Prescriptive Authority – Are Pharmacists “Write”?




Drugs and Clinical Trials CategoryPharmacists are integral members of the health care team in the US. The profession is composed of highly-educated, well-trained health-care providers. Pharmacists promote themselves as “drug experts” for good reason: the four-years of education required to obtain the Doctor of Pharmacy (PharmD) degree encompasses the etiology, pathophysiology, clinical manifestations, prevention, and management of human disease states. Pharmacists study the clinical application of pharmacology, biopharmaceutics, pharmacokinetics, therapeutics, adverse drug reactions, laboratory data, and drug information to the management of disease states. This training enables pharmacists to identify and prevent drug interactions, plan patient evaluation of drug-related problems and recommend changes in pharmaceutical care plans, and evaluate and interpret pharmaceutical data.

PharmacistStill, these drug experts are not granted prescriptive authority under state or federal laws. Of course, physicians, osteopaths, dentists, and veterinarians have long-standing authority and experience in writing medication orders and prescriptions. In most states, these practitioners are granted full prescribing rights to any medication available, whether or not it falls within the scope of his or her practice. Each state governs its own laws regarding the prescriptive authority of more specialized practitioners, including podiatrists, nurse practitioners, and physician assistants. In some states, these practitioners have broad prescribing powers, while other states limit the type or schedule of medication allowed to be prescribed, or require strict collaborative practice agreements with physicians. Yet, almost no state allows pharmacists to prescribe or manage medication therapy outside the strict bounds of tightly controlled protocols for relatively routine medications.

Nurse practitioners and physician assistants have fought long legal battles to change the regulations governing their practice and their prescriptive authority. As more legislation is poised to expand their role further in many states, these groups are exploring the opportunity for almost completely autonomous practice. These groups focus on education and training as part of their battle for professional independence, and do not take their prescriptive authority lightly. These practitioners emphasize the need for continued education as part of their expanding role, and it has paid off, as patients accept their role as prescribers freely and believe the practitioners are knowledgeable about medications.

Still, pharmacists are the profession with the most education and experience in drug therapy. Expanded prescriptive authority for pharmacists would have benefits in cost and safety for the public. Pharmacists already govern the dispensing of some medications in a quasi-prescriptive role. Such “behind the counter” medications require pharmacists to consult with patients prior to the sale of medications that do not require a prescription, but do necessitate some level of supervision by a health care provider. The pharmacist is required to assess a patient for medical history, current medications, and drug allergies before dispensing the medication. Many professional groups advocate for an expanded “pharmacist-only” class of over-the-counter medications to increase the public’s access to medications.

Several studies have shown positive outcomes when pharmacists are directly involved in the prescribing, dispensing, and managing patients’ medication therapies. Many test cases have allowed pharmacists to independently manage therapy for diabetes, and overall improvement in patient’s glycemic control was seen when pharmacists were afforded prescriptive authority. Further, a reduction in costs and use of health care resources was seen, since diabetes-related complications were diminished. Favorable outcomes were also achieved when pharmacists took a lead role in the prescription and management of medications to treat chronic pain patients. The patients were effectively treated and costs were reduced when pharmacists were allowed prescriptive authority.

Barriers do exist to pharmacists’ prescriptive authority. Among the most significant include workload and time demands, particularly in today’s busy community pharmacy settings. A busy pharmacy counter or drive-through does not provide a safe or appropriate arena for discussing medication management. Further, most insurance providers do not compensate pharmacists for providing any sort of medication management service and providing clinical care is expensive. However, the expanding clinical role of pharmacists in hospital, long term care, and outpatient settings increase the opportunity for medication therapy management programs in which pharmacists are integral providers of effective health care. Even in a community pharmacy, pharmacists are accessible to the public and they are poised to assess and counsel patients more easily than any other health care provider.

Pharmacists are well-trained and well-educated medical professionals with richly-developed clinical judgment and scientific skills that are unparalleled by any other medical profession. Pharmacists need to fulfill their potential as drug experts and increase the value and access of quality health care to the public. The profession of pharmacy — and the public — should challenge the notion that pharmacists merely count pills and demand that they be directly involved in the prescription and management of medication therapy.

References

Dole, E.J., Murawski, M.M., Adolphe, A.B., Aragon, F.D., Hochstadt, B. (2007). Provision of pain management by a pharmacist with prescribing authority. American Journal of Health-System Pharmacy, 64(1), 85-89. DOI: 10.2146/ajhp060056

Kaplan, L., Brown, M. (2004). Prescriptive Authority and Barriers to NP Practice. The Nurse Practitioner, 29(3), 28-35. DOI: 10.1097/00006205-200403000-00004

Kaplan, L., Brown, M. (2007). The Transition of Nurse Practitioners to Changes in Prescriptive Authority. Journal of Nursing Scholarship, 39(2), 184-190. DOI: 10.1111/j.1547-5069.2007.00165.x

McCann, T.V., Clark, E. (2008). Attitudes of patients towards mental health nurse prescribing of antipsychotic agents. International Journal of Nursing Practice, 14(2), 115-121. DOI: 10.1111/j.1440-172X.2008.00674.x

Wubben, D.P., Vivian, E.M. (2008). Effects of Pharmacist Outpatient Interventions on Adults with Diabetes Mellitus: A Systematic Review. Pharmacotherapy, 28(4), 421-436. DOI: 10.1592/phco.28.4.421

  • I think of it like this: it’s checks and balances.

    We give the doctor the training and the right to prescribe the drugs, but we don’t let him have access to the stash.

    We give the pharmacist the training and the right to dispense the drugs, but we don’t let her write prescriptions to the stash.

    While the pharmacist has an important role and is the expert on the drugs, that role is secondary to the doctor who is the expert on the treatment. A pharmacist can (and should) “veto” a prescription that is demonstrably harmful, fraudulent, or contraindicated – an important check on the doctor against possible mistakes.

    However, absent “probable cause”, the pharmacist must dispense a legal prescription, because otherwise we are allowing a pharmacist to intrude on the doctor-patient relationship.

    In the case of so-called “conscience” pharmacists who refuse to dispense birth control or Plan B? Way out of line. Your conscience or your job – if you really believe birth control is murder, find a new job.

    • Ace

      Actually, physicians can dispense (think “samples”) they just choose not to bother with it because its not cost effective.

    • Brightfire

      If the pharmacy owner doesn’t want to fire someone who doesn’t want to dispense birth control, they’re within their rights. It’s a violation of the 13th Amendment(the one against slavery) to force a pharmacist to perform a service(dispensing birth control) he doesn’t want to perform. If the owner wants to fire him, he sure can, but otherwise there’s nothing you can do.

  • Hi Jennifer– Thanks for your comment on my blog post, “Technology meets Health- Web-based Pharmacists lower Blood Pressure” and for inviting me to read this very interesting posting.

    I am a medical doctor who worked closely with Pharm.D pharmacists in patient care, teaching medical and pharmacy students and residents, and conducting clinical trials. This experience has given me some familiarity with the training and competency of this cadre of pharmacists.

    I think we need to clarify between different categories of pharmacists– those who have doctorate degrees and completed residencies, those with a Doctorate degrees and no residency, and those with college/master degrees (R.Ph.).

    I have seen highly qualified pharm.d who have completed residencies… i.e. with expertise in pain, cancer, heart failure be equally qualified (and sometimes more qualified than non-specialist MDs) in the management of medications pertaining to selecting alternate meds, adjusting dose etc. I would,however, reserve diagnosis of a condition which subsequent initial recommendation of treatment to MDs.

    Dr Brad

  • Dear All!

    Today’s world have a sever crunch for doctors especially in the under developing world, and in some developing countries governments where thinking of introducing short term course for solving doctors shortage and all your discussions above conclude one point very fairly that Pharmacist is the person who have got an in-depth knowledge in medicine, but lacks knowledge in diagnosis. Still they claim to have prescription rights.

    To conclude such problems and to bring out an end point to the topic named Prescriptive Authority – Are Pharmacists “Write”?”. The regulatory authority of different countries can afford a BS Program [Bachelor of Surgery] containing 2 yr including house surgeon program. To this kind of high end skilled Pharmacist, so there by giving the above said right too.. And coming out with a permanent solution for the same.

    Thank’s and Regard’s

    Alin J.S. Jinu

  • It’s easier to fight for one’s principles than to live up to them.–Alfred Adler (1870-1937), psychologist

  • George McGinn

    What happened to the pharmacist was the reverse – back in the 1700 – the early 1900’s (pre WWII) a pharmacist used to make the medicines in their store.

    As the manufacturers started making the same drugs, and developing newer drugs, their sales teams started to target the doctors to get them to prescribe their brand.

    So now, instead of a pharmacist making a soda drink (the drug revolution of the 1850’s) that cured ailments, today they are left with pre-made pills. And all the public thinks of them are pill counters.

    If we are training them in complete drug etiology, interdiction, we should trust their decisions again. They need to come back into the patient care family, and become less than the convenience store on the corner that also has a drug store.

    And I know if you ask doctors, many would like the drug expert to help in drug decisions.

  • Pingback: Pharmacists Really Do Have Prescribing Power | Brain Blogger()

Jennifer Gibson, PharmD

Jennifer Gibson, PharmD, is a practicing clinical pharmacist and medical writer/editor with experience in researching and preparing scientific publications, developing public relations materials, creating educational resources and presentations, and editing technical manuscripts. She is the owner of Excalibur Scientific, LLC.
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