Twin Cities hospitals are struggling amid a nationwide shortage to keep adequate supplies of critical care drugs, including pain meds like fentanyl and morphine that are necessary to surgery and recovery.

As the long-simmering shortage ripples across the U.S. health care system, local hospitals and health systems are designating special pharmacy staff to monitor their inventories and search for new sources of the vital drugs.

“Pain medications are what keeps the wheels on the bus for the hospital,” said Jeffrey Bouman, pharmacy manager at Abbott Northwestern Hospital in Minneapolis. “These drugs are what makes us tick, what makes us work.”

For the most part, pharmacy managers say they have been able to meet demand, which at times has meant finding a similar drug or using the same drug that comes prepackaged in a different dose. But even slight departures from long-established routines involve retraining doctors and nurses to avoid harmful medication errors.

“It causes the health system a lot of pain, literally,” said Vini Manchanda, vice president of supply chain services at Bloomington-based HealthPartners.

Drug shortages nationwide peaked in 2011, when over 300 medications were in short supply. The U.S. Food and Drug Administration stepped in shortly after that and required all manufacturers to report current and anticipated shortfalls. The FDA says it has averted some shortages by finding alternative manufacturing sources or by encouraging imports from other countries.

Although there are fewer shortages now, more are occurring among drugs that are used commonly.

“There are 198 different outages or shortages of product and most of them are what you think of as inexpensive, easily available generic products,” said Jason Varin, an interim associate dean at the University of Minnesota College of Pharmacy.

Also affected are drugs that have high consumer demand, including the EpiPen, which delivers a lifesaving dose to people having severe allergic reactions, and the new shingles vaccine Shingrix, which is recommended for anyone over age 50 who had chickenpox.

Apart from pain medications, hospitals have been dealing with shortages of antibiotics, electrolyte solutions that help replenish body chemistry and even saline bags, which are basic to administering other medications as well as countering dehydration.

The saline bag shortage was the direct result of damage caused last year when Hurricane Maria hit Puerto Rico, where 10 percent of all medications used by Americans are manufactured.

Many Puerto Rican factories are now back online and the saline bag shortage is dissipating. Natural disasters play a small role in shortages. Sometimes factories are forced to stop production because the FDA has identified problems in the cleanliness or quality of its equipment, as was the case recently with a Kansas plant that made injectable pain medications.

Other times, companies will decide to discontinue production, especially of low-cost generic medications that are expensive to produce but yield small profits.

Drugmakers’ “fiduciary responsibility is not to provide health care, it is to return profits to their shareholders,” Varin said.

That often means hospitals get little warning of the newest drug shortage.

“The unpredictability and the volatility is what challenges most of us in pharmacy,” said John Pastor, system director of acute care pharmacy services at Minneapolis-based Fairview Health Services.

Pastor is one of 15 Fairview employees who meet on a daily basis, reviewing inventory and purchasing options and responding to information from other teams scattered throughout the health care system.

One response employed by Fairview is to have its pharmacies prepare medications for clinical use. When it couldn’t obtain prefilled syringes of heparin, an anti-clotting medication, pharmacy workers prepared syringes for use by nurses using a larger vial of the drug.

Fairview’s compounding pharmacy, where pharmacists most often custom-assemble medications for use in children, has also been doing more work preparing drugs for adults, Pastor said.

All the health systems say they are casting wider nets for alternative sources of supply. But it can take some arm-twisting.

“With the fentanyl shortage, there were moments when I had to personally get involved and chase down executives from wholesalers and make things happen,” said HealthPartners’ Manchanda.

The other solution is to substitute one drug with an acceptable alternative, although that requires a lot of discussion among physicians and nurses to make sure errors are not introduced. It also has ripple effects for information systems, such as the electronic medical record and the billing system, which may need to be reprogrammed to reflect nonstandard medication changes.

“It is not as easy as substituting generic ketchup for Heinz ketchup,” said Bouman at Allina Health’s Abbott Northwestern.

The FDA announced this summer that it will form a task force to further study the issue, and a public meeting is scheduled in late November.

PhRMA, the drug industry trade group, said it looks forward to learning more about the task force.

For now the drug shortages have become part of normal operations and show no signs of letting up.

“There are always some manufacturing delays of some sort,” said Bouman. “We struggle on the front side with a lack of information and also a very short notice on these types of things.”