Should pharmacists be given (limited) autonomous prescriptive authority?

[JayRx1981]

[QUOTE=Qadgop the Mercotan]
As for the OP, I’m leery. Most antihistamines are already available over the counter.
[/QUOTE]

Not really. Of the second-generation antihistamines, only one is available over the counter. Of the first-generation antihistamines, quite a few are by prescription only.

But is a pharmacist going to dispense warfarin without knowing the patient’s most recent INR results, or up the dose of methadone without having seen how wide their QRS complex is on their baseline EKG? Or know that the patient has already been on triple therapy for their elevated H. Pylori titers in the past, so there’s no sense in re-treating their GI upset with yet another course of antibiotics and acid blockers?

Of course a pharmacist wouldn’t alter a dose of or dispense warfarin without up-to-date labs. Most GP’s and NP’s send their bloodwork off-site to get test results, what’s to prevent a pharmacist from doing the same?

And the only way for the pharmacist to know if they’d already been on triple-therapy is to check the patient history, ask the patient, or check a central database of other linked sites/stores–but the same holds true for a physician/NP/PA.

[Qadgop_the_Mercotan]

[QUOTE=JayRx1981]
Of course a pharmacist wouldn’t alter a dose of or dispense warfarin without up-to-date labs. Most GP’s and NP’s send their bloodwork off-site to get test results, what’s to prevent a pharmacist from doing the same?
[/quote]

But what range will the pharmacist decide the INR needs to be in? And how long will the pharmacist keep the patient on anticoagulants? Is your typical pharmacist trained to determine these answers?

Again, which drugs do you want to prescribe?

[JayRx1981]

[QUOTE=Qadgop the Mercotan]
JayRx, want to address the point about just what types of drugs should be allowed to be prescribed by pharmacists, in your opinion?

The subject’s just a bit too nebulous for me to dig into, otherwise.
[/QUOTE]

Note before I go on: I am not yet a licensed pharmacist. I have one year of school yet to go (my year of clinical rotations) before I can sit for the boards. If I speak like I am one, it’s because the school and my preceptor(s) have been training me TO think like one, so that when I’m licensed, I’m already mentally in practice.

For starters, I’d argue that a pharmacist should NOT have to consult with a physician in order to substitute within a drug class. Given how often third-party drug formularies will pay for x-astatin but not y-astatin and that many drugs in the same therapeutic class are pretty comparable to each other in terms of efficacy, adverse events, etc, I see no good reason why I have to waste my time or the physician’s time playing phone tag to switch patient Z from Nexium to Protonix when we know what the equivalent doses are and could easily just do it ourselves.

We should also have prescriptive authority for some of the slightly stronger NSAIDs (Ibuprofen 400-800, Naproxen 500, and potentially for some of the other Rx-only NSAIDs), steroid creams, prescription only antihistamines (Zyrtec and Allegra, promethazine, hydroxyzine all come to mind), and to compound by our own prescriptive authority common remedies (Cincinnati mouthwash, magic butt-cream for diaper rash), and alternate forms of nicotine replacement therapy for the purposes of helping a patient quit smoking (ie, nicotine lollipops). Heck, I’d be happy if they even just let us do this per a physician-approved protocol like they do with PA’s here in Ohio.

We should be allowed to prescribe/administer any adult immunization which has FDA approval, as well as the drugs that may be required to treat the patient in case of anaphylaxis.

And we should be allowed to prescribe emergency supplies of medicines (without later having to go back and get a prescription from a physician) which we feel, in our professional opinion, that the patient could be in danger of harm if they did not receive.

Beyond that? Well, I could probably diagnose DM or hypercholesterolemia or hypertension as well as your generic GP/NP could (we’re trained in what is required for diagnoses in those cases, what other etiologies we need to rule out, and basic physical assessment), so I suppose we could prescribe for those conditions as well–though I’d be fine without that particular prescriptive authority if the rest of the above was met.

And I’ll also note that other than schedule-V exempt narcotics, I personally don’t want ANY other scheduled drug prescriptive authority. Heck, i’m still not convinced PA’s and NP’s should have it.

[Qadgop_the_Mercotan]

[QUOTE=JayRx1981]

For starters, I’d argue that a pharmacist should NOT have to consult with a physician in order to substitute within a drug class. Given how often third-party drug formularies will pay for x-astatin but not y-astatin and that many drugs in the same therapeutic class are pretty comparable to each other in terms of efficacy, adverse events, etc, I see no good reason why I have to waste my time or the physician’s time playing phone tag to switch patient Z from Nexium to Protonix when we know what the equivalent doses are and could easily just do it ourselves.
[/quote]

Go for it, with some exceptions. Some statins are preferred over others based on patient presentation.

We should also have prescriptive authority for some of the slightly stronger NSAIDs (Ibuprofen 400-800, Naproxen 500, and potentially for some of the other Rx-only NSAIDs), steroid creams, prescription only antihistamines (Zyrtec and Allegra, promethazine, hydroxyzine all come to mind), and to compound by our own prescriptive authority common remedies (Cincinnati mouthwash, magic butt-cream for diaper rash), and alternate forms of nicotine replacement therapy for the purposes of helping a patient quit smoking (ie, nicotine lollipops). Heck, I’d be happy if they even just let us do this per a physician-approved protocol like they do with PA’s here in Ohio.

Go for it

We should be allowed to prescribe/administer any adult immunization which has FDA approval, as well as the drugs that may be required to treat the patient in case of anaphylaxis.

Go for it

And we should be allowed to prescribe emergency supplies of medicines (without later having to go back and get a prescription from a physician) which we feel, in our professional opinion, that the patient could be in danger of harm if they did not receive.

For the most part, go for it.

Beyond that? Well, I could probably diagnose DM or hypercholesterolemia or hypertension as well as your generic GP/NP could (we’re trained in what is required for diagnoses in those cases, what other etiologies we need to rule out, and basic physical assessment), so I suppose we could prescribe for those conditions as well–though I’d be fine without that particular prescriptive authority if the rest of the above was met.

Best not to go there. New diabetics, hyperlipidemics, and hypertensives need examination and specific testing before deciding on specific therapies. My decisions about which meds to prescribe them (a small part of what I need to do with them) depends on my exam findings, lab results, my interpretation of EKGs, and a raft of stuff I’ve picked up over decades. Accreditation agencies review the charts of these patients to see that clinical benchmarks are being met. Unless the pharmacist is willing to chart these benchmarks (For DM: annual dilated fundal exam, urine microalbumin results, whether the patient is on ACE/ARB therapy, adequate frequency of HgbA1C, adequacy of DM control, annual comprehensive foot exams), I’d recommend they stay away from it.

And I’ll also note that other than schedule-V exempt narcotics, I personally don’t want ANY other scheduled drug prescriptive authority. Heck, i’m still not convinced PA’s and NP’s should have it.

Believe me, you do not want the headaches associated with schedule-V dispensing. Talk about getting nibbled to death by ducks! I’ve no objection to pharmacists passing these things out, I just think they’re idealistic fools if they do it.

[JayRx1981]

[QUOTE=Qadgop the Mercotan]
But what range will the pharmacist decide the INR needs to be in? And how long will the pharmacist keep the patient on anticoagulants? Is your typical pharmacist trained to determine these answers?

Again, which drugs do you want to prescribe?
[/QUOTE]

The pharmacist would target the INR range recommended by the most current evidence-based ACCP guidelines on the topic most appropriate for the current condition–generally an INR of 2.5 ideally, but acceptable within a range of 2-3 for most indications.

As for how long, well, that depends. If a physician initiated the patient on warfarin therapy, I would say either as long as the physician didn’t order a stop to treatment, or as long as suggested by evidence-based guidelines dependent on the condition in question. If, by some chance, pharmacists could diagnose and prescribe warfarin on their own, they’d need to follow the guidelines and/or professional experience.

Your older BSPS R.Ph’s probably aren’t trained to determine the answers to these questions (with exceptions), but your younger Pharm.D (or recent older BS to Pharm.D converts) RPh’s should be. However, I really don’t care if we can’t initially diagnose a patient and start them on warfarin therapy. The physician is better equipped to do that, IMO. The monitoring and dose-alteration IS potentially within our purview, though, and again I could see pharmacists doing all the monitoring of chronic drug therapy under a physician-approved protocol in collaboration with a physician practice or hospital.

[JayRx1981]

[QUOTE=Qadgop the Mercotan]
Go for it, with some exceptions. Some statins are preferred over others based on patient presentation.
[/quote]

Oh, I know that. And in those cases, we should be able to obtain a prior authorization rather than a substitution without bothering your office and making y’all call/fax the insurance company for approval.

Of course, to help identify those patients, a system should probably be in place listing the most relevant diagnostic values on the prescription blank or on an accompanying lab sheet (ie the various cholesterol levels for hypercholesterolemia and desired reduction in LDL/TG levels, CPK levels, etc), but I’m of the opinion that even now we should have that information anyways (it’s useful and allows us to make more informed decisions on our part, reinforce certain counseling points beyond the standard, and generally tailor our role more to the individual’s specific health issues).

And regarding the statins anyways, there is/has been considerable talk about making those a “third-class of drug” to be given out and monitored by pharmacists anyways.

Go for it

Believe me, if we could enlist Physician support here in Ohio for that, I’d be thrilled.

Best not to go there. New diabetics, hyperlipidemics, and hypertensives need examination and specific testing before deciding on specific therapies. My decisions about which meds to prescribe them (a small part of what I need to do with them) depends on my exam findings, lab results, my interpretation of EKGs, and a raft of stuff I’ve picked up over decades. Accreditation agencies review the charts of these patients to see that clinical benchmarks are being met. Unless the pharmacist is willing to chart these benchmarks (For DM: annual dilated fundal exam, urine microalbumin results, whether the patient is on ACE/ARB therapy, adequate frequency of HgbA1C, adequacy of DM control, annual comprehensive foot exams), I’d recommend they stay away from it.

It may surprise you, but in the present Pharm.D curriculum at OSU, part of our training in therapeutics involves the importance of accurate, concise charting and monitoring using clinical guidelines. In Ohio, under collaborative practice agreements, for certain conditions, pharmacists are already doing all that you’ve mentioned. The problem with those is that they have to be entered into for each individual patient, for each individual diagnosis, for each practitioner the pharmacist will be practicing with. In any event, we can do this, and in some cases we do this. It’s just incredibly limited up to this point.

Believe me, you do not want the headaches associated with schedule-V dispensing. Talk about getting nibbled to death by ducks! I’ve no objection to pharmacists passing these things out, I just think they’re idealistic fools if they do it.

Well, in Ohio, we already have C-V dispensing rights–though most pharmacists I’ve worked with don’t want to deal with it at all (and refuse to carry the product in stock). But yeah, as an over-arching rule, I do NOT want to deal with scheduled drug prescribing.

[Qadgop_the_Mercotan]

[QUOTE=JayRx1981]
It may surprise you, but in the present Pharm.D curriculum at OSU, part of our training in therapeutics involves the importance of accurate, concise charting and monitoring using clinical guidelines. In Ohio, under collaborative practice agreements, for certain conditions, pharmacists are already doing all that you’ve mentioned. The problem with those is that they have to be entered into for each individual patient, for each individual diagnosis, for each practitioner the pharmacist will be practicing with. In any event, we can do this, and in some cases we do this. It’s just incredibly limited up to this point.
[/quote]

So you’re doing monofilament foot exams, cardiovascular checks, and neuropathy assessments? Color me impressed! How about prostate checks before starting tamsulosin? Cool!

How much training do you get in clinical examination?

I studied under Sol Snyder for a bit back in the late 70’s and early 80’s, and briefly entertained the idea of going into neuropharmacology. Sol has a license to use Schedule I drugs. :eek:

[Qadgop_the_Mercotan]

[QUOTE=Qadgop the Mercotan]
Sol has a license to use Schedule I drugs.
[/QUOTE]

Let’s rephrase that a little. He has a license to prescribe Schedule I drugs. For select patients. Of his.

[JayRx1981]

[QUOTE=Qadgop the Mercotan]
So you’re doing monofilament foot exams, cardiovascular checks, and neuropathy assessments? Color me impressed! How about prostate checks before starting tamsulosin? Cool!

How much training do you get in clinical examination?

I studied under Sol Snyder for a bit back in the late 70’s and early 80’s, and briefly entertained the idea of going into neuropharmacology. Sol has a license to use Schedule I drugs. :eek:
[/QUOTE]

Heh, yes, actually, we were trained to do monofilament foot exams, to take blood pressure, to measure jugular venous distension, the basics of auscultation of the lungs, heart sounds, and bowel sounds, how to percuss, palpate, do a very very basic reading of an x-ray (more so we know what a radiologist is talking about than to do any diagnostic reading of our own), how to use an otoscope to exam the tympanic membrane and outer ear canal, examination of the nares, the throat, basic skin examination, and how to examine the retina to look for signs of microvasculature damage (most often in diabetic patients), in addition to the need to take vitals at every visit.

Of course, we only got one quarter of that, and other than blood pressure and monofilament tests, we haven’t really been able to practice on real live patients since then, but I suspect if we were required to do a rotation or a residency dealing with this again, I could become far more proficient at basic physical exam taking.

Of course, in no way do I mean to say that we are the equivalent of MD’s or DO’s. Y’all get as much school as we do (in number of years) and far more in the way of hands on training (thanks to required residency) than we do (residency is optional right now and the stuff i’ve seen regarding pharm.d residencies isn’t nearly as “neat” as yours probably were). We aren’t trained to give IV shots or draw blood (we could be, we just aren’t as a standard part of our present curriculum). Y’all are very clearly king when it comes to diagnosis–just like we’re the top dog in most regards when it comes to drugs.

And in reality, what I’d rather see other than simple prescribing of some of the above things you had previously agreed on, is a collaborative practice between physicians and pharmacists where y’all deal with the diagnosis, and we deal with drug choice and monitoring, freeing each of us up to do what we are really trained to focus on. However, I just kindof have a difficult time with people thinking pharmacists can’t do simple (and as I’ve argued above, that’s all we want is simple) prescription writing when we get doctorate level training in therapeutics and pharmacology.

[1010011010]

I’d be comfortable with a pharmacist being given limited autonomous prescriptive authority to swap “substantially similar” drugs. I’ve definitely gotten scripts before that explicitly gave the pharmacist options on what to put in the bottle to fill it (generally “RecentlyUnderPatent™ or generic”). Or to swap various drugs or preparations used for the same purpose (thinking of birth control and its thousand different variations of cyclic dosages).

And it seems like everything’s either Off The Shelf or Only By Prescription. Are there real authentic Over The Counter drugs that aren’t there due to shoplifting or “controlled precursor” drug laws? If it’s available in multiple doses, some only by prescription, some no questions asked… shift the prescription level doses to pharmacist discretion (i.e., literally OTC).

And on preview I see I’ve been ninja’d by about half the thread.

[Damuri_Ajashi]

[QUOTE=Kalhoun]
I think any pharmacist who gets into the business had better be ready to dole out whatever the doctor prescribes, within legal limits. If he’s got a religious hard-on with anything that might be prescribed, his time might be better spent in the pulpit than in the pharmacy. My rights trump his in EVERY case, as long as it’s legal. And any pharmacist who refuses to fill a prescription based on his personal beliefs should be stripped of his license immediately. No second chances.
[/QUOTE]

I know that there have been some sensational stories of pharmacists refusing to fill script but this is so rare it doesn’t bear mentioning. How would you feel if a pharmacist simply didn’t stock day after pills or birth control pills? Should they be required to?

[Damuri_Ajashi]

[QUOTE=Kalhoun]
I get that, but in most cases, they will not have enough information to make that decision; at least not without talking to the doctor. If they make the call to the physician and he OKs the prescription, what is the basis of their refusing it (barring an obvious error…oxycontin for tonsillitis or something equally bizarre)? Exactly what is the verification process and what situation would make a denial prudent, providing the doctor has been consulted?
[/QUOTE]

I believe that 99% of refusals to fill script is based on contraindications or for narcotics and other addictive drugs.

[Damuri_Ajashi]

[QUOTE=OneCentStamp]
Maybe I’m just comfortable with the line being drawn where it is because I can’t think of where else we’d draw it.
[/QUOTE]

Plenty of places draw the line elsewhere. There are places where doctors diagnose and pharmacists prescribe. My sister spent 6 years getting a PharmD and 6 years getting an MD and she thinks most pharmacists fresh out of school know more about drugs than doctors fresh out of fellowship.

Ask your neighborhood pharmacist how often they see misprescriptions or prescriptions for drugs that are now obsoleted by some new drug that the doctors don’t even know about yet. Pharmacists know more about interactions and side effects than most doctors and they are suually more accessible to patients.

With all this said, I don’t think our current system is broken and I am not convinced changing the system would present any significant efficeincies.