Prescribing powers for pharmacists.. the case against

[badxmojo]

Hey guys in one of my electives we have to do a debate. My group was assigned prescribing powers for pharmacists. We're trying to look at it from both sides. We can find lots of articles and points of view for prescribing powers for pharmacists... can't really find much on the case against prescribing powers.. you guys got any ideas?
so far all i got is..
Infringing upon Doctors turf
Pharmacist don't have adequate trraining to asses a pateint

anything else?

I know this might be tough for you guys since we're all going to be pharmacists.. but any help will be apprieciated

Thanks!

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[GravyRPH]

I think I know a med student you could contact for some material. Heh.

 

[OSURxgirl]

How about pharmacist workload is already heavy enough without ADDING responsibilities. Rx volume is rising, and pharmacist supply is lower. How are pharmacists supposed to do everything they do AND have time to prescribe AND not make more mistakes?

 

[badxmojo]

Ku06 thank for you response.. I will try to do a better job researching ;-)

..as for your question the pharmacist does not need to diagnose to presCribe.. A doctor might refer a pharmacist to a clinic after diagnosing a pateint with HIV or hypertension.. your point about liability is a good one though thanks..

OSU girl: the pharmacsts who would be prescribing would not nessarily be dispensing the medications. They would be working in clinics were the primary job would be to make reccomendations about the pateints drug therapy. A seprate pharmacist would be processing the presrcition and dispensing the meds.

thanks for your input though..anyone else?

 

[bananaface]

Think about the liability this would open up for pharms. Since they are diagnosing they would need insurance, right?

A prudent pharmacist will carry liability insurance of their own, even if an employer has a policy covering their employees. You should never count on someone else to cover your rear end. Policies aren't terribly expensive at this point in time. But, if prescriptive authority is granted, insurance companies are likely to catch on and jack up premiums. We could be placed in a situation where we are forced to carry our own insurance as a condition of employment. Think of how large of a dent that could take out of your income. And, salaries would probably not rise to offset the burden.

Here is one you may not have thought of:
If pharmacists are given prescriptive authority, they would have an incentive to influence patients to use a prescription medication when an OTC or adjunct method of therapy might be more appropriate.

 

[jdpharmd?]

I have $1,000,000/$3,000,000 insurance as a student. I think my annual premium is about $28.

 

[jemc2000]

Here is one you may not have thought of:
If pharmacists are given prescriptive authority, they would have an incentive to influence patients to use a prescription medication when an OTC or adjunct method of therapy might be more appropriate.

Ooh, a conflict of interest. That's a good one.

 

[bananaface]

Drug companies would be likely to start enticing pharmacists with more expensive "freebies", making expenses go up and inflating drug costs.

 

[WVUPharm2007]

Wow, we actually had the EXACT same assignment for pathophys/therapeutics. And, honestly, the two things you listed are basically everything the con side could muster.

 

[group_theory]

Having Pharmacists with prescribing authority might catch the attention of drug seekers. The retail pharmacists in cities and suburbs will be hit hard, as it might be easier (MIGHT because it really depends on individual pharmacists) to obtain control drugs through a pharmacist than to go to the ED or PCP, wait for hours just to finally get a script for one.

Now the smart thing to do when someone comes up to you in pain (that can't be assuage by Tylenol/ASA) is to refer them to a doctor BUT if they are drug-seekers, they will be persistant (and rude) and sometimes violent if they don't get their drugs right there and then.

I'm sure the retail pharmacist will love dealing with that, esp at night.

Also don't forget the possibility of multi-pharmacy stops for the same drug seeker (or drug-seller seeking drugs for $$$)

 

[bananaface]

Having Pharmacists with prescribing authority might catch the attention of drug seekers. The retail pharmacists in cities and suburbs will be hit hard, as it might be easier (MIGHT because it really depends on individual pharmacists) to obtain control drugs through a pharmacist than to go to the ED or PCP, wait for hours just to finally get a script for one.

Now the smart thing to do when someone comes up to you in pain (that can't be assuage by Tylenol/ASA) is to refer them to a doctor BUT if they are drug-seekers, they will be persistant (and rude) and sometimes violent if they don't get their drugs right there and then.

I'm sure the retail pharmacist will love dealing with that, esp at night.

Also don't forget the possibility of multi-pharmacy stops for the same drug seeker (or drug-seller seeking drugs for $$$)

VERY good point.

How about increasing potential for abuse and diversion BY pharmacists if the prescribing and dispensing steps could be performed by the same provider in thousands of pharmacies across the country.

 

[DrPharm]

Everyone, go read this same thread in the Allopathic Forum. There are some great responses from medical students on this subject.

 

[Pilot]

How about who is going to take care of patients that are hospitalized for medication related problems created by a pharmacist prescriber (i.e. gork a kidney 2° to metformin or lisinopril)? I doubt pharmacists can pull off getting admitting privileges at hospitals, so some poor doctor will end up taking care of problems which he/she didn't generate. It wouldn't take long to build up some real animosity between the physicians and pharmacists. And if you think I'm kidding about building up animosity, just ask a hospitalist their opinion of urgent care doctors (who don't generally admit patients).

 

[Pilot]

Guess I killed another thread.......

 

[ultracet]

How about who is going to take care of patients that are hospitalized for medication related problems created by a pharmacist prescriber (i.e. gork a kidney 2° to metformin or lisinopril)? I doubt pharmacists can pull off getting admitting privileges at hospitals, so some poor doctor will end up taking care of problems which he/she didn't generate. It wouldn't take long to build up some real animosity between the physicians and pharmacists. And if you think I'm kidding about building up animosity, just ask a hospitalist their opinion of urgent care doctors (who don't generally admit patients).

Don't doctors take care of problems they don't create all the time..... Other doctors stupidity/ mistakes, patient stupidity/ noncompliance/ mistakes, nursing stupidity/ mistakes?

I think you make a very good point about the admitting process as i believe most pharmacists would refer to the physician they are practicing under or the ED.
I can see if the pharmacist made some stupid mistakes they would definitely have a bad rap and the physician would probably terminate their agreement.

 

[bananaface]

Technically we as pharmacists would need to tell physicians what meds we have given their patients. Not all of us would be scrupulous about it. And, even if we are good about passing information on, things aren't always charted on the other side of the fax machine.

WA has a program in place where pharmacists can change existing prescriptions so long as the physician is enrolled in the state's therapeutic interchange program, the patient is on a state sponsored insurance plan, and the prescriber did not indicate dispense as written. Retail pharmacies are supposed to participate, but hardly anyone does. They tend to throw the decisions back to the prescribers. Reasons for underutilization of the program: time constraint, inadequate pharmacist training (I work with people who say they are not comfortable for this reason), no reimbursement for time spent, no available prescriber-notification paperwork. Also, who is supposed to follow up on the changes? The pharmacist or physician? What if the patient has no PCP? What if it's an ER prescription? Around here we have problems with people on DSHS being able to find PCPs.

 

[Pilot]

So now we are talking about practicing under the authority of a doctor? This was not mentioned in this thread until now... If a physician is willing to let a pharmacist prescribe under his authority, then that physician also should take on the hospital care for any problems that occur with that physician/pharmacist agreement. BTW - I think this should be the case for NP/PA prescribing as well. I can't tell you how many admits I have taken from doctors that have mid-levels practitioners who tell the patient to go to the hospital when problems happen, but then the physician does not have privileges at the hospital and I take them on my service.

 

[bananaface]

So now we are talking about practicing under the authority of a doctor? This was not mentioned in this thread until now... If a physician is willing to let a pharmacist prescribe under his authority, then that physician also should take on the hospital care for any problems that occur with that physician/pharmacist agreement. BTW - I think this should be the case for NP/PA prescribing as well. I can't tell you how many admits I have taken from doctors that have mid-levels practitioners who tell the patient to go to the hospital when problems happen, but then the physician does not have privileges at the hospital and I take them on my service.

The intention of this thread is to discuss independent authority, as I understand it.

In WA, pharmacist authority for the TIP program is kind of independant. State law gives pharmacists the authority to change the drug to a state formulary item. There is no prior contact needed between prescriber and pharmacist. The prescriber just signs up for the program with the state and that's it. The law says the pharmacist notifies the prescriber of the interchange afterwards (ie: so it can be charted). Prescriber consent is inferred by their enrollment in the program. The pharmacist has NO CHOICE but to participate (supposedly).

 

[Rxdealer]

What about re-imbursement? As it stands, pharmacists are trying to venture outside of their scopes of practice and the basis of this is to provide better health care. Things like patient medication reviews certainly address a patient's health needs, but at what cost? A Dr can request that a pharmacist do a patient medication review, and through that consultation, the Dr is reimbursed a hefty sum of money. The pharmacist then runs around like a busy bee and works for hours on end to produce a full medication review, and for their efforts gets paid considerably less. So this perhaps stands as an appropriate argument against stepping outside the boundaries of pure pharmacy - that of financial viability.

Prescribing definitely holds a sense of power over a patient's health, however with that power comes responsibility (as eloquently quoted from "Spiderman") and pharmacists might not get paid adequately for the amount of responsibility that they want.

 

[ultracet]

What about re-imbursement? As it stands, pharmacists are trying to venture outside of their scopes of practice and the basis of this is to provide better health care. Things like patient medication reviews certainly address a patient's health needs, but at what cost? A Dr can request that a pharmacist do a patient medication review, and through that consultation, the Dr is reimbursed a hefty sum of money. The pharmacist then runs around like a busy bee and works for hours on end to produce a full medication review, and for their efforts gets paid considerably less. So this perhaps stands as an appropriate argument against stepping outside the boundaries of pure pharmacy - that of financial viability.

Prescribing definitely holds a sense of power over a patient's health, however with that power comes responsibility (as eloquently quoted from "Spiderman") and pharmacists might not get paid adequately for the amount of responsibility that they want.

i think it will be interesting to see what reimbursement for MTMS will be...

 

[confettiflyer]

I have $1,000,000/$3,000,000 insurance as a student. I think my annual premium is about $28.

there's a reason why it's $28.

same logic why life insurance policies become generally unrenewable at age 95.

 

[Vort3x]

Just saw this topic, interesting about your views on prescribing rights.

Very recently in the past few years, various provinces here in Canada have begun allowing Pharmacists to prescribe for certain conditions (listed as "minor ailments"). The complete list currently available can be found here for Nova Scotia: https://pans.ns.ca/minor-ailment-assessments/

Basically, a quick assessment leads to having the patient come into a private counselling area (must be a separate room), complete a full assessment for a fee after which we can write a prescription that they can fill at our pharmacy or another. The prescription products aren't restricted for the conditions (except narcotics and controlled substances). The latest regulations available here: https://www.novascotia.ca/just/regulations/regs/pharmdrugrx.htm

It's working really, really well here so far! If anyone had any questions about it I'd be happy to answer (I'm just finishing my third year of pharmacy school).

 

[a runner]

Just saw this topic, interesting about your views on prescribing rights.

Very recently in the past few years, various provinces here in Canada have begun allowing Pharmacists to prescribe for certain conditions (listed as "minor ailments"). The complete list currently available can be found here for Nova Scotia: https://pans.ns.ca/minor-ailment-assessments/

Basically, a quick assessment leads to having the patient come into a private counselling area (must be a separate room), complete a full assessment for a fee after which we can write a prescription that they can fill at our pharmacy or another. The prescription products aren't restricted for the conditions (except narcotics and controlled substances). The latest regulations available here: https://www.novascotia.ca/just/regulations/regs/pharmdrugrx.htm

It's working really, really well here so far! If anyone had any questions about it I'd be happy to answer (I'm just finishing my third year of pharmacy school).

This is interesting. I can see why many of those minor ailments would be appropriate. The questions is, how does the pharmacist know that the "minor ailment" is indeed a minor ailment and not a manifestation of a larger underlying issue without doing an appropriate history and physical exam to rule out a more serious etiology?

 

[Vort3x]

This is interesting. I can see why many of those minor ailments would be appropriate. The questions is, how does the pharmacist know that the "minor ailment" is indeed a minor ailment and not a manifestation of a larger underlying issue without doing an appropriate history and physical exam to rule out a more serious etiology?

Very valid question!

We're trained to do the necessary history and what to look for in the physical exam in our school curriculum now. As I said this assessment must be completed in a private counseling area and not just at the counter. Minor ailment prescribing is a big part of our skills lab. We learn the red flags (what questions to ask) and what would warrant referral. If they don't meet the criteria because yes it sounds like something more serious during our assessment, then they are referred to their physician or a walk-in clinic.

I can't speak too much of the knowledge of Pharmacists already in practice, they are able to take minor ailment courses if they feel they need refreshing or want to learn the new material. But the process is absolutely at the discretion of the Pharmacist and only if they feel comfortable doing it. I can't speak to the training of Pharmacists in the US, however here most would have definitely gained a lot of the knowledge even in the older curriculum. Also throughout your practice you gain a lot of clinical experience, you already assess a patient to determine if the OTC is appropriate or if the medication they are being prescribed is appropriate.

 

[Bubba98]

I'll take it one step further. How about the case for moving more rx meds to OTC status or OTC with pharmacist available for consultation. Viagra, ventolin mdi with say 20 doses in it, low dose statins, metformin, low dose SSSRIs, antibiotics for traveler's diarrhea and uti, all NSAIDs, migraine medication, OCs, ear drops for otitis externa and the list goes on. What would that do for healthcare costs(it would help them go down), accessibility increases and pharmacists gain by being a resource to instruct in their use if necessary. Hopefully Nasacort is just the beginning.

 

[KidPharmD]

I would say that at least for Am Care/Community the answer to accessiblity is not prescriptive authority as most people would see it, but a Behind-the-counter class of medications that might not need a physician's exam, but aren't quite safe enough for OTC use.
PPI's, NSAIDs, Cough/Cold products, etc. would be kind of things I am thinking about.

For the drug companies this could mean the FDA requiring a lower burden of proof that the drug is safe (only has to be safe enough with pharmacist consultation).

 

[Carboxide]

I'll take it one step further. How about the case for moving more rx meds to OTC status or OTC with pharmacist available for consultation. Viagra, ventolin mdi with say 20 doses in it, low dose statins, metformin, low dose SSSRIs, antibiotics for traveler's diarrhea and uti, all NSAIDs, migraine medication, OCs, ear drops for otitis externa and the list goes on. What would that do for healthcare costs(it would help them go down), accessibility increases and pharmacists gain by being a resource to instruct in their use if necessary. Hopefully Nasacort is just the beginning.

Noooo way. For one thing, this just means that they won't be covered Rx. The average patient will pay WAY more for these. For another, these things have serious and potentially fatal side effects. Let's go through this one drug at a time..

-Viagra: prevents pharmacists/doctors from making sure the patient is not also on nitrates. This interaction could kill people.
-ventolin: I'm ok with this, but cost is very prohibitive. Plus, it might prevent us from knowing how well controlled a patient is.
-Metformin: do we REALLY want people diagnosing themselves with diabetes?
-SSRIs: do we REALLY want people diagnosing themselves with psychiatric disorders?
-Antibiotics: resistance, anyone? We should NEVER have OTC antibiotics. Also, UTIs can be a sign of a more serious condition (such as uncontrolled diabetes).
-NSAIDS: serious risk for overdosing with meds already on the market. Patients will take large amounts of Celebrex, etc and get bleeds/GI ulcers like mad.
-Migraine meds: patients do not know the difference between headache and migraine. Imitrex, etc have a lot of potentially serious drug interactions as well. Also, patients should not be taking these every day and if they are OTC patients will never go to the doctor with migraines. That is vitally important.
-Patients will use these on kids with ear infections. They don't have a clue what otitis externa is and will not care, either.

OTC drugs will be more expensive long-term (Prilosec OTC, anyone? The OTC price is WAAAAY more than the Rx price) and will also allow patients to self-diagnose potentially life-threatening conditions.

 

[CynicalIntern]

Saying OTC ventolin would be cost prohibitive is a little bit silly, because if the manufacturers knew they could sell a bajillion inhalers OTC, they would happily drop the price back down to where inhalers were back when it was albuterol HFA, and still rack up a tidy little profit. Most chains still jack up the cash price of Rx Omeprazole/Lansoprazole because they can, so plenty of patients would realize cost savings here.

I also have no concerns about people diagnosing themselves as diabetic and going crazy on metformin, because 1) Diabetics are probably the most notorious I KNOW MY BODY BETTER THAN THE DAMN LAB TEST patients, and 2) even the ones who accept that they're diabetic still won't take but half of their three pills BID anyways. So yeah, if everyone was intelligent about how important their medicine was, then maybe we could be concerned about people blowing out their kidneys by taking more metformin than they needed, but I don't really think it's an issue.

Not that I disagree with your main assertation that we shouldn't be throwing all these things OTC of course.

I was once told, but it was before my time so I can't confirm - that there used to be an OTC product that was similar to A/B Otic drops, but it got pulled from the market because too many people were just treating the pain from their ear infections and let the infection sit, causing long term repercussions - is this true?

 

[KidPharmD]

Saying OTC ventolin would be cost prohibitive is a little bit silly, because if the manufacturers knew they could sell a bajillion inhalers OTC, they would happily drop the price back down to where inhalers were back when it was albuterol HFA, and still rack up a tidy little profit. Most chains still jack up the cash price of Rx Omeprazole/Lansoprazole because they can, so plenty of patients would realize cost savings here.

I also have no concerns about people diagnosing themselves as diabetic and going crazy on metformin, because 1) Diabetics are probably the most notorious I KNOW MY BODY BETTER THAN THE DAMN LAB TEST patients, and 2) even the ones who accept that they're diabetic still won't take but half of their three pills BID anyways. So yeah, if everyone was intelligent about how important their medicine was, then maybe we could be concerned about people blowing out their kidneys by taking more metformin than they needed, but I don't really think it's an issue.

Not that I disagree with your main assertation that we shouldn't be throwing all these things OTC of course.

I was once told, but it was before my time so I can't confirm - that there used to be an OTC product that was similar to A/B Otic drops, but it got pulled from the market because too many people were just treating the pain from their ear infections and let the infection sit, causing long term repercussions - is this true?

First, lets be clear... There hasn't ever been an albuterol HFA generic. There was an albuterol CFC before the mandate of removal of all CFCs. Second, I fear that metformin would be used inappropriately as a weight loss drug instead of just for diabetics. Also, the risk of Lactic acidosis is too high/too serious for it to ever be OTC. Frankly, I think we have too many OTC's as it is. That is why I advocate for a BTC class of drugs to improve safety without limiting availability.

 

[owlegrad]

Frankly, I think we have too many OTC's as it is.

I agree with this. APAP poisonings account for hundreds of deaths every year and thousands of ER visits. Even the stuff considered safe enough for OTC use is hardly safe.

 

[Ackj]

Safety is the key for making something available OTC? How about insulin?

 

[sosoo]

as someone mentioned competency is an issue. once a while a pharmacist would post on this forum asking for quick review of drugs. im sure in retail practice plenty of pharmacists have forgotten a lot of drug knowledge. if pharmacists are not competent in their area of expertise.... (re-read that sentence!)...... how can they accurately assess disease states when they're never trained to do so?

 

[DelPharm]

Any legitimate proposal involving privileging has involved requirements for establishing competency (e.g. California advanced practice pharmacist). I can't say there has never been a push for un-supervised prescribing privileges for practitioners without post-graduate training, but I can say the idea is just as ridiculous as giving a med school graduate un-supervised prescribing privileges without post-graduate training.

 

[owlegrad]

Safety is the key for making something available OTC? How about insulin?

What do you think the key is?

 

[Digsbe]

As far as competency goes I would say with any prescribing power should come liability for things prescribed. Liability is a huge check/balance that needs to be accounted for. In fact, I think PAs and NPs need to have more liability instead of so much falling on their supervising physicians. If we are talking about competency though, what about the fact that dentists have full prescribing authority and physicians can legally prescribe out of specialty? Liability largely keeps them from doing this, and I think the same could apply for pharmacists.

As far as reasons why a pharmacists shouldn't prescribe, I think it depends on if we are discussing independent prescribing or more dependent under a CPA or specific for institutions.

 

[tungsten87]

First, lets be clear... There hasn't ever been an albuterol HFA generic. There was an albuterol CFC before the mandate of removal of all CFCs. Second, I fear that metformin would be used inappropriately as a weight loss drug instead of just for diabetics. Also, the risk of Lactic acidosis is too high/too serious for it to ever be OTC. Frankly, I think we have too many OTC's as it is. That is why I advocate for a BTC class of drugs to improve safety without limiting availability.

are you KIDDING me? the studies that this "association" was derived from had pretty sick patients who were already at high risk for these types of renal complications, and even then the risk was infinitesimally small. In fact, the incidence of LA with sulfonylureas is actually higher than that of metformin according to those studies.

 

[KidPharmD]

are you KIDDING me? the studies that this "association" was derived from had pretty sick patients who were already at high risk for these types of renal complications, and even then the risk was infinitesimally small. In fact, the incidence of LA with sulfonylureas is actually higher than that of metformin according to those studies.

If you are referring to the Cochrane review, then, yes, they determined that the risk was small as they found no reports in the RCT's analysed. However, a quick Medline search reveals that we are still reporting quite a few cases every year. These patients are often sick when reported. If you have another review, I would enjoy reading it if you could point me to the article. I would love to be able to advocate for more not less metformin use. In clinical experience I have seen several of these patients. I could be skewed by living in an area with a lot of undiagnosed/unmanaged CKD and uncontrolled diabetes.

I already stated that I think we have way too many OTC's as it is. A year of community practice taught me that our patients are not as smart about their OTC's as we would like them to be. Therefore, I would say that the risk of Lactic Acidosis with metformin is still too high for its use as an OTC. I am not opposed to Metformin being a drug that could be included in pharmacist prescribing/BTC drugs. OTC's should be safe without the supervision of a medical professional. Most of them are not as safe as we would like. 500mg aspirin would never make it OTC if it was approved today.

 

[Ackj]

What do you think the key is?

Key definitely should be safety. Wide therapeutic index, few interactions, low incidence of serious side effects, very high doses required for adverse events, minimal monitoring required. What they actually use to determine it? I dunno. We've got Tagamet and it's load of interactions, various NSAIDs, insulin, etc.

 

[Digsbe]

I think another thing to consider is if the condition the drug is intended to treat is also something that can be commonly self diagnosed in regards to the OTC debate.

 

[MatCauthon]

I like the idea of prescribing, but I really don't want to add any more paperwork into the pharmacy. How would we realistically have time to perform all the necessary vitals, health history, medication review, and then write the prescription, consult the patient, and then write a SOAP note? That kind of practice would be impossible under the current retail model. The medication review alone would be a nightmare. I do a ton of med rec in the hospital setting and it sometimes take me close to an 45 minutes just to finish one complicated med rec. And that is assuming I have the medical records.

Pharmacists would be at risk because we would often have incomplete medical records, missing labs, and patients would coming in merely to save themselves money on a PCP visit. I cannot even imagine how pesky some of these patients would be if they knew we had the power to prescribe drugs and authorize more refills.