Nabilone is a synthetic cannabinoid, originally marketed for nausea and vomiting secondary to chemotherapy. However, its recent drug shortage isn’t because we have many patients who require it for nausea and vomiting. I think the drug shortage is a side effect of two things that are happening in our society: 1) the opioid crisis, 2) legalization of marijuana
As the new opioids guidelines from CDC and McMaster University both advocate for safer and lower dose limit of opioids – specifically to a maximum of 50 MME (milligram of morphine equivalent) for the majority of patients and no more than 90MME (90mg morphine equivalent) for all patients to prevent opioid overdose, many clinicians are re-examining how to manage their current patients with chronic non-cancer pain who are on much higher doses of opioids.
Some have turned to non-opioid options such as acetaminophen, NSAIDs and other agents that may be helpful in neuropathy such as amitriptyline, gabapentin and pregabalin. Many also ponder around non-drug options such as exercise and psychotherapy. But there is still a general sentiment that a “substitute” or “replacement” may be needed for high dose opioids.
Given there is some evidence for benefits of medical marijuana in neuropathic pain, more clinicians are beginning to consider it in chronic pain management. In addition as we hear more media coverage on legalization of marijuana, many patients may be interested and are starting to ask their physicians about the use of medical marijauna for other various conditions (e.g. seizure, Parkinson’s disease, Multiple sclerosis).
As this is an uncharted territory, some physicians may be reluctant to prescribe medical marijuana. I believe it is under these circumstances that many clinicians have turned to nabilone. Therefore the demand of nabilone has steadily increased over the last several months. I also suspect many manufacturing companies have not caught up with recent changes in guidelines and their rate of production has not been adjusted to account for possible increased demand. As such, we are facing the drug shortage of nabilone as we speak.
This isn’t the first time I see the connection between drug shortage of a particular drug and possible changes in guidelines or prescribing practices. Chlorthalidone went into drug shortage when the new hypertension guidelines put this old drug in many prescribers’ mind. Perphenazine went into drug shortage when the CATIE trial suggested that the extrapyrimidal side effects are not significant different between first generation antipsychotics (e.g. perphenazine) versus second generation antipsychotics.
I know drug shortage is a complicated matter that involves many stakeholders and cannot be easily understood. But perhaps one of the solutions is that we can analyze the prescribing patterns in relations to the release of new guidelines that may impact on specific drugs. I feel that we can develop an algorithm to predict the prescribing trends and results can help manufacturing companies to adjust their productions to avoid drug shortages – and ultimately therapy interruptions for real patients who may be affected.
Many drug shortages occur in medications that are not as profitable (e.g. generics) and the manufacturers may not have the means and resources to analyze the market trends. Perhaps to fix the ongoing drug shortages, our government can implement resources to better understand the causes of current drug shortages so that we can proactively manage them.
So I don’t think nabilone is the next best thing but the current drug shortage is NOT a result of shortage of raw materials either. It is a natural consequence of what has been happening with the opioid crisis and the legalization of marijuana. Both of which we could have predicted and prevented. Yet we have failed to do anything about it and allow it lead to therapy interruptions for patients who have been stabilized on the medication.
We need to fix our drug shortages now. I am tired of managing drug shortages for patients over the last several years. I also dislike switching to alternatives that are either suboptimal or more expensive.
When will we do something about our drug shortages?