Drug Shortages: Better Management of the Quota Process for Controlled Substances Needed; Coordination between DEA and FDA Should Be Improved
Highlights
What GAO Found
Shortages of prescription drugs containing controlled substances have increased sharply in recent years; of the 168 shortages reported from January 2001 through June 2013, nearly 70 percent began after 2007. Such shortages lasted for nearly a year, on average. Additionally, many shortages involved generic pain relievers and drugs where there was only one manufacturer.
The Food and Drug Administration (FDA), an agency within the Department of Health and Human Services (HHS), and organizations representing patients and providers report that during shortages of drugs containing controlled substances, patients may receive less effective care, experience medication errors, or not receive treatment at all. They said providers are also affected as they spend time and resources mitigating the effects of shortages, rather than providing care.
The Drug Enforcement Administration (DEA), an agency within the Department of Justice (DOJ), has not effectively administered the quota process that limits the amount of controlled substances available for use in the United States. Each year, manufacturers apply to DEA for quota needed to make their drugs. DEA, however, has not responded to them within the time frames required by its regulations for any year from 2001 through 2014. DEA officials attributed this lack of compliance to inadequate staffing. Manufacturers who reported quota-related shortages cited late quota decisions as causing or exacerbating shortages of their drugs. Additionally, DEA's weak internal controls jeopardize the agency's ability to effectively manage the quota process. For instance, agency officials said that DEA does not conduct quality checks to ensure the accuracy of the data in its Year-End Reporting and Quota Management System (YERS/QMS). GAO estimates that 44 percent of YERS/QMS records in 2011 and 10 percent in 2012 had errors. DEA officials said that 2011 was the first year manufacturers applied for quota electronically and they expected data from 2012 and beyond to be more accurate. DEA also lacks critical management information because it does not have performance measures related to setting quotas, nor does it monitor data to assess its performance. Moreover, DEA does not have reasonable assurance that the quotas it sets are in accordance with its requirements and cannot ensure continuity of its operations, as it does not have protocols, policies, training materials, or other documentation to manage the quota process.
Despite statutory provisions requiring DEA and FDA to coordinate certain efforts to address shortages of drugs containing controlled substances, the agencies have not established a sufficiently collaborative relationship. For example, DEA and FDA disagree about what constitutes a shortage. DEA officials also said that they do not believe FDA appropriately validates or investigates the shortage information it posts on its website and that posting this information encourages manufacturers to falsely report shortages to obtain additional quota. However, FDA reports that it takes steps to investigate and confirm the shortages on its website. Given such barriers to coordination, DEA and FDA cannot effectively act to prevent or alleviate shortages. Although DEA and FDA have a memorandum of understanding (MOU) in place, it has not been revised since the 1970s and they have been working for more than two years to update it. Officials from both agencies said an updated MOU could facilitate information sharing and help prevent and mitigate future shortages of drugs containing controlled substances.
Why GAO Did This Study
In the last decade, shortages of prescription drugs containing controlled substances, such as narcotics and stimulants, have increased nationwide, preventing providers and patients from accessing essential medications for treatment. Controlled substances are regulated by DEA because of the potential for abuse and addiction. To prevent diversion of controlled substances, DEA sets quotas that limit the amount of certain substances that are available in the United States.
GAO was asked to examine shortages of drugs containing controlled substances. This report examines (1) the trends in such shortages, (2) the effect on patients and providers, (3) DEA's administration of the quota process, and (4) coordination between DEA and FDA to prevent and mitigate shortages. GAO analyzed data from 2001 through 2013 from the University of Utah Drug Information Service, which is generally regarded as the most comprehensive source of drug shortage data, and from 2011 and 2012 from YERS/QMS, which is the official record for the quota process. GAO interviewed officials from DEA, FDA, organizations representing patients and providers, and drug manufacturers. GAO reviewed relevant statutes, regulations, and documents.
Recommendations
DEA should take five actions to improve its management of the quota process; DEA and FDA should quickly update their MOU and agree on steps each will take regarding drug shortages. HHS agreed with the applicable recommendations. DEA neither agreed nor disagreed, but raised multiple objections to this report.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Drug Enforcement Administration | To ensure that DEA is best positioned to administer the quota process to ensure an adequate and uninterrupted supply of controlled substances for legitimate medical use and respond to shortages of drugs containing controlled substances, the Administrator of DEA should establish controls, including periodic data checks, to ensure that the YERS/QMS data accurately reflect both manufacturers' quota submissions and DEA's decisions. |
In June 2016, DEA stated it had implemented a series of system-generated flags in its Year-End Reporting and Quota Management System (YERS/QMS) to verify the information manufacturers enter into their quota applications and identify entries made by DEA staff that warrant further review by the agency. For example, when DEA staff grant a greater quantity of quota than is requested by the manufacturers, the entry is flagged for review and explanation. Further, the agency conducted a comparison of a random sample of 146 manufacturers' applications and DEA's responses in YERS/QMS from March through May 2016 and found a nearly nonexistent error rate (0.1 percent). DEA officials said that they plan to continue to compare a random sample of manufacturers' applications and DEA's responses in YERS/QMS on a quarterly basis. With these additional controls in place and DEA checking to ensure that the controls are working, the agency now has reasonable assurance that the information in YERS/QMS, which serves as the official record of the quota process, is accurate.
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| Drug Enforcement Administration | To ensure that DEA is best positioned to administer the quota process to ensure an adequate and uninterrupted supply of controlled substances for legitimate medical use and respond to shortages of drugs containing controlled substances, the Administrator of DEA should establish performance measures for DEA related to quotas and ensuring an adequate and uninterrupted supply of controlled substances for legitimate medical use. |
In June 2016 reported that it would develop performance standards that outline time frames for when manufacturers should expect DEA to respond to their quota applications. In February 2017, DEA provided GAO with these performance metrics, which include goals for establishing quotas each year by October 1, and an estimated timeframe for responding to applicants. DEA also provided training to manufacturers in April 2016 about the quota process to improve the accuracy and quality of their quota applications and plans to finish developing web-based training in fiscal year 2017. These steps should strengthen the agency's oversight of this important program.
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| Drug Enforcement Administration | To ensure that DEA is best positioned to administer the quota process to ensure an adequate and uninterrupted supply of controlled substances for legitimate medical use and respond to shortages of drugs containing controlled substances, the Administrator of DEA should monitor and analyze YERS/QMS data to assess DEA's administration of the quota process. |
DEA began monitoring and analyzing data from its Year End Reporting/Quota Management System (YERS/QMS) to assess its administration of the quota process in 2016 and periodically updating us on its progress. Specifically, in June 2016 and September 2016, DEA provided the results of its quarterly analyses of the accuracy of YERS/QMS. Both analyses found that there were essentially no errors in the sample of records reviewed (0.01 percent and 0 percent accordingly). Additionally, the agency has used YERS/QMS to analyze its response times to manufacturers' quota applications and found that it was meeting its required time frames of establishing quotas and generally responding to manufacturers' quota applications within four weeks. The agency reported that all of the responses that took longer than four weeks were because of delays by manufacturers in providing DEA with necessary information to support the quota requests. Lastly, DEA used YERS/QMS data to evaluate its performance against the measures DEA established in response to another of our recommendations. By monitoring and analyzing YERS/QMS data the agency is now able to monitor the quality of its data and assess its timeliness in issuing its quota decisions.
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| Drug Enforcement Administration | To ensure that DEA is best positioned to administer the quota process to ensure an adequate and uninterrupted supply of controlled substances for legitimate medical use and respond to shortages of drugs containing controlled substances, the Administrator of DEA should establish internal policies for processing quota applications and setting aggregate, annual, and supplemental quotas to ensure that staff conduct these activities consistently and in accordance with the Controlled Substances Act and agency's regulations. |
In June 2016, DEA reported that it established internal policies for its quota setting process. It also said that it was in the process of updating its employee training materials for new staff to help ensure that each staff member had the information needed to issue quotas in accordance with the Controlled Substances Act and DEA's regulations. In June 2017, DEA provided GAO with these policies, which include guidance on quota setting and steps related to processing quota applications and responding to applicants. GAO believes these written policies and training efforts will help DEA staff to ensure that quotas are set in accordance with the law and regulations.
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| Drug Enforcement Administration | To ensure that DEA is best positioned to administer the quota process to ensure an adequate and uninterrupted supply of controlled substances for legitimate medical use and respond to shortages of drugs containing controlled substances, the Administrator of DEA should expeditiously establish formal policies and procedures to facilitate coordination with FDA as directed by the Food and Drug Administration Safety and Innovation Act, including a specific time frame in which DEA will be expected to respond to FDA requests to expedite shortage-related quota applications. |
In March 2018, DEA established formal procedures to facilitate coordination with FDA during shortages of drugs containing controlled substances. These procedures were included in an update to the memorandum of understanding (MOU) the two agencies had last executed in 2015. The MOU now incorporates these procedures in an addendum. Among other things, the procedures outline the type of information to be shared, such as verified reports from manufacturers of interruptions in their production of controlled substances. The procedures call for the establishment of an electronic mailbox to facilitate efficient communication between the two agencies and describe how DEA and FDA will track written and verbal information exchanges. In addition, the procedures specify safeguards to prevent unauthorized disclosure of information by either agency. Finally, they include a specific time frame-48 hours-in which DEA will be expected to respond to FDA's requests for assistance in averting or responding to shortages.
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| Food and Drug Administration | To strengthen DEA's and FDA's ability to respond to shortages of drugs containing controlled substances, the Administrator of DEA and the Commissioner of FDA should promptly update the MOU between the two agencies. |
In March 2015, DEA and FDA signed a new memorandum of understanding (MOU) which may be helpful in preventing or addressing shortages of drugs containing controlled substances. Some of these drugs, such as narcotics and stimulants, play a vital role in health care. However, they are regulated by DEA because of the potential for abuse and addiction. We found that DEA and FDA did not have a sufficiently collaborative relationship, despite a requirement that they coordinate certain efforts to address shortages of drugs containing controlled substances. Although the agencies had an MOU in place, it had remained unchanged since the 1970s. Both agencies told us that they were subject to restrictions on exchanging the proprietary information they receive from drug manufacturers, which may be helpful to prevent or address these shortages. The agencies had therefore been working for more than 2 years to revise the MOU to facilitate the sharing of such information. The new MOU was finalized about a month after GAO's report was issued. The MOU establishes procedures regarding the exchange of proprietary and other sensitive information between FDA and DEA in both written and verbal communications. It also specifies that information must be shared in accordance with applicable laws, regulations, and policies, and safeguarded against improper use.
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| Drug Enforcement Administration | To strengthen DEA's and FDA's ability to respond to shortages of drugs containing controlled substances, the Administrator of DEA and the Commissioner of FDA should promptly update the MOU between the two agencies. |
In March 2015, DEA and FDA signed a new memorandum of understanding (MOU) which may be helpful in preventing or addressing shortages of drugs containing controlled substances. Some of these drugs, such as narcotics and stimulants, play a vital role in health care. However, they are regulated by DEA because of the potential for abuse and addiction. We found that DEA and FDA did not have a sufficiently collaborative relationship, despite a requirement that they coordinate certain efforts to address shortages of drugs containing controlled substances. Although the agencies had an MOU in place, it had remained unchanged since the 1970s. Both agencies told us that they were subject to restrictions on exchanging the proprietary information they receive from drug manufacturers, which may be helpful to prevent or address these shortages. The agencies had therefore been working for more than 2 years to revise the MOU to facilitate the sharing of such information. The new MOU was finalized about a month after GAO's report was issued. The MOU establishes procedures regarding the exchange of proprietary and other sensitive information between FDA and DEA in both written and verbal communications. It also specifies that information must be shared in accordance with applicable laws, regulations, and policies, and safeguarded against improper use.
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| Food and Drug Administration | To strengthen DEA's and FDA's ability to respond to shortages of drugs containing controlled substances, the Administrator of DEA and the Commissioner of FDA should, either in the MOU or in a separate agreement, specifically outline what information the agencies will share, and time frames for sharing such information, in response to a potential or existing drug shortage. |
In March 2018, FDA and DEA updated a memorandum of understanding (MOU) they had last executed in 2015. The prior MOU did not fully describe what information the agencies were to share and the time frames for doing so during potential or existing shortages of drugs containing controlled substances. Instead, it called for the development of a separate plan to specify these details. The recently updated MOU now includes this plan in an addendum. It outlines the substance of the information the two agencies will exchange. It also includes a specific time frame for DEA to respond to requests made by FDA to help avert or respond to shortages.
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| Drug Enforcement Administration | To strengthen DEA's and FDA's ability to respond to shortages of drugs containing controlled substances, the Administrator of DEA and the Commissioner of FDA should, either in the MOU or in a separate agreement, specifically outline what information the agencies will share, and time frames for sharing such information, in response to a potential or existing drug shortage. |
In March 2018, FDA and DEA updated a memorandum of understanding (MOU) they had last executed in 2015. The prior MOU did not fully describe what information the agencies were to share and the time frames for doing so during potential or existing shortages of drugs containing controlled substances. Instead, it called for the development of a separate plan to specify these details. The recently updated MOU now includes this plan in an addendum. It outlines the substance of the information the two agencies will exchange. It also includes a specific time frame for DEA to respond to requests made by FDA to help avert or respond to shortages.
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