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China and India now manufacture about 80% of the drugs consumed in the U.S.
LAST WEEK, DRUGMAKER Novartis issued a recall of generic versions of the popular heartburn medication Zantac. The Food and Drug Administration recently announced that the drug’s active ingredient, ranitidine, had been contaminated with a carcinogen known as NDMA. On Monday, CVS pulled Zantac and its generics from its shelves; Walgreens had already stopped selling the drug earlier.
This recall will impact patients suffering from a variety of excess stomach acid conditions. But it’s the safety of the generic drug supply as a whole that should give all Americans heartburn.
Congress is currently focusing on a legislative effort to reduce the out-of-pocket costs of brand name prescription drugs. This is a worthy effort. Yet it shouldn’t overlook the other pressing prescription drug problem: the safety risks posed by many generic drugs, which make up roughly 90% of the drugs Americans take.
Ranitidine is just the latest in a string of generic prescription drug safety contaminations in recent years. Last year, the FDA announced that the same carcinogen contaminated the popular blood-pressure medication valsartan, spurring a massive recall that affected tens of millions of patients.
The biggest prescription drug crisis of recent years was the 2008 contamination of heparin, a widely used blood thinner. The FDA estimates that 149 Americans died and many hundreds more were seriously injured as a result.
What’s responsible for the repeated drug safety lapses? The offshoring of the American drug supply to China and, to a lesser extent, India during the past couple of decades.
Lax safety standards and FDA oversight at plants in those two countries have allowed these drugs – and likely countless more we don’t know about – to become contaminated and endanger patients. China and India now manufacture about 80% of the drugs consumed in the U.S. This figure understates China’s dominance because many of the active ingredients in the Indian manufactured drugs come from China. The U.S. doesn’t even manufacture vital drugs like antibiotics anymore, with the last penicillin factory closing in 2004.
In 2017, FDA inspectors investigated a plant at China’s Huahai Pharmaceuticals, which manufactured contaminated valsartan, and found rust, deteriorating equipment, ignored consumer complaints, testing anomalies and potential contamination. Two other Chinese plants were cited by the FDA last year for inadequate cleaning and maintenance procedures, unlocked and improper recording formulas, and inadequate testing, among other violations.
FDA inspectors are unable or unwilling to provide appropriate oversight of Chinese manufacturing. In contrast to the robust testing required for approval for new prescription drugs, the FDA only requires that generic manufacturers prove that patients will absorb drugs at the same rate as the brand-name medications they copy.
A 2016 Government Accountability Office report finds that some Chinese drug manufacturing plants are never investigated, while others are looked at infrequently. At the time of the report, the FDA only has 29 staff to inspect more than 3,000 foreign manufacturing facilities. And, the number of FDA investigators abroad dropped by 25% between 2016 and 2018, with two out of the three inspection offices in China closing in recent years. According to a Bloomberg analysis, the FDA checks less than 1% of drugs manufactured abroad for safety before allowing them into the country. And manufacturers are generally warned before inspections occur.
Given the growing trade war and animosity between the two countries, the utter dependence on China for the U.S.’s basic medicines also poses a national security threat. China’s drug manufacturing dominance gives it a nuclear option in the ongoing trade war. Millions of Americans could die without access to lifesaving medications if China decides to weaponize its drug-making.
In order to ensure generic drug safety and protect against this national security threat, the U.S. must produce its most vital medications, such as antibiotics, insulin, and anesthesia, at home. In their 2018 book “China RX,” authors Rosemary Goodwin and Janardan Prasad Singh lay out 10 steps to achieve this goal. These include deeming medicines a strategic asset, providing incentives to bring manufacturing home, and increasing FDA testing of medications.
Lawmakers plan to hold hearings soon about China’s dominance in prescription drug manufacturing. These hearings should recommend that any forthcoming comprehensive prescription drug legislation include a reshoring element. If the status quo prevails, the country will continue experiencing dangerous and widespread drug contaminations – at best.
The US Justice Department’s inspector general has found that the agency in charge of preventing drug misuse and diversion failed to stop either as the American opioid epidemic worsened.
In a report published yesterday (pdf), inspector general Michael E. Horowitz criticized the Drug Enforcement Administration (DEA) for being “slow to respond” to a sharp rise in opioid use and misuse, for not using the tools at its disposal to better assess and regulate opioid diversion, and for weaknesses in how it handed out registrations to handle controlled substances. “While the Department and DEA have recently taken steps to address the crisis,” the report states, “more work is needed.”
Handling a controlled substances or restricted chemical in the US requires a DEA registration. About 1.8 million have been distributed. The system is meant to “determine the fitness and suitability of the applicant” to sell, prescribe, distribute, import, export, or manufacture narcotics.
The report from the Office of the Inspector General (OIG) found gaping holes in the registration process. The DEA often rubber-stamps approvals for those who already have state licenses, yet is not always aware of doctors or pharmacists who have had state licenses revoked. It relies on the “good faith of applicants to disclose relevant information, even in cases in which the applicant had previously engaged in criminal activity,” the report says.
DEA policy prohibits investigators from performing “criminal background checks” on applicants in favor of less complete “background checks.”
That means they can’t search the FBI’s National Crime Information Center database, nor can they access the DEA’s own internal investigative database, the Narcotics and Dangerous Drugs Information System. Instead, background investigations are done using a privately-run commercial database with more limited information. A DEA spokesperson declined to provide details of why the databases are off-limits.
Not enough vetting by DEA
Physicians and pharmacies are not being sufficiently vetted either, the OIG report says. A corporation that owned a pharmacy and was registered with the DEA could sell the pharmacy to another corporation, which wouldn’t have to then re-apply for a registration. And if registrants get their licenses revoked, they can reapply within a day, giving offenders an opening to re-obtain clearance.
Dean Arneson, who leads the school of pharmacy at Concordia University Wisconsin, told Quartz there are other checks in place for pharmacies when the DEA licensing process fails. Individual states usually require “that you need to get approval from the state board of pharmacy,” Arneson said, and pharmacies need to provide proof they have a license.
Pharmaceutical manufacturers and distributors are required to report all transactions involving Schedule I and II controlled substances—deemed to have the most potential for abuse—and certain Schedule III and IV substances. The DEA doesn’t require distributors and manufacturers to report orders of benzodiazepines such as klonopin and valium, which are involved in more than 30% of all opioid overdoses. Nor does the DEA track nine opioid compounds, such as cough syrup with codeine.
The agency could conceivably enact a requirement that distributors and manufacturers report all controlled-drugs sales, Holly Strom, former president of the California State Board of Pharmacy, told Quartz. However, this would create its own problems. There are many legitimate reasons for benzodiazepine orders to increase, Strom said—a group medical practice opening nearby with a large number of psychiatrists and primary-care providers, would be one example—and the many legitimate patients taking benzodiazepines but not opioids face a much lower risk of overdose than those taking what can be a potentially deadly combination.
A separate database specifically for reports of suspicious orders was also incomplete and ineffective, says the OIG report. Of roughly 1,400 manufacturers and distributors required to report suspicious orders to the DEA, its suspicious orders database only included reports from eight of them. DEA officials told the OIG that most suspicious orders reports are sent to local field officers and not headquarters, where they would be entered into the centralized system. Yet, when OIG investigators asked to see records verifying this, the DEA was “unable to locate them.”
Reviews of sales are not timely
Finally, the ad hoc system the DEA uses to collect information from the marketplace makes it all but impossible for investigators to keep abreast of current trends, the OIG report says. Some distributors and manufacturers report transactions monthly, others report quarterly. Thus, nothing gets analyzed until the end of the year. The associate section chief of the DEA’s Pharmaceutical Investigations Section told the OIG that the agency would not be able to identify trends and issues emerging in 2018 until sometime in 2019.
“Monthly isn’t appropriate and quarterly is ridiculous, that [data] should be uploaded daily,” Strom said. “If the enforcement entities have their algorithms set up properly, they would see these spikes in orders immediately and they’d be able to respond to them appropriately.”
At the state level, things are different. In California, Strom said pharmacies have to reconcile their inventory of Schedule II drugs every 90 days, matching the prescriptions they’ve filled with all invoices showing what’s been received. Those then have to be reconciled down to the dosage unit, and any overages or shortages have to be reported to the Board of Pharmacy within 30 days. This theoretically allows the pharmacy to stop diversion schemes before they have a chance to get out of control.
Overall, the OIG report paints a critical picture of an agency unable or unwilling to use the tools at its disposal to track the diversion of opioids, identify and crack down on offenders, and perform its primary function—enforcement. From 2002 to 2013, the DEA allowed manufacturers to produce a lot more opioids, including a 400% increase in the production of oxycodone, the key ingredient in the popular painkiller OxyContin. During that same period, the opioid overdose death rate grew by an average of 8% per year, increasing to an astounding 71% per year from 2013 through 2017.
These numbers might seem like a lot but Arneson says sometimes high doses or more prescriptions aren’t an indication of misuse or diversion. “Pain management is…an art. I was always taught that the dose that works is the dose that works.” What pharmacists should do, Arneson explains, is “make sure that the prescriptions are for a legitimate medical purpose and…if they suspect that a person is abusing the medications, that they’re supposed to take steps into reporting that.”
“DEA appreciates the OIG’s assessment of the programs involved in the report and the opportunity to discuss improvements made to increase the regulatory and enforcement efforts to control the diversion of opioids,” the agency wrote in response to the report. “While only a minute fraction of the more than 1.8 million manufacturers, distributors, pharmacies and prescribers registered with DEA are involved in unlawful activity, DEA continuously works to identify and root out the bad actors.”
Nick Schwellenbach, director of investigations at the nonprofit Project on Government Oversight, is slightly less generous with his assessment. As he told Quartz, “This report makes clear that, had the DEA’s oversight of these deadly drugs been more robust, thousands of our family members, friends, and neighbors might be alive today.”
In 2005, the Food and Drug Administration found that close to 85% of “Canadian” drugs actually came from 27 other countries. It is also estimated that 1 in 10 drugs from developing countries are counterfeit, according to the World Health Organization. (PHOTO GETTY STOCK IMAGES)
EFFORTS TO IMPORT prescription drugs from Canada received a big boost in May when President Donald Trump reiterated his support for the proposal. Trump reportedly directed Health and Human Services Secretary Alex Azar to work with Florida, which is one of 16 states pursuing importation legislation, to get the necessary federal approvals as quickly as possible. According to Florida Rep. Matt Gaetz, the president is “chomping at the bit for this solution to lower drug prices.”
As former presidents of the California State Pharmacy Board, we sympathize with patients suffering from the significant increase in prescription drug list prices in recent years. We’ve seen personally and professionally the medical and financial consequences of rising out-of-pocket drug costs throughout our careers.
Widescale drug importation from Canada, however, is not a practical solution to this problem. It is a distraction from efforts to address the real prescription drug cost drivers. In the words of Secretary Azar, it’s “a gimmick.” Trump and legislators should redirect their efforts to proposals that could actually make a difference short term and long term in lowering costs.
Perhaps conflating its geographic size, importation proponents seem to overlook Canada’s small population, which is less than California’s. There’s no way that our neighbors to the north could supply the U.S. market — or even a handful of states — with all of its prescription drug needs. According to the Canadian Pharmacists Journal, Canada’s drug supply would run out in 224 days if merely 10% of U.S. prescriptions were filled with Canadian drugs. The former Health Minister of Canada said, “Canada cannot be the drugstore for the United States.”
Yet the bigger problem with drug importation is not logistics but safety. While bona fide Canadian drugs are surely safe, there’s just no way to ensure that drugs marketed as Canadian are actually Canadian. It’s easy for a supplier in, say, Turkey to set up a “Canadian” drug website and route its product through a Canadian address. Federal investigations have repeatedly found drugs that supposedly came from Canada really originated in other nations.
In 2005, the Food and Drug Administration found that nearly half of the imported drugs intercepted from four developing countries were marketed as “Canadian.” They found that the vast majority — some 85% — of “Canadian” drugs actually came from 27 other countries. Last year, Canadadrugs.com was fined $34 million by U.S. prosecutors for selling two cancer drugs with no active pharmaceutical ingredients.
The World Health Organization estimates that 1 in 10 drugs from developing countries are counterfeit. In 2018, the FDA found 3,600 websites selling illicit and counterfeit drugs.
According to Katherine Eban, author of “Bottle of Lies,” FDA investigators found fraud and deceptive practices in the vast majority of drug plants inspected in India and China, including bird and insect infestations and potential urine contamination.
Counterfeit concerns have only grown with the prevalence of fentanyl, just 500 micrograms of which is enough to cause an overdose. Law enforcement uncovered 130,000 counterfeit pillslaced with fentanyl in Alberta in 2016.
A compromised drug supply threatens the only thing more important to patients than cost: safety. This has led to a bipartisan consensus among recent FDA chiefs of both Republican and Democratic Administrations opposing Canadian drug imports. There’s “no effective way to ensure drugs coming from Canada really are coming from Canada rather than being routed from say a counterfeit factory in China,” says HHS chief Alex Azar.
So if not by importation, how can prescription drug prices be brought down? Drug distribution and supply channels must be reformed to allow for more competition to bring down prices as well as eliminate pricing distortions that thrive behind a veil of secrecy — what former FDA chief Scott Gottlieb has called “Kabuki” theater.
Yet to address these real drivers of prescription drug costs, policymakers must avoid using up their political capital on this distracting and dangerous importation delusion.
Holly Strom, a licensed pharmacist, is a former president of the California Board of Pharmacy and the founder of Strom and Associates LLC, a health care consulting practice.
Kenneth Schell, a licensed pharmacist, is former president of the California Board of Pharmacy.
Holly Strom | Originally published in the San Francisco Chronicle | Feb. 6, 2016 | Updated: Feb. 7, 2016 12:23 p.m. |
With New Hampshire’s first-in-the-nation primary coming up Tuesday, you may be surprised to learn that the issue most concerning the Granite State’s voters isn’t jobs, national security or immigration. It’s drug abuse.
A prescription drug epidemic — mainly driven by the wide availability and abuse of opioid prescription drugs such as OxyContin — is ravaging New Hampshire. There were roughly 400 deaths from overdose in 2015 — double those from 2014. Here in California, Orange, San Diego and Los Angeles counties have the most opioid-related deaths. Roughly 125 Americans now die from drug overdoses every day.
What would the presidential candidates do to solve this crisis? Unfortunately, most of them have given little indication. I have some suggestions:
Require states to share information. Every state except Missouri has a drug monitoring program that tracks controlled substances sold within their borders. But the moment someone crosses a state line to get a prescription filled, they can drop off the radar. This makes it incredibly difficult for law enforcement and medical professionals to know what’s happening in their own neighborhoods. I’ve seen this firsthand in California — we desperately want to share information with our peers in Oregon, Nevada and Arizona, yet are unable to do so.
Propose creation of a national database to keep track of opioid use. The National Association of Boards of Pharmacy has funded and helped develop a secure system that conforms to the data standards put in place by the federal government for such interstate data sharing. It is in use in 34 states, although California is not one. By the end of 2016, about 40 states will either be connected to or working toward a connection to this system. The next president should propose that the remaining states participate, even as soon as 2020.
Increase funding for medical training programs. Pharmacists and other medical professionals are often given insufficient training when it comes to the dangers of prescription opioid abuse. As a result, many medical professionals unintentionally overprescribe opioids when another, less dangerous, substance will do. Prescriptions — and addiction rates — would start to drop.
To be clear: Any sort of nationally mandated training and prescribing guidelines would fail to account for all of a state’s or city’s specific needs. The federal government could step up funding for programs such SafeMedLA, which is run in my county of Los Angeles. An equally important part of this puzzle is the creation of training programs for those who have been in practice for many years — not just current medical and pharmacy school students.
We must spur a larger conversation on how to fight the prescription opioid abuse epidemic so that the presidential candidates take it seriously. So far, they have remained largely silent, even though this issue profoundly matters to millions of Americans.
Holly Strom, a licensed pharmacist, is a former president of the California Board of Pharmacy and the founder of Strom and Associates LLC, a health care consulting practice.