Paramedics turn to expired drugs due to shortages

by JONATHAN J. COOPER
Salem fire department paramedics Scott Alt, left, and Jennifer Pratt check over medications in an ambulance in Salem, Ore., Tuesday, July 10, 2012. When faced with medication shortages, some paramedic outfits are forced to dig into their stash of expired medications to load up trucks and treat critical patients with outdated prescriptions. It’s a practice on the rise as first responders react to a shortage of the lifesaving drugs they use every day, from painkillers to heart medicines, despite the risk that they won’t work as intended in life-or-death situations. (AP Photo/Don Ryan)

(AP) — When paramedics ran out of a critical drug used to treat irregular heartbeats, the Bend Fire Department in Central Oregon dug into its stash of expired medications, loaded up the trucks and kept treating patients.

Paramedics reported asking some of those facing medical emergencies: "Is it OK if we use this expired ?"

Emergency responders in various jurisdictions have reported turning to last resort practices as they struggle to deal with a shortage of drug supplies created by manufacturing delays and industry changes. Some are injecting expired medications or substituting alternatives. Others are simply going without.

As the drug crisis mounted for the Bend Fire Department earlier this year, the agency had 11 medications in its drug kits that were expired, despite risks that the pharmaceuticals might not work as intended in life-or-death situations. The crisis has eased a bit, but the agency still carries expired doses of two drugs in serving a city of 80,000 people.

"We've never (before) had to go diving back into the bin to try to retrieve expired boxes of drugs," said Tom Wright, emergency medical services coordinator for the Bend Fire Department, which has been administering outdated medicines for about a year. "We had the backing of our insurance company that giving expired drugs is better than giving no drugs at all."

He said that medics have not reported any adverse reactions.

Medications are only guaranteed to work as intended until their expiration date. When stored properly, most expired drugs won't be harmful to patients but will become less effective with time, according to medical professionals. However, EMS officials said it's often difficult to get information from manufacturers or regulators about how long specific medications will work.

The University of Utah's Drug Information Service reports 275 medications are in short supply. Clinics and hospitals have reported struggles getting chemotherapy drugs to treat cancer and anesthetics used in surgery.

Medications in a Salem fire department ambulance kit are shown in Salem, Ore., Tuesday, July 10, 2012. When faced with medication shortages, some paramedic outfits are forced to dig into their stash of expired medications to load up trucks and treat critical patients with outdated prescriptions. It's a practice on the rise as first responders react to a shortage of the lifesaving drugs they use every day, from painkillers to heart medicines, despite the risk that they won't work as intended in life-or-death situations. (AP Photo/Don Ryan)

In the past two years, paramedics from different agencies have dealt with shortages of critical first-line drugs like Valium to treat seizures, dextrose 50 to boost the blood sugar of diabetics and magnesium sulfate for eclampsia, an attack of convulsions during pregnancy. They've run low on painkillers and sedation drugs.

Right now, EMS directors say they're keeping a nervous eye on their supplies of epinephrine, for heart attacks and allergic reactions, and morphine, a painkiller.

Most of the shortages affecting emergency responders are of injectable generic medications. Drug manufacturers and the Food and Drug Administration say they're working aggressively to track and prevent shortages, but it could take years to get supplies back to normal levels.

"Drug shortages are not a new phenomenon," said Dave Gaugh, senior vice president for regulatory sciences at the Generic Pharmaceutical Association. "What's new is the crisis level they're at today."

State public health officials, who license ambulances and in some cases dictate the medications they must carry, are loosening their rules to help emergency responders deal with the various shortages. Oregon health officials last week began allowing ambulances to carry expired drugs, and southern Nevada has extended the expiration dates for drugs in short supply. Arizona has stopped penalizing ambulance crews for running out of mandated medications.

Some agencies have reported keeping their drug kits fully stocked by substituting alternative medications, some of which have additional side effects or higher costs, or by diluting higher dosages to get the less-concentrated dose needed.

Several agencies reported using morphine in place of the painkiller fentanyl, even though adverse reactions are more common from morphine. Some said they're diluting their stronger epinephrine doses.

Even those stopgap solutions carry risks, though, as fast-moving paramedics have extra steps and new dosage protocols to remember under pressure.

"It has such significant risk of patient harm or provider error that it's worthy of immediate attention," said Dia Gainor, director of the National Association of State EMS Officials.

The Food and Drug Administration recommends that expired drugs not be used, although the agency occasionally allows the use of specific batches if testing has shown they're safe.

Manufacturing quality lapses, production shutdowns for contamination and other serious problems are behind many of the shortages, according to manufacturers and the FDA. Other reasons include increased demand for some drugs, companies ending production of some drugs with small profit margins, consolidation in the generic drug industry and limited supplies of some ingredients.

The EMS community is far from united on whether to use expired drugs. Emergency responders work under the license of a supervising physician, and some doctors are uncomfortable allowing the use of drugs after the effectiveness date expires. While Oregon's Public Health Division has agreed not to fine ambulances for carrying outdated drugs, the state medical board that licenses doctors has been silent about whether that is an appropriate practice of medicine.

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Contact or follow AP writer Jonathan J. Cooper at twitter.com/jjcooper

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