Pharmacists changing prescriptions - thoughts?

[dr nomis]

BCMA sounds alarm on pharmacists' new powers

 

Prescription policy is aimed at relieving the burden on doctors, government says

 

 

Mary Frances Hill, Vancouver Sun

 

Published: Friday, September 19, 2008

A new provincial policy that will give pharmacists the power to renew and adapt prescriptions without prior approval from a doctor could be dangerous for patients, according to the B.C. Medical Association.

Starting Jan. 1 next year, pharmacists across B.C. can exercise a new authority to renew customers' prescriptions and make limited changes to them based on their own judgment, and without consulting the patients' doctors.

The policy was initiated by the Health Ministry last spring, and announced in the throne speech.

 

 

It came up again Thursday after a B.C. Pharmacists Association document detailing discussions over fees for the services was leaked to media.

B.C. Pharmacy Association chief executive Marnie Mitchell said pharmacists will be given the authority to renew prescriptions for up to one year and to change a prescribed dosage if they judge it's appropriate.

"The pharmacist will not make any of these changes unless they have adequate information to understand that this is in the best interests of the patient," she said.

B.C. Medical Association president Bill Mackie said the new rules give pharmacists powers that are far too broad, and could open the door to serious errors on the part of the pharmacists and abuse by patients.

"What if things go wrong? Even [getting pharmacists] to renew a year of prescriptions may give some people the opportunity to hoard them," Mackie said.

"We've had doctors who've said, 'What about medicines that have the potential to cause suicide or enable suicide?'

"There has to be some tracking of how the medication is working for an individual."

He said doctors would be happy with limited renewals, or a renewal in case of emergency -- when a patient runs out or misplaces medication while travelling, for instance -- but it takes medical training to identify whether a patient requires a prescription renewal.

Health Minister George Abbott said his ministry initiated the changes partly in response to the success Alberta's health ministry has experienced with a similar program, and in order to relieve the burden on doctors.

Alberta pharmacists have exercised similar powers for more than three years. In that province, select pharmacists are empowered to write prescriptions and give immunizations. Abbott said earlier media reports that claimed customers would be forced to pay for each renewal were false.

"I was surprised and disappointed to hear the suggestion that somehow the public will be paying for this," he said.

"We have never at any point envisioned a public fee for renewal of a prescription."

But Mitchell said her association and the government still haven't ruled out fees for what she called "value-added" pharmacists' services, and payments from Pharmacare may not be out of the question.

"Those discussions [over reimbursements for pharmacists] haven't produced concrete results at this time," she said. "We're working towards having a publicly funded support for this service."

The B.C. Pharmacy Association includes 2,100 pharmacists and 670 pharmacies in its membership.

The B.C. College of Pharmacists has put some rules in place, including that pharmacists can deal only with prescriptions which are still valid, and that they must report every renewal to the original prescriber of the medication -- most likely the client's family doctor, said college spokeswoman Lori DeCrou. "It's our place to say, 'If pharmacists do this, do they really have the skills, knowledge and abilities to do this?' We think so."

Mackie said he understands how the average person would consider it convenient to visit a local pharmacist to renew a prescription, rather than make an appointment and endure long delays in a doctor's waiting room for a quick appointment. But he said it's far safer to take the precaution of consulting a medical professional.

"The government has tried to solve the issue of people waiting in the doctors' waiting rooms by changing the rules," Mackie said. "Do you want your doctor who knows you and knows what you came in for originally to renew your prescription, or a pharmacist [who doesn't know you] to do it?"

John Tse, vice-president of pharmacy for London Drugs, said he's confident his company's pharmacists can adapt to the new responsibilities if they're comfortable with them.

They will get extra training before the rules come into effect, and aren't obliged to take part.

[Satsuma]

The B.C. College of Pharmacists has put some rules in place, including that pharmacists can deal only with prescriptions which are still valid, and that they must report every renewal to the original prescriber of the medication -- most likely the client's family doctor

 

I don`t think I understand what this means...prescriptions that are still valid? Either there are renewals still on the precription or the prescrition is filled with no more renewals left and so it wouldn`t be valid no? I just don`t seem to understand what they are saying.

 

I personally think this is a bad idea for so many reasons.

[futuredoc]

The system could work, but I would reserve the service for people who are long time users of a particular drug whose dosage does not change. Just think what could happen if this were for narcotics.

[Satsuma]

Even people with chronically treated conditions need to be followed by their primary caregiver (or whoever is following their condition). Often pts are given a certain amount of drug (eg 3 months or 6 months etc) because the doc takes the opportunity of the prescription refill to ensure a follow-up with the pt.

[Sheena815]

Well, from a patient's perspective, I would love not to have to go to the doctor (which typically takes hours with my doc) for a 30 second renewal of a common drug that I've been on for years and will continue to be on for years. If there is any "risk" involved with this, I'm happy to take responsibility for that.

[Satsuma]

I agree it is unreasonable to wait for hours to have prescription refilled. And I am well aware that this happens...it is frustrating from both the perspectives of the patient and the physician.

 

There is clearly something wrong with the system if patients consistenly wait hours for a renewal. But I don`t think that the solution to the problem is fragmenting care. In my view that just breaks the system more.

[Sheena815]

I see you point, but for example, all the docs ever actually do is ask if I've had any problems with it and take my blood pressure to make sure its normal... then renew it. (And its actually the nurses who do the bp anyway). That I have to actually wait to see the doctor for this is quite annoying. Can't the pharmacists be trained to take a blood pressure? (Its pretty simple). Or even employ a nurse perhaps? This might help to cut down wait times and needless doctor visits. I'm also irritated that I have to bargain with them to write a renewal for more than 6 months. For pete's sake.

[rogerroger]

It seems like a good idea in theory. Yet I question the potential trend such a policy could start. I cannot help but feel this is an attempted band aide on a bigger problem. I would rather see the source of the problem addressed.

[BlackJack]

The lack of primary care doctors is having far-reaching effects on our health care system. Many people who need a doctor don't have one, and those that do have doctors wait for months to get something simple done. It's ridiculous.

 

Thus, to remedy the problem, the bureaucrats have many options at their disposal. such as:

 

1. To increase the pay of FPs (if this happened, the doctor wouldn't care if you wanted your prescription renewed for 1 year, eh Sheena?)

 

2. To go back to the old, less constrictive, career selection system.

 

3. To hire lower-paid NPs to fill the void, and allow pharmacists to refill prescriptions without doctors' orders.

 

Which one of these looks the cheapest on paper?

[Satsuma]

Your point 1 and 2 I think would go a long way. Especially point 2. I can say that alot of people in my class completing carms right now at times have contemplated family med....but know that if they don`t like it or later wish to specialize it is alot harder than matching into a 5-year specialty and then deciding to switch to family med after. And realistically, once you match into a 5-year what are the chances you bother switching out...like you'd have to just hate what you are doing I think to make the switch. Whereas with a rotating internship people may actually find they like family med and decide to stick with it. At the very least I think it would create an environment where specialists have more respect for primary caregivers as they would know more what they do.

 

For point 3...I would rather have an NP at my family docs office refill my prescriptions than the pharmacist.

[FMX]

For point 3...I would rather have an NP at my family docs office refill my prescriptions than the pharmacist.

 

It can go one of two ways if you really consider the training that both the pharmacist and the NP receive.

 

The pharmacist is trained in 3rd year anatomy and physiology along with upper level biochemistry. The nurse practitioner is trained in anat/physio during their undergraduate nursing degree along with 4-8 months of pathophysiology (which ofcourse can't cover everything without a basic knowledge of the fundamentals required in upper level undergraduate anat/physio courses).

 

The pharmacist is trained in all drugs, where they work, how they act, what they do. The nurse practitioner is NOT formally trained in medication information to the extend the pharmacists are (neither are MD's.. but at least they have a better knowledge than NP's).

 

The nurse practitioner would very likely not be able to tell the difference between the different classes of beta agonists and they very likely won't be able to tell you what they do (beta1/beta2. unless you tell them that an example of a beta 1 agonist is dopamine.. then they will be able to use their practical experience to tell you that it increase bp).

 

Pharmacists are also trained to READ (basic) lab values, serum K/Na/Ca (lytes), LFT's, GGT's etc. We are trained to read these to help dose certain medications in the hospital.. nurses are there to just dispense whatever is ordered or whatever pharmacy has changed the prescription to .. blindly without really knowing the cause.

 

But anyhow all the above compares the educational differences between nursing/pharmacy.

 

Experience wise, I'm sure there are basic community assessments that nurses can do that pharmacists can't, i.e. stethoscope to the chest to listen for crackles or whatever, but if the pharmacies will begin providing training for these assessments I'm sure that pharmacists can become just as competent if not more competent than an NP. And blood pressure.. give me a break, we have machines that measure this in every superstore/safeway/shoppers drug mart.. no need for training in that

[Satsuma]

Everyone on the healthcare team has an important job to do. I think you present a very narrowminded view of what nurses do and also you are lumping together NPs, RNs and RPNs I think (the only explanation I can think of right now to explain this limited view).

 

Nurses are not there to just dispense meds blindly without knowing the cause. And if you think that nurses can't read and INTERPRET basic lab values I have no idea what hospital you have been working at.

 

Pharmacists provide a valuable ressource to the healthcare team, because of their extensive knowledge in drugs. However, they are not trained to make the same clinical judgements as an MD or an RN. We all have different training and different perspectives and different roles. In my experience, not all suggestions that pharmacists make in the hospital are appropriate by the way....and it isn`t because they are stupid or incompetent, it is because they didn`t see the patient and they weren`t inside my brain when I made whatever decision I made.

 

Of course if pharmacists get additional training they could become competent at various clinical skills. That is no surprise...if you get the training you can do anything. But that training comes from going to medical school. I am in medical school...when I am done I will hopefully be a competent MD, but I would make a crappy nurse and a crappy pharmacist. If I got extra training, sure I could get competent at nursing care...but why would I want to...because there is a nursing shortage? Doesn`t really make sense (to me) just like it doesn't make sense that we try and make band-aid solutions to the doctor shortage.

[youbrokeit]

Most pharmacists aren't out to abuse their powers by randomly altering prescriptions. The power to modify prescriptions and advance some refils is meant to make life easier for physicians and patients.

 

Example: doc prescribes "pensaid" for tendonitis which is 40 bucks or so a bottle and isn't covered by blue cross. Pharmacist changes prescription to diclofenac cream. Same drug, different packaging, covered. In the past this wouldn't have been possible if the doctor wasn't available to approve the change.

 

Another example: You're travelling on business and run out of medication on your trip. There's a five hour wait at the local ED or walk-in clinic to get refils and you need your meds. Depending on the drug, it may now be possible to go and get a prescription at the pharmacy in five minutes to tide you over until you can book a visit with your GP.

 

Other pharmacists in remote locations may need to take a more active role in diagnosis and initiating therapy but most probably will not need to do this and therefore won't.

 

There is potential for abuse/misuse of power here, but responsible professionals will educate themselves in the areas important to their practice, and stay out of areas where they know they're lacking knowledge.

[ploughboy]

If pharmacists are able to write prescriptions, I think it's entirely reasonable that I should be allowed to sell medications directly to my patients and charge a dispensing fee...

[FMX]

If pharmacists are able to write prescriptions, I think it's entirely reasonable that I should be allowed to sell medications directly to my patients and charge a dispensing fee...

 

Heh. I'm sure there will be some kind of law put in place NOT allowing the prescribing pharmacist to fill the prescription at their own pharmacy.. otherwise.. more money for me

[monkey799]

This reply from pharmacist or student is making me crack up. To think that pharmacy training is sufficient for altering prescription meds for good patient care is totally naive.

 

The pharmacist is trained in 3rd year anatomy and physiology along with upper level biochemistry. The nurse practitioner is trained in anat/physio during their undergraduate nursing degree along with 4-8 months of pathophysiology (which ofcourse can't cover everything without a basic knowledge of the fundamentals required in upper level undergraduate anat/physio courses).

 

This is a joke isn't it. 3rd year anatomy and physiology? What can you do with that in terms of patient care? It's just a basic to understand how drug works.

 

And Upper level biochemistry? That is even more useless when it comes to clinical medicine.

 

The pharmacist is trained in all drugs, where they work, how they act, what they do. The nurse practitioner is NOT formally trained in medication information to the extend the pharmacists are (neither are MD's.. but at least they have a better knowledge than NP's).

 

This is even worse. Knowing the mechanism and side effects does not make you able to prescribe safely. Anyone with basic medical understanding and a PDA loaded with drug programs can do that. Heck even a 14-year old high school kid can do that too.

 

Pharmacists are also trained to READ (basic) lab values, serum K/Na/Ca (lytes), LFT's, GGT's etc. We are trained to read these to help dose certain medications in the hospital.. nurses are there to just dispense whatever is ordered or whatever pharmacy has changed the prescription to .. blindly without really knowing the cause.

 

Any one can READ lab values. It's knowing what to do with those values that make prescribing meds safely. An elevated LFT has a broad differential, and drug s/e is only one of the many. So is the serum K / Na / Ca which you listed above. To know those, and apply those to the patients you see - requires training far beyond those that a pharmacist possess.

[RxUBC]

Monkey799 - there's no need to disrespect the ability of a pharmacist. Assuming you are a medical student, you should respect the abilities of other healthcare professionals - in particular nurses and pharmacists because they are vital cogs in our healthcare system. There is a reason that clinical pharmacists in BC have a starting wage of around 93K/year.

 

I accepted a 1 year deferred admission to medical school last year because I wanted to finish my pharmacy degree from UBC. Graduated on the same day as my 22nd BDAY!!

 

If you actually have an idea of what pharmacists know, do and what we are taught then you are free to downplay the role of a pharmacist. If not, I recommend that you educate yourself because your behaviour is not congruent with those of a healthcare professional. I will be graduating from UBC Med in 4 years but I will be very grateful that I have a Bachelor of Pharmacy too... It will make me a more complete physician and I will be able to best utilize the abilities of my pharmacist colleagues.

 

For the record, pharmacists do know how to interpret lab values and the potential meanings of them...

[chemgirl]

The only reservation I have with this is psych meds... I don't think pharmacists graduate knowing how to conduct a psychiatric interview. An across-the-counter consult can never be a good substitute for this. I think pharmacists prescribing antidepressants, antipsychotics and mood stabilizers could turn into a disaster, and quickly.

 

However, lets say a patient was taking lithium or prozac for example, and has been taking them with the same prescription from the same pharmacy for a set time period, say 6 mo to 1 yr. Certainly I agree with pharmacists being able to extend the prescription for up to 1 month if the prescribing physician is away, moved, deceased etc. I just don't agree with the ability to start a new prescription for this particular drug class.

 

I don't like to be anecdotal, but I have been surprised at the way I have been treated by professional pharmacists when I go to refill my psych meds. It is clear that at some point in the chain of pharmacy education, that education is lacking and behaviour can become demeaning to the patient or unprofessional.

[RxUBC]

The only reservation I have with this is psych meds... I don't think pharmacists graduate knowing how to conduct a psychiatric interview. An across-the-counter consult can never be a good substitute for this. I think pharmacists prescribing antidepressants, antipsychotics and mood stabilizers could turn into a disaster, and quickly.

 

However, lets say a patient was taking lithium or prozac for example, and has been taking them with the same prescription from the same pharmacy for a set time period, say 6 mo to 1 yr. Certainly I agree with pharmacists being able to extend the prescription for up to 1 month if the prescribing physician is away, moved, deceased etc. I just don't agree with the ability to start a new prescription for this particular drug class.

 

I don't like to be anecdotal, but I have been surprised at the way I have been treated by professional pharmacists when I go to refill my psych meds. It is clear that at some point in the chain of pharmacy education, that education is lacking and behaviour can become demeaning to the patient or unprofessional.

 

I agree that pharmacists should not be making diagnoses or initiating drugs in different therapeutic classes unless they are comfortable. The BC College of Pharmacists has begun instructing their pharmacists as to what is considered safe practice and expecting a pharmacist to know about every drug in the world and how to safely prescribe/renew them would be a bit absurd. It would be akin to telling a CT surgeon to diagnose someone with schizophrenia and write a safe + effective prescription too... possible but not the best idea...

 

Pharmacists that could modify psychiatric medications would have to specialize at psych (ie. in a hospital setting) and have considerable experience before they are comfortable with adapting those prescriptions.

 

Few, if any pharmacists would adapt a prescription unless they were sure of their actions and had evidence based reasons to justify their decision. They are liable once they have modified the prescription.

[ploughboy]

Obviously, they're not going to be giving pharmacists all these new controlled acts without extra training.

 

rotflmao

 

(sorry, just old and cynical)

[leviathan]

It can go one of two ways if you really consider the training that both the pharmacist and the NP receive.

 

The pharmacist is trained in 3rd year anatomy and physiology along with upper level biochemistry. The nurse practitioner is trained in anat/physio during their undergraduate nursing degree along with 4-8 months of pathophysiology (which ofcourse can't cover everything without a basic knowledge of the fundamentals required in upper level undergraduate anat/physio courses).

Sorry, but when you say "3rd year anatomy and physiology", you make it sound like they've done 3 years. Correct me if I'm wrong, but don't pharmacy students just take the one 6 credit course in physiology? That is just an introductory course, and nurses take the same amount of credits to that effect. The difference is that nurses also have clinical training and experience to apply that physiology knowledge, whereas pharmacists have that knowledge to apply towards understanding of drug pharmacology.

 

The nurse practitioner would very likely not be able to tell the difference between the different classes of beta agonists and they very likely won't be able to tell you what they do (beta1/beta2. unless you tell them that an example of a beta 1 agonist is dopamine.. then they will be able to use their practical experience to tell you that it increase bp).

You actually think that nursing education doesn't include the difference between different adrenergic receptors? You are clearly misled. Also, that would demonstrate a really shallow understanding of beta agonists and/or dopamine to say that it just "increases bp". And by the way, dopamine would be a pretty poor example to use for a beta 1 agonist...unless you meant to say dobutamine, but I'm sure you know that as a pharmacist, right?

 

Pharmacists are also trained to READ (basic) lab values, serum K/Na/Ca (lytes), LFT's, GGT's etc. We are trained to read these to help dose certain medications in the hospital.. nurses are there to just dispense whatever is ordered or whatever pharmacy has changed the prescription to .. blindly without really knowing the cause.

Yeah, nurses are just robots that dispense medications without knowing why. I think you have a lot to learn about the different professions in health care and what they are capable of.

 

But anyhow all the above compares the educational differences between nursing/pharmacy.

No, not really.

 

Experience wise, I'm sure there are basic community assessments that nurses can do that pharmacists can't, i.e. stethoscope to the chest to listen for crackles or whatever, but if the pharmacies will begin providing training for these assessments I'm sure that pharmacists can become just as competent if not more competent than an NP.

The fact that you think auscultation for pulmonary edema constitutes an advanced nursing skill also demonstrates your ignorance.

 

And blood pressure.. give me a break, we have machines that measure this in every superstore/safeway/shoppers drug mart.. no need for training in that

Right, but do you have training in understanding the clinical significance of various causes of hypotension/hypertension and how to manage them? A nurse certainly does not know it to the same extent as an MD, but they in turn have a much better understanding than a pharmacist.

[RxUBC]

Leviathan, FMX - both nurses and pharmacists are key components of healthcare... no need to continue this comparison of professions...

 

Having been a pharmacist for all of a few months - I would say my competency in diagnosis is not up to par to prescribe many medications comfortably. That being said, there are many circumstances and examples of times where it really is a no-brainer and I would feel comfortable extending a patient's prescription provided that I contact their physician and ensure that the patient schedule's an appointment with their MD within a year.

 

The main barriers to pharmacists prescribing/renewing a prescription are these:

 

1) Public opinion and misinformation

2) MDs

3) old-school pharmacists who are still in the last century (only 8 years ago haha)

4) reimbursement from the gov't b/c no pharmacist is going to adapt a prescription and take the liability without some compensation

5) ability

 

I like pharmacy a ton and although I will be pursuing my MD this fall, I will certainly keep pharmacy in mind. When I do graduate from medical school, I will certainly try to promote pharmacy practice as a MD by giving the pharmacists around me a much greater say in the treatment of a patient because they are more than capable and did not go through 4 years of school + a 1 year residency merely to fill prescriptions. I might not be the most popular MD amongst my colleagues =) but I am proud that I was a pharmacist (albeit for 3 months before i go back to school) and I feel that it is the least I could do (think of it as a debt of honor).

[A-Stark]

I do not see any great need to expand the roles of pharmacists with respect to the treatment of patients. Is not their main responsibility to ensure the safe and effective use of medication? Diagnosis is generally outside of their field, with the exception of making note of drug-to-drug interactions and the like. If that should not be the case, does current training methods and standards reflect that?

 

For that matter, what sort of malpractice liabilities and insurance will these prescribing pharmacists carry? Will they take proper histories from patients arriving for renewals and new prescriptions? Does the training reflect this responsibility? What is the potential for conflict-of-interest in making new prescriptions in the local pharmacy?

[shaka84]

UBCRx

 

How do you know you are attending UBC med next fall? Did you defer from last year?

 

I got a kick out of your list of barriers. #5 floored me. Wouldn't that be true for janitors as well. No offence to janitors.

 

shaka

[RxUBC]

I do not see any great need to expand the roles of pharmacists with respect to the treatment of patients. Is not their main responsibility to ensure the safe and effective use of medication? Diagnosis is generally outside of their field, with the exception of making note of drug-to-drug interactions and the like. If that should not be the case, does current training methods and standards reflect that?

 

For that matter, what sort of malpractice liabilities and insurance will these prescribing pharmacists carry? Will they take proper histories from patients arriving for renewals and new prescriptions? Does the training reflect this responsibility? What is the potential for conflict-of-interest in making new prescriptions in the local pharmacy?

 

Valid points A-Stark. I would say that diagnosis is not entirely outside the scope of practice of pharmacy. One of the key roles of a pharmacist is to be able to listen to patient's chief complaint and decide if it is treatable via over the counter prescriptions or if a referral to a physician is necessary. That is a form of diagnosis and our training and curriculum prepare us adequately for it. As to more complex conditions, unless I specialized in a certain area and had access to lab values and the trust of a physician, I wouldn't even think about prescribing/adapting a prescription.

 

In BC, pharmacists are not yet allowed to "prescribe" they may only adapt or renew. In Alberta, they can prescribe but only if they are competent and well-trained.

 

As to the liability issue, in BC pharmacists will carry a 2 million dollar liability for malpractice (is that the right term?)

 

Conflict of interest is an interesting point - The college of pharmacists regulates its pharmacists and does regular audits of prescriptions filled by a pharmacist - it's hard to elude them especially because prescribing rights are a new issue... I can see how it might be a problem if a pharmacist insists on giving a patient a brand name vs a generic medication and making more profit from it.