the shortfalls is multifaceted but really boils down to two words; Puerto Rico. Almost all the morphine used in the U.S. is made in Puerto Rico (who knew?), and Hurricane Maria has devastated the pharmaceutical manufacturing facilities there.

Due to tax incentives implemented in 1976 Puerto Rico became a giant in the pharmaceutical manufacturing industry.  There are about 50 pharmaceutical plants on the island representing all of the major pharma firms and about 30 that make medical devices. It is the fifth largest manufacturer of drugs in the world.

Pharmaceuticals and devices represent 75 percent of Puerto Rico’s exports, valued at $14.5 billion, according to the U.S. Bureau of Labor Statistics.

About ten percent of all the pharmaceuticals used in the U.S. come from Puerto Rico and at least 13 are manufactured only in Puerto Rico. The island accounted for 25 percent of total U.S. pharmaceutical exports.

The FDA has compiled a list of 40 drugs that are likely to be in short supply due to the hurricane but they have not released that list. That’s concerning, since the plants produce treatments for cancer and HIV, as well as immunosuppressants for patients with organ transplants, anticoagulants to prevent strokes, as well as insulin pumps and pacemakers. Oh, and all those sterile bags for mixing and administering antibiotics are made there and we are out of those too. We can improvise around that for now, but it is time consuming and introduces additional processes that increase the possibility of error.

The solution to these ongoing dangerous shortages is for FEMA to get the power back on in Puerto Rico and soon. 70% of the island still lacks power six weeks after the hurricane. This is hard to believe.  The pharmaceutical plants are largely intact but lack electrical service. Some are running on generators, but that poses its own challenges, including finding enough diesel fuel to keep them running. The tax breaks that created the successful pharmaceutical economic miracle were phased out in 2006 and if Puerto Rico does not reopen the plants soon the industry is likely to go elsewhere, taking 25 percents of Puerto Rico’s economy with it. The island will not recover from this.

Meanwhile the opioid epidemic rages on. 62,000 Americans died of opioid overdoses in 2016. That is more people lost in one year than we lost in the wars in Vietnam and Iraq combined. Public health experts estimate that nationwide over 500,000 people could die from the epidemic over the next 10 years.

Declaring a National Public Health Emergency  (PHE) sounds like a good thing, but it is an empty gesture. The PHE fund currently contains only $57,000. That is not going to go too far. In fact at $4,500 per dose it would only buy 12 doses of narcan, a lifesaving antidote to opiate overdoses. Of course Congress could vote to more robustly fund the declared PHE, but so far their record on additional health care funding has not been encouraging.

In a more productive step the Drug Enforcement Admin-istration has reduced the amount of opioids that can be manufactured in the US this year. Production of all opioids has been cut by at least 25 percent in 2017. While this is good step toward combatting the opioid epidemic, the change also paradoxically affects morphine, which has not contributed to the epidemic and now is gone from our hospital.

As a final note, if a hospital without morphine does not alarm you, guess what else is made in Puerto Rico? All of America’s Viagra.

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