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PHARMAC is tasked with, among other things, the challenge of providing continuity of supply of funded medicines for our relatively small country, and stands behind the nature of the sole supply contracts resulting in fewer supply issues compared to most other countries. When supply issues do occur, for instance due to manufacturing shortages, epidemics or other global factors affecting supply chains, PHARMAC has several ways to manage them. These include that they can “work with the supplier to find alternative stock” and “require medicines to be dispensed in smaller amounts”.1

One such supply issue was a nationwide shortage of Levlen ED in early 2019. Levlen ED is the most commonly prescribed combined oral contraceptive pill in New Zealand with just under 100,000 users annually.2 PHARMAC first notified pharmacists of this shortage on 17 January in the February 2019 Pharmaceutical Schedule Dispatch, with removal of Stat dispensing from 1 February.3 Levlen ED was to be dispensed in one-month lots, which contains 21 active hormone tablets and seven inactive sugar pills, rather than up to a six-month supply being dispensed at a time. A letter was then sent out to prescribers on 24 January to inform them of the shortage and that prescribing practices should not be affected.4 The shortage was forecast to last until new stock arrived in late March 2019.3 The shortage was also reported on by media outlets, with articles appearing in the media on 21 January.5

As the prescription charge would only have to be paid once, the shortage would not have caused an increase in direct costs to users. However, indirect costs to users are likely to have risen due to the need to return to the pharmacy more often, and there are other potential impacts too. Not having a new pill pack is a commonly reported reason by users for missing pills, and 21.9% of users who miss one pill for this reason miss pills on consecutive days.6 This in turn puts the user at an increased risk of pregnancy. A study conducted in the US showed that users who reported any difficulty in obtaining their method of contraception (pill, patch or ring) were more than twice as likely to discontinue, and the majority of users who discontinued switched to less effective methods of contraception, or no method.7 Dispensing fewer pill packets at a time is also associated with higher rates of unintended pregnancy in users,8 and there is a positive relationship between a greater number of pill packets dispensed at a time and continuation, and continuous oral contraceptive coverage.9

Shortages such as the one in early 2019 are not uncommon in New Zealand. There have been a number of shortages prior to this, and during the COVID-19 pandemic a number of oral contraceptives were placed on short supply, or alternatives were sourced and supplied with a time limited, conditional approval from Medsafe after originally being listed under Section 29 of the Medicines Act 1981.10 We therefore need to investigate the impacts of shortages on users, as we need to identify whether these temporary shortages and associated short supply of contraceptive pills resulted in higher rates of unintended pregnancy and discontinuation in users. Prescribers should consider counselling women affected by short supply of contraceptives who do not want to risk pregnancy to change to long-acting reversible contraceptives, which are less affected due to their longer efficacy.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Caryn Thomas, Medical Student, University of Otago, Dunedin; Rhiannon Braund, Professor, Department of Preventive and Social Medicine, University of Otago, Dunedin; Helen Paterson, Senior Lecturer and Head of Section of Obstetrics and Gynaecology (DSM), Department of Women’s and Children’s Health (Dunedin), University of Otago, Dunedin.

Acknowledgements

Correspondence

Dr Helen Paterson, Department of Women’s and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin.

Correspondence Email

helen.paterson@otago.ac.nz

Competing Interests

Nil.

1. Managing medicine supply: PHARMAC; 2016 [updated 28 April 2016. Available from: http://www.pharmac.govt.nz/about/your-guide-to-pharmac/factsheet-07-managing-medicine-supply/

2. Pharmaceutical data web tool version 26 September 2019 (data extracted from Pharmaceutical Collection on 26 March 2019): Ministry of Health; 2019 [Available from: http://minhealthnz.shinyapps.io/pharmaceutical_data_web_tool/

3. Williams L. PHARMAC Dispatch Fax 17 January 2019. Wellington, New Zealand: PHARMAC; 2019.

4. Betty B. 2019-01-24 Letter to Prescribers - Levlen ED. PHARMAC; 2019.

5. Martin H. Contraceptive pill Levlen ED rationed as supply runs low across New Zealand: Stuff; 2019 [Available from: http://www.stuff.co.nz/national/health/110053366/contraceptive-pill-levlen-ed-rationed-as-supply-runs-low-across-new-zealand

6. Smith J, Oakley D. Why Do Women Miss Oral Contraceptive Pills? An Analysis of Women’s Self-Described Reasons for Missed Pills. Journal of midwifery & women’s health. 2005; 50(5):380–5.

7. Stuart JE, Secura GM, Zhao Q, et al. Factors Associated With 12-Month Discontinuation Among Contraceptive Pill, Patch, and Ring Users. Obstet Gynecol. 2013; 121(2):330–6.

8. Foster DG, Hulett D, Bradsberry M, et al. Number of Oral Contraceptive Pill Packages Dispensed and Subsequent Unintended Pregnancies. Obstet Gynecol. 2011; 117(3):566–72.

9. Foster DG, Parvataneni R, de Bocanegra HT, et al. Number of Oral Contraceptive Pill Packages Dispensed, Method Continuation, and Costs. Obstet Gynecol. 2006; 108(5):1107–14.

10. Oral contraceptives: Supply updates: PHARMAC; 2020 [updated 5 June 2020. Available from: http://www.pharmac.govt.nz/information-for/enquiries/oral-contraceptives-supply-updates/

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

PHARMAC is tasked with, among other things, the challenge of providing continuity of supply of funded medicines for our relatively small country, and stands behind the nature of the sole supply contracts resulting in fewer supply issues compared to most other countries. When supply issues do occur, for instance due to manufacturing shortages, epidemics or other global factors affecting supply chains, PHARMAC has several ways to manage them. These include that they can “work with the supplier to find alternative stock” and “require medicines to be dispensed in smaller amounts”.1

One such supply issue was a nationwide shortage of Levlen ED in early 2019. Levlen ED is the most commonly prescribed combined oral contraceptive pill in New Zealand with just under 100,000 users annually.2 PHARMAC first notified pharmacists of this shortage on 17 January in the February 2019 Pharmaceutical Schedule Dispatch, with removal of Stat dispensing from 1 February.3 Levlen ED was to be dispensed in one-month lots, which contains 21 active hormone tablets and seven inactive sugar pills, rather than up to a six-month supply being dispensed at a time. A letter was then sent out to prescribers on 24 January to inform them of the shortage and that prescribing practices should not be affected.4 The shortage was forecast to last until new stock arrived in late March 2019.3 The shortage was also reported on by media outlets, with articles appearing in the media on 21 January.5

As the prescription charge would only have to be paid once, the shortage would not have caused an increase in direct costs to users. However, indirect costs to users are likely to have risen due to the need to return to the pharmacy more often, and there are other potential impacts too. Not having a new pill pack is a commonly reported reason by users for missing pills, and 21.9% of users who miss one pill for this reason miss pills on consecutive days.6 This in turn puts the user at an increased risk of pregnancy. A study conducted in the US showed that users who reported any difficulty in obtaining their method of contraception (pill, patch or ring) were more than twice as likely to discontinue, and the majority of users who discontinued switched to less effective methods of contraception, or no method.7 Dispensing fewer pill packets at a time is also associated with higher rates of unintended pregnancy in users,8 and there is a positive relationship between a greater number of pill packets dispensed at a time and continuation, and continuous oral contraceptive coverage.9

Shortages such as the one in early 2019 are not uncommon in New Zealand. There have been a number of shortages prior to this, and during the COVID-19 pandemic a number of oral contraceptives were placed on short supply, or alternatives were sourced and supplied with a time limited, conditional approval from Medsafe after originally being listed under Section 29 of the Medicines Act 1981.10 We therefore need to investigate the impacts of shortages on users, as we need to identify whether these temporary shortages and associated short supply of contraceptive pills resulted in higher rates of unintended pregnancy and discontinuation in users. Prescribers should consider counselling women affected by short supply of contraceptives who do not want to risk pregnancy to change to long-acting reversible contraceptives, which are less affected due to their longer efficacy.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Caryn Thomas, Medical Student, University of Otago, Dunedin; Rhiannon Braund, Professor, Department of Preventive and Social Medicine, University of Otago, Dunedin; Helen Paterson, Senior Lecturer and Head of Section of Obstetrics and Gynaecology (DSM), Department of Women’s and Children’s Health (Dunedin), University of Otago, Dunedin.

Acknowledgements

Correspondence

Dr Helen Paterson, Department of Women’s and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin.

Correspondence Email

helen.paterson@otago.ac.nz

Competing Interests

Nil.

1. Managing medicine supply: PHARMAC; 2016 [updated 28 April 2016. Available from: http://www.pharmac.govt.nz/about/your-guide-to-pharmac/factsheet-07-managing-medicine-supply/

2. Pharmaceutical data web tool version 26 September 2019 (data extracted from Pharmaceutical Collection on 26 March 2019): Ministry of Health; 2019 [Available from: http://minhealthnz.shinyapps.io/pharmaceutical_data_web_tool/

3. Williams L. PHARMAC Dispatch Fax 17 January 2019. Wellington, New Zealand: PHARMAC; 2019.

4. Betty B. 2019-01-24 Letter to Prescribers - Levlen ED. PHARMAC; 2019.

5. Martin H. Contraceptive pill Levlen ED rationed as supply runs low across New Zealand: Stuff; 2019 [Available from: http://www.stuff.co.nz/national/health/110053366/contraceptive-pill-levlen-ed-rationed-as-supply-runs-low-across-new-zealand

6. Smith J, Oakley D. Why Do Women Miss Oral Contraceptive Pills? An Analysis of Women’s Self-Described Reasons for Missed Pills. Journal of midwifery & women’s health. 2005; 50(5):380–5.

7. Stuart JE, Secura GM, Zhao Q, et al. Factors Associated With 12-Month Discontinuation Among Contraceptive Pill, Patch, and Ring Users. Obstet Gynecol. 2013; 121(2):330–6.

8. Foster DG, Hulett D, Bradsberry M, et al. Number of Oral Contraceptive Pill Packages Dispensed and Subsequent Unintended Pregnancies. Obstet Gynecol. 2011; 117(3):566–72.

9. Foster DG, Parvataneni R, de Bocanegra HT, et al. Number of Oral Contraceptive Pill Packages Dispensed, Method Continuation, and Costs. Obstet Gynecol. 2006; 108(5):1107–14.

10. Oral contraceptives: Supply updates: PHARMAC; 2020 [updated 5 June 2020. Available from: http://www.pharmac.govt.nz/information-for/enquiries/oral-contraceptives-supply-updates/

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

PHARMAC is tasked with, among other things, the challenge of providing continuity of supply of funded medicines for our relatively small country, and stands behind the nature of the sole supply contracts resulting in fewer supply issues compared to most other countries. When supply issues do occur, for instance due to manufacturing shortages, epidemics or other global factors affecting supply chains, PHARMAC has several ways to manage them. These include that they can “work with the supplier to find alternative stock” and “require medicines to be dispensed in smaller amounts”.1

One such supply issue was a nationwide shortage of Levlen ED in early 2019. Levlen ED is the most commonly prescribed combined oral contraceptive pill in New Zealand with just under 100,000 users annually.2 PHARMAC first notified pharmacists of this shortage on 17 January in the February 2019 Pharmaceutical Schedule Dispatch, with removal of Stat dispensing from 1 February.3 Levlen ED was to be dispensed in one-month lots, which contains 21 active hormone tablets and seven inactive sugar pills, rather than up to a six-month supply being dispensed at a time. A letter was then sent out to prescribers on 24 January to inform them of the shortage and that prescribing practices should not be affected.4 The shortage was forecast to last until new stock arrived in late March 2019.3 The shortage was also reported on by media outlets, with articles appearing in the media on 21 January.5

As the prescription charge would only have to be paid once, the shortage would not have caused an increase in direct costs to users. However, indirect costs to users are likely to have risen due to the need to return to the pharmacy more often, and there are other potential impacts too. Not having a new pill pack is a commonly reported reason by users for missing pills, and 21.9% of users who miss one pill for this reason miss pills on consecutive days.6 This in turn puts the user at an increased risk of pregnancy. A study conducted in the US showed that users who reported any difficulty in obtaining their method of contraception (pill, patch or ring) were more than twice as likely to discontinue, and the majority of users who discontinued switched to less effective methods of contraception, or no method.7 Dispensing fewer pill packets at a time is also associated with higher rates of unintended pregnancy in users,8 and there is a positive relationship between a greater number of pill packets dispensed at a time and continuation, and continuous oral contraceptive coverage.9

Shortages such as the one in early 2019 are not uncommon in New Zealand. There have been a number of shortages prior to this, and during the COVID-19 pandemic a number of oral contraceptives were placed on short supply, or alternatives were sourced and supplied with a time limited, conditional approval from Medsafe after originally being listed under Section 29 of the Medicines Act 1981.10 We therefore need to investigate the impacts of shortages on users, as we need to identify whether these temporary shortages and associated short supply of contraceptive pills resulted in higher rates of unintended pregnancy and discontinuation in users. Prescribers should consider counselling women affected by short supply of contraceptives who do not want to risk pregnancy to change to long-acting reversible contraceptives, which are less affected due to their longer efficacy.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Caryn Thomas, Medical Student, University of Otago, Dunedin; Rhiannon Braund, Professor, Department of Preventive and Social Medicine, University of Otago, Dunedin; Helen Paterson, Senior Lecturer and Head of Section of Obstetrics and Gynaecology (DSM), Department of Women’s and Children’s Health (Dunedin), University of Otago, Dunedin.

Acknowledgements

Correspondence

Dr Helen Paterson, Department of Women’s and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin.

Correspondence Email

helen.paterson@otago.ac.nz

Competing Interests

Nil.

1. Managing medicine supply: PHARMAC; 2016 [updated 28 April 2016. Available from: http://www.pharmac.govt.nz/about/your-guide-to-pharmac/factsheet-07-managing-medicine-supply/

2. Pharmaceutical data web tool version 26 September 2019 (data extracted from Pharmaceutical Collection on 26 March 2019): Ministry of Health; 2019 [Available from: http://minhealthnz.shinyapps.io/pharmaceutical_data_web_tool/

3. Williams L. PHARMAC Dispatch Fax 17 January 2019. Wellington, New Zealand: PHARMAC; 2019.

4. Betty B. 2019-01-24 Letter to Prescribers - Levlen ED. PHARMAC; 2019.

5. Martin H. Contraceptive pill Levlen ED rationed as supply runs low across New Zealand: Stuff; 2019 [Available from: http://www.stuff.co.nz/national/health/110053366/contraceptive-pill-levlen-ed-rationed-as-supply-runs-low-across-new-zealand

6. Smith J, Oakley D. Why Do Women Miss Oral Contraceptive Pills? An Analysis of Women’s Self-Described Reasons for Missed Pills. Journal of midwifery & women’s health. 2005; 50(5):380–5.

7. Stuart JE, Secura GM, Zhao Q, et al. Factors Associated With 12-Month Discontinuation Among Contraceptive Pill, Patch, and Ring Users. Obstet Gynecol. 2013; 121(2):330–6.

8. Foster DG, Hulett D, Bradsberry M, et al. Number of Oral Contraceptive Pill Packages Dispensed and Subsequent Unintended Pregnancies. Obstet Gynecol. 2011; 117(3):566–72.

9. Foster DG, Parvataneni R, de Bocanegra HT, et al. Number of Oral Contraceptive Pill Packages Dispensed, Method Continuation, and Costs. Obstet Gynecol. 2006; 108(5):1107–14.

10. Oral contraceptives: Supply updates: PHARMAC; 2020 [updated 5 June 2020. Available from: http://www.pharmac.govt.nz/information-for/enquiries/oral-contraceptives-supply-updates/

Contact diana@nzma.org.nz
for the PDF of this article

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