PharmD prescribing rights

I don't have references, but I am 99% sure that there are several situations in which pharmacists that have prescribing rights. Some can prescribe pretty much everything except narcotics. A prime example would be some of the clinical pharmacists that work in VA (Veterans) Hospitals. THey do still work "under" the supervision of a physician though, as far as I know.

What pharmacists are engaging in in many practice settings in many states are "protocols". The ability of these pharmacists to prescribe is based on another medical provider's prescriptive authority. For a protocol to be established, state law must allow this type of collaborative agreement. I am unaware of any situation in which simply being a pharmacist practicing within a state allows one the "right" to prescribe.

In Florida, pharmacists can prescribe Transderm Scop for motion sickness. There's lots of people going on cruises. I've never seen it done, but it is legal. Other than that, it's like pharmagirl said, you can prescribe at the VA.

dgroulx said:

Other than that, it's like pharmagirl said, you can prescribe at the VA.

Click to expand...

When I was touring the local VA they told us that they are not mandated by state laws since they are a government entity. I guess that's the reason things are different there and pharmacists are given more responsibility.

Hey Dana, are pharmacists in FL actually prescribing Transderm Scop, or just dispensing without a prescription based on the schedule 5 logbook system? I searched nabplaw.net and found no evidence that any states have set up prescriptive authority for pharmacists based on anything besides a collaborative practice agreement. One really old (1996) site I found says there is a formulary of about 50 drugs that pharmacists licensed in FL can prescribe independantly under the Pharmacy Practice Act, but I can't back that up with any existing formulary on the state website or anything like that.

psisci said:

I made the statement in the NP/PA forum that PharmD's in some states with extra training and residency can prescribe certain meds. I knw this is true in NM and other states, but perhaps one of you could chime in there with some references to the point?? Help...

Click to expand...

Guess this fishing expedition didn't land you much of a catch did it Psisci? When you finally expend all that effort trying to show that it doesn't take a physician to do a physician's job, realize that at the end of the day, you will still be wrong

Little fishy in the brook, come along and bite my hook...

An overview from the American Society of Consultant Pharmacists

This is old, but still, you will notice that in some states a protocol is established with the state board of pharmacy, not a physician. So, it would be a bit different than a collaborative practice agreements that are gaining in popularity. Likely, it would involve extra training or something along the lines that psisci is talking about. FL is the only place listed as having pharmacists with any sort of independant prescriptive authority. As I said before, I can't find the Pharmacy Practice Act online anywhere. Supposedly, the formulary of the 50 drugs or so they can prescribe would be listed.

bananaface said:

Hey Dana, are pharmacists in FL actually prescribing Transderm Scop, or just dispensing without a prescription based on the schedule 5 logbook system? I searched nabplaw.net and found no evidence that any states have set up prescriptive authority for pharmacists based on anything besides a collaborative practice agreement. One really old (1996) site I found says there is a formulary of about 50 drugs that pharmacists licensed in FL can prescribe independantly under the Pharmacy Practice Act, but I can't back that up with any existing formulary on the state website or anything like that.

Click to expand...

The documentation is such that the chains won't touch it. Same goes for the
C-V log. The laws and possibilities are much more progressive in Washington

I practiced retail in Florida recently for five years and have been licensed there since 1984 when the C-V log was still alive and well. I never ran into
the formulary or chatted with other pharmacists who utilized it. That does not mean that it isn't done, just that it is rare enough to be considered still born.

What the OP is really looking for are examples of prescriptive authority for pharmacists, (I presume) outside of protocols. Here in WA, we aren't at that point yet. Even the direct access study is still protocol based. Perhaps when the clinical trial ends we will see prescriptive authority granted to pharmacists in WA. That appears to be one of the project targets.

Would a system that requires that a protocol be established through the BOP be more progressive than one that requires a collaborative agreement with a physician? My initial instinct was to say yes, since this type of authority is not dependent upon another prescriber's authority. But, then I get to thinking that perhaps in the states with BOP based protocols pharmacists may not be able to do the same sorts of things as we can set up on protocol here. What's more important, what we can do, or where our authority originates?

bananaface said:

Hey Dana, are pharmacists in FL actually prescribing Transderm Scop, or just dispensing without a prescription based on the schedule 5 logbook system? I searched nabplaw.net and found no evidence that any states have set up prescriptive authority for pharmacists based on anything besides a collaborative practice agreement. One really old (1996) site I found says there is a formulary of about 50 drugs that pharmacists licensed in FL can prescribe independantly under the Pharmacy Practice Act, but I can't back that up with any existing formulary on the state website or anything like that.

Click to expand...

I never saw it done in practice, but in my Dosage Forms class last year it was mentioned that we can prescribe certain drugs from a formulary. The only one I remembered was Transderm Scop because I felt it could be useful. Why waste money going to see a doctor when you just need a motion sickness patch for a cruise? The pharmacist is going to be the one that counsels the patient on side effects, anyway.

this is an article we had to read for one of our classes... if the link doesn't work, just go to accp.com and look under their position papers. this is a general overview, but i think it gives you some good background info. it also has a list of the states that are involved with cdtm and what their requirements are.

http://www.accp.com/position/pos2309.pdf

**i just realized that psisci was looking for prescribing rights outside of protocols... so this paper wouldn't really help with that issue.. but it's an interesting read none the less regarding protocols...**

I wonder if WA's Therapeutic Interchange Program would fit what piscsi is looking for. There is a pseudo-protocol in place. But, the setup definitely DOES NOT meet the guidelines for a protocol under WA state law. All pharmacists (and interns) have the authority to make a switch to a "therapeutic equivalent" on the state formulary as long as the doctor is endorsing, DAW=1 is not selected, and the patient is on a state sponsored insurance plan (WA medicaid, WA L&I, Uniform Medical). The "therapeutic equivalents" listed are often from different drug classes.

It's a pretty shoddy law. They actually have some CII's listed for swap, even though that is not legal. Doctor wrote for Oxycontin? Just give them methadone! It's jacked up. Nobody is touching that part of the program with a 10 foot pole...

Doesn't Washington have a Pharmacy Practition program that gives some prescribing rights to the pharmacist? I am almost certain I have that this was the case, can someone elaborate on the details of that?

Pharmacy Practition program? I'm from WA and I am not sure what you are referring to.

Offhand, I think of prescribing as an authority granted by law, not a right. Could this be the reason I never thought of applying to medical school?

bananaface said:

Pharmacy Practition program? I'm from WA and I am not sure what you are referring to.

Offhand, I think of prescribing as an authority granted by law, not a right. Could this be the reason I never thought of applying to medical school?

Click to expand...

agreed. i dont know why some ppl are so hung up on whether pharmacists can prescribe or not- is it just so they can feel more like physicians?

maybe in some clinical setting, pharmacists choosing appropriate drugs after physician's Dx can help. however in the avg pharmacy setting in a drug store, i don't see how prescribing rights, even if pharmacists have them, could be beneficial.

LestatZinnie said:

agreed. i dont know why some ppl are so hung up on whether pharmacists can prescribe or not- is it just so they can feel more like physicians?

maybe in some clinical setting, pharmacists choosing appropriate drugs after physician's Dx can help. however in the avg pharmacy setting in a drug store, i don't see how prescribing rights, even if pharmacists have them, could be beneficial.

Click to expand...

EXACTLY!! Just because a pharmacist has prescription priviledges does not mean that they have any clue what to prescribe for what conditions. I see patients all the time who say, "the pharmacist looked at my rash and told me to use XXXX", when the problem was so far removed from needing XXXX, that the only person capable of diagnosing this would be the PHYSICIAN. I find it comical how many pharmacists think they are dermatologists. I have seen Shingles treated by a PharmD who recommended cortisone cream for "poison ivy", antibiotic cream for psoriasis, and even allergy eye drops of purulent conjunctivitis. Bottom line...pharmacists are not clinicians and have no business presribing anything.

Oh! Can we really start a big fight about PharmD vs DO/MD??

PACtoDOC said:

EXACTLY!! Just because a pharmacist has prescription priviledges does not mean that they have any clue what to prescribe for what conditions. I see patients all the time who say, "the pharmacist looked at my rash and told me to use XXXX", when the problem was so far removed from needing XXXX, that the only person capable of diagnosing this would be the PHYSICIAN. I find it comical how many pharmacists think they are dermatologists. I have seen Shingles treated by a PharmD who recommended cortisone cream for "poison ivy", antibiotic cream for psoriasis, and even allergy eye drops of purulent conjunctivitis. Bottom line...pharmacists are not clinicians and have no business presribing anything.

Click to expand...

Heh, I got shingles 2 summers ago and when I went to the ER thinking it was a weird spider bite the physician told me it was poison oak. I knew there was no way in hell it was poison oak since I was experiencing severe nerve pain. To cover all his bases he prescribed doxicyclin (sp?) and valtrex. When the nurse came in to give me the scrips and release me she took one look and told me it was shingles (her husband had it as well). Just a simple antidote...nothing more...
On topic- In our classes it's always stressed that our job is not to diagnose (that's the physician's area of expertise). I don't see any reason for pharmacist's to prescribe outside of the protocol of a physician. I can see where it can be of some help in the hospital setting working in an environment directly with the physician. The physician does the diagnoses who then seeks out the pharmacist whose expertise is drug therapy. But there's definitely no need for a retail pharmacist to have such a right.

emogrrrrl said:

Heh, I got shingles 2 summers ago and when I went to the ER thinking it was a weird spider bite the physician told me it was poison oak. I knew there was no way in hell it was poison oak since I was experiencing severe nerve pain. To cover all his bases he prescribed doxicyclin (sp?) and valtrex. When the nurse came in to give me the scrips and release me she took one look and told me it was shingles (her husband had it as well). Just a simple antidote...nothing more...
On topic- In our classes it's always stressed that our job is not to diagnose (that's the physician's area of expertise). I don't see any reason for pharmacist's to prescribe outside of the protocol of a physician. I can see where it can be of some help in the hospital setting working in an environment directly with the physician. The physician does the diagnoses who then seeks out the pharmacist whose expertise is drug therapy. But there's definitely no need for a retail pharmacist to have such a right.

Click to expand...

I agree with everything you say. In a clinical setting the pharamcist may be able to collaborate with the physician after the latter has made a diagnosis. Even at this level, the 'right' of the pharmacist to prescribe is not that essential, because dialogue is still needed with the physician to figure out the best Tx. Prescription can't be done without history, examination, and diagnosis, and pharamcists don't do those. They have other expertise but not in the above areas. The right to prescribe doesnt really empower pharmacists, imo, except maybe bragging rights for some ppl.

PACtoDOC said:

EXACTLY!! Just because a pharmacist has prescription priviledges does not mean that they have any clue what to prescribe for what conditions. I see patients all the time who say, "the pharmacist looked at my rash and told me to use XXXX", when the problem was so far removed from needing XXXX, that the only person capable of diagnosing this would be the PHYSICIAN. I find it comical how many pharmacists think they are dermatologists. I have seen Shingles treated by a PharmD who recommended cortisone cream for "poison ivy", antibiotic cream for psoriasis, and even allergy eye drops of purulent conjunctivitis. Bottom line...pharmacists are not clinicians and have no business presribing anything.

Click to expand...

Let's see you do the workup and patient history in 30 seconds or less with two phone lines ringing and a technician tugging at your elbow and see how well you do on the fly.

LestatZinnie said:

I agree with everything you say. In a clinical setting the pharamcist may be able to collaborate with the physician after the latter has made a diagnosis. Even at this level, the 'right' of the pharmacist to prescribe is not that essential, because dialogue is still needed with the physician to figure out the best Tx. Prescription can't be done without history, examination, and diagnosis, and pharamcists don't do those. They have other expertise but not in the above areas. The right to prescribe doesnt really empower pharmacists, imo, except maybe bragging rights for some ppl.

Click to expand...

The key is realizing your limitations and respecting them. There are times when it would be handy to be able to give someone something to get them
through till they can follow up with more expensive medical talent. Examples
would be auralgan for that childs ear at 3am in the morning till they can get
to their pediatrician in the morning. Do you have any idea how frequently that happens and how devastating an ER visit can be on a family budget? Another possibility would be enough Tylenol 3 and PVK for that Friday night toothache. At the moment all we can do is shrug and tell them to go somewhere else to suffer.

I am not suggesting attempting to diagnose anything. My forte is catching and correcting errors sent through the system by "qualified clinicians" before they get to the patient. I am also expected to know everything about everything from the pharmacokinetics of phenytoin to the treatment for
penile habenero burns right off the top of my head. The position is as challenging as any clinical position, albiet at a grass roots level.

Remember, a pharmacist is often the first interface with the health care system. We are valued and needed if for no other reason than to forcefully
say;"Son, you need a doctor!"

Heh. Or maybe they could give us their cell phone number so we could hand it out to all the patients that stop in to ask how to treat every little thing because they can't get a hold of or afford a doctor visit.

I don't know about everyone else, but I always preface any recommendation with: "I am not a dermatologist/cardiologist/neurologist/etc./etc./etc., but you may try xxx. If it doesn't help after xx days, you need to see your doctor. " I'm sure most doctors would feel real bad about me "pretending to be a doctor" or "playing physician" instead of sending every patient who walks in with a question to their front door.

PACtoDOC said:

Just because a pharmacist has prescription priviledges does not mean that they have any clue what to prescribe for what conditions.

Click to expand...

You are correct. The "clue" that pharmacists have has nothing to do with prescriptive authority. It has to do with the fact that they spent most of their time in school learning about drugs and their uses.

Prescriptive authority is not a bragging right. It is a potential means to better medical care and access for patients. I would personally like to see CE certifications leading to the independent to prescribe certain useful products like ECP, vaccinations (& the Epi-Pen to go along with them), birth control pills, etc. You know, the stuff that is already commonly on protocol and is Rx because it has to be administered IM or requires more counseling than would be read from a box by the average patient.

wow. I had no idea how crazy pre-med students are. do pharmacy people on SDN go into med school forums and make fun of pre-meds about stupid things doctors do every day? The truth is no healthcare professional is infaliable. I'm sure that anyone who has ever been to a doctor more than 5 times in their life can see that. I've been misdiagnosed by doctors at least 4 times, had rights to sue at least once, but I've never been screwed by a pharmacist. But I do know pharmacists make mistakes too. If a pharmacist wants to give a patient some peridex or IBU 800, or Humbid LA for a few days worth, don't worry doctors it isn't going to break your practice. It is just the sad state of healtcare in this country taht makes this sometimes a necessity. I don't know any pharmacsit taht would think to perscribe lipitor 40 qd x 11 refills! That is silly, but don't get all in a huff about he or she handing out a few tablets for an obvious condition. As far as I am personally concerend, my doctor is just as likley to misdiagnose my condition as I am..... just personal experience!!!

Personally, when it come to antibiotics, I want to see the whole regimen dispensed at once, not just a few tablets. Otherwise we are going to generate oodles of resisitant bacteria.

I know pharmacists who would be comfortable dealing with the statins as long as LFTs were being performed.

bananaface said:

Personally, when it come to antibiotics, I want to see the whole regimen dispensed at once, not just a few tablets. Otherwise we are going to generate oodles of resisitant bacteria.

Click to expand...

I agree totally. That toothache won't be treated by the dentist till the infection is gone anyway. There is something about Friday and toothaches, so you give them a minimum of five days worth of PVK or Cleocin. Itwill be about that long before they can get in to be seen.

Based on what you see actually done in practice, it wouldn't be a big deal to dispense a bottle of amoxil or keflex with that childs auralgan, though that WOULD be diagnosing. The auralgan would also have to be done in such a way that the parents really **DID** follow up with the pediatrician in the morning and not just blow it off. Perhaps repackaging a tiny amount from a stock bottle to get them through the night?

you really want to open a can of worms....
lets talk about physician dispensing...

I know someone for whom a physician concurently dispensed thioridazine and paroxetine out of the office for about 8 years. Consequences included pseudoparkinsonism, urinary incontinence, passing episodes of blurred vision, cardiac arrythmia, clouded mental state, and other issues.

In most cases, the consequences of physicians dispensing out of the office are not alot different that the issues that come up when patients use multiple pharmacies or fill prescriptions written by multiple physicians. Physicians or patients can, and should, call the patient's regular pharmacy to have interactions checked. And, patients should use the same pharmacy whenever possible. That is my 2 cents.

baggywrinkle said:

I agree totally. That toothache won't be treated by the dentist till the infection is gone anyway. There is something about Friday and toothaches, so you give them a minimum of five days worth of PVK or Cleocin. Itwill be about that long before they can get in to be seen.

Based on what you see actually done in practice, it wouldn't be a big deal to dispense a bottle of amoxil or keflex with that childs auralgan, though that WOULD be diagnosing. The auralgan would also have to be done in such a way that the parents really **DID** follow up with the pediatrician in the morning and not just blow it off. Perhaps repackaging a tiny amount from a stock bottle to get them through the night?

Click to expand...

That's not *necessarily* true at all. The biggest obstacle to treating an active pulpal infection (the predominant cause of toothache) is achieving anesthesia. If we can get that, performing definitely therapy (doing a root canal) on the spot is no problem.

I don't have anything to contribute to the topic of pharmacist prescriptive privileges, but saw this and thought it worth responding to. Also, a major reason you get a surge of calls for "toothaches" on Fridays has to do with drug seekers knowing the dentist doesn't really want to definitively deal with an emergency ten minutes before closing for the weekend, and would rather just palliate with antibiotics and (far more importantly, in the seekers's eyes) some Darvocet or Tylenol III till Monday.

I think in a majority of cases the right to prescribe is all about bragging. It does nothing substantial to the profession of Pharmacy other than to open it up to litigation. I think people just want to go around and say im a Pharmacist but I can prescribe so that makes me hot stuff.... Im curious what the President's plans are for reforming health care.

I can honestly say that I have never heard a more uneducated bunch of idiots talking out their wrong orifice in my life. You pharm people I can only pray are not representative of all who are in your profession. You people are seriously crazy and you show your true UNeducated status when you open your mouths.

Which one of you said you could just "dish out some Keflex" for OM? Do you even realize the most common 3 bacteria causing OM are not even normally susceptible to cephalexin? And can any one of you pharmacists actually tell me enough about hepatic physiology that you could even know what an LFT even stood for? But sure, go ahead and prescribe Lipitor because you have about the same knowledge of LFT's as the patient.

And do you guys even realize the greatest complication of Cleocin? The dreaded PC, caused by C-diff is caused by Cleocin more than any other antibiotic on earth. But sure, I guess we should let the pharmacists dish this out.

The best one I heard though was the pharmacist prescribing birth control. I doubt there is one pharmacist on earth who can draw out the hormonal fluctuations compared with endometrial histology changes as well or better than the world's dumbest third year medical student. Prescribing birth control comes with serious monitorring issues that a pharmacist could never understand.

You guys will always be pill pushers as long as you talk like this. I have a great deal of respect for the clinical pharmacists who round with us in the hospital, but for the average PharmD or retail pharmacist, I suggest you continue fantasizing around the campfire about your prescribing days that will never occur, and tell those stories about all those terrible physicians you have saved patients from. You guys are a bunch of arrogant wannabes.

I think you guys should shack up with the psychologists who want script priviledges and be forced to provide each other's healthcare. Then we wouldn't have to worry about any of you any longer because you would all be dead within a generation from pseudomembranous colitis, opiate dependence, central nervous system abscesses from peri-aural spread, and Rhabdomyolysis from your vitamin L, and neuroleptic malignant syndrome.

I am done with this thread. You guys can have your fantasy thread back.

psisci said:

Clearly still a student...sorry for bringing this ***** to your forum. I picture a 5'4" balding early science drop out, with a big SUV???

LOL

Click to expand...

6'1"
full head of hair
Triumph Bonnevlle
3.9 GPA
99th percentile Step I
making more NOW as a student than your "toilet paper is on aisle 3" a$$
since I still prescribe under my PA license.
Will continue to laugh my a$$ off when pharmacies call me asking if I am concerned about the potential cross-allergy between PCN and cephalosporins.

G'day dreamers!

Closing due to TOS violations.