Melissa Keith

Should pharmacists be allowed to prescribe?
It’s a late night, a holiday weekend, or you’re away on vacation, and suddenly you realize that your medication is almost―or already―gone. It can be weeks before your next appointment with your doctor, and so an emergency room or walk-in clinic may be the only option for a last-minute prescription renewal. It isn’t always the best option when it comes to psychiatric medications; careful assessment of symptoms and side effects is usually an ongoing process for patient and doctor.

The question of whether pharmacists should be legally permitted to prescribe is a natural corollary to the situations described above. Some Canadian, American, and European jurisdictions have been allowing it for years, yet it remains a divisive subject: Every major American medical, pharmaceutical, and mental health organization contacted for this edition of “Points of View” declined to comment on what was frequently described as a “controversial” or somehow exclusively Canadian concern. A variety of Canadian panelists proved more than willing to share their thoughts on whether pharmacists can and/or should play a more central role in helping people access and manage their essential medications. These are their “Points of View.”

Heather Piccott, pharmacist-in-training:
I’m presently in my first year of pharmacy at Dalhousie University and I’ve just completed my Law and Ethics course, and basically, I say go for it. We’re trained for it; pharmacy is an intensive four-year program that educates us on far more than just pharmaceutical drugs.  Anatomy, physiology, biochemistry, pharmacology, microbiology, organic chemistry―these are all areas we focus on. Volunteering, practical experience programs in both community and hospital settings, and weekly skills labs are other aspects of the curriculum. We are also all required to have a minimum of one year of university prior to acceptance into the program. I, myself, already have a biology degree.

What I’m getting at is that we have a lot of training―not just in drugs, but in the body itself. By no means am I saying we can replace doctors…but pharmacists are the drug experts, just as doctors are experts of diagnosis. Health care encompasses many areas; to ensure optimal care for patients, all health care professionals need to work towards an integrated system where we use each other’s strengths and expertise. And letting pharmacists prescribe would be a good way to alleviate the burden in other areas of health care. Pharmacists are the most accessible of all the health professionals: anyone can walk in off the street and talk to us, no appointment necessary. There’s always a pharmacist available if the pharmacy is open―it’s required by law. There are certain drugs that can only be sold when a pharmacist is present, such as many cold and allergy medications. We obtain information from the patient and then decide when to give them out and when to suggest something else. In this way, we are already making decisions about what drugs and supplements will best benefit patients. We also have access to a wide variety of databases and information on disease-states, herbal products, over-the-counter medications, and much more.

There is also something called a “continuing care prescription,” which can be given by a pharmacist. The regulations on these are detailed, but they are basically a one-time extension of an already existing prescription for a chronic/long-term condition. They enable pharmacists to give their patients extensions on their medications to give them more time to see a doctor and obtain refills. I believe giving pharmacists the right to prescribe―even if just for long-term, stable conditions―would relieve strain on our health care system. I see no reason why a patient diagnosed with diabetes should need to go to their doctor every time they need a refill on their medication. Not only is it inconvenient for the patient, but it adds to wait times. Pharmacists are already monitoring their patients and following up with them to see how they are doing. We communicate with doctors on a daily basis, [so] we would not be taking patients away from doctors. Instead we would be helping to lighten the load. Let each professional use their individual expertise, while at the same time communicating with each other to ensure the best care possible. Pharmacists are professionals with a high level of skill, training, and educational background in more than just drug therapies. Why not be allowed to prescribe?

Heather Piccott is a first-year student at Dalhousie College of Pharmacy, Halifax, Nova Scotia, who resides in Dartmouth. She also holds a Bachelor of Science degree from Saint Mary’s University (Halifax, Nova Scotia), and is the daughter of a pharmacist.

Glen Pearson, PharmD, prescribing pharmacist:
As a pharmacist with prescribing authority, it should not come as a surprise that I emphatically support the concept of pharmacists prescribing medications. Pharmacists are currently recognized as the “drug therapy experts” within our complex system of health care delivery. In collaboration with physicians, nurses, and many other health professionals, the role of the pharmacist is to consistently strive to optimize medication therapy management to produce positive health outcomes in patients. Consequently, granting pharmacists the authority to prescribe medications is a logical and appropriate evolution.

This evolution is now being enabled across Canada; a number of provinces (Alberta, Manitoba, New Brunswick, and British Columbia) have adopted legislation which provides pharmacists within those jurisdictions the opportunity to obtain prescribing privileges. The impetus for health care policy-makers to create such legislation was born from the desire to make greater use of the unique knowledge and skills of pharmacists for the purpose of promoting and developing a more flexible health care system for medication management (prescribing, supplying, and administering). The specific goals of pharmacist prescribing include: improving patient access to drug therapy and optimizing patient outcomes; reducing the redundancy and interruptions in drug therapy which are common in our current model of health care service delivery; and increasing collaboration and synergy among pharmacists, physicians, and other health care professionals for an improved service delivery model.

Obviously, pharmacy practice is very diverse, both in terms of the services pharmacists provide and the settings they work within. While it is recognized that most pharmacists practice in community pharmacies, many others work in hospitals, long-term care facilities, and ambulatory medical clinics. Depending on the practice environment, different levels of collaboration with physicians and other health professionals are necessary to provide patient care services. 

In an optimal health care delivery service model, a physician would be responsible for diagnosing the patient’s condition and making the decision to treat them medically (as opposed to surgically), and then the pharmacist would be responsible for selecting, dosing, modifying, and monitoring the appropriate drug therapy. Achieving this type of practice will require significant collaboration and cooperation among physicians and pharmacists and other health care professionals. However, this effort should be worth it if patients are able to obtain more efficient and effective health care services. 

The education of pharmacists (a minimum of five years of university) prepares them well for assuming more responsibility for prescribing medications. Health care reform requires that all providers maximize their skills and full scope of practice. A pharmacist authorized to prescribe medications in collaboration with other health providers achieves these goals.
 
Dr. Glen Pearson is an associate professor of medicine in cardiology at the University of Alberta in Edmonton. He practices as a clinical pharmacotherapy practitioner in cardiology and cardiac transplantation at the Mazankowski Alberta Heart Institute. Notably, he was one of the first 15 pharmacists in Canada to be granted additional prescribing authorization.

Bruce Miller, patient-consumer and hospital worker:
Pharmacists are well trained professionals [who] I would say know a lot more than some doctors when it comes to knowing how the medications work in the brain, and what interactions there are if different medications are taken at the same time. I heard recently that [Nova Scotia is considering allowing] pharmacists…to prescribe some types of medications for minor physical problems. I can see that under some situations it would be okay for this to happen, but when it comes to prescribing psychiatric medication, I think that is not appropriate.
 
To know what type of medication to prescribe, you need to talk about what you are experiencing and what is happening with you. This is a very personal and private thing to do, and I don’t think pharmacists are trained in how to deal with the psychological issues associated with mental illness. I have anxiety and depression, and I have also worked in the mental health field; I know that it can take a while to get the right medication. I get medications for anxiety and depression, and I would not be comfortable talking to the pharmacist about the [reasons] why I am taking the medications. If all that was involved with psychiatric medications was looking at side effects, then maybe a pharmacist could be involved.

Should pharmacists be allowed to prescribe? The key word is “prescribe,” and I really don’t think that they have the training. Psychiatrists and general practitioners have many years of training when it comes to diagnosing illnesses. When it comes to psychiatric illnesses, there are many complex issues that need to be carefully considered to properly prescribe psychiatric medications. There is still stigma around mental illness, and I would not want the pharmacist to know some of the very personal issues around my illness.
 
Another issue is the confidentiality of my private information. In a pharmacy, there is more than just the pharmacist [present]: there are pharmacy technicians―[and] not just one pharmacist or technician. Would this mean that if your pharmacist was away, another pharmacist would have access to your file? Would the technicians have access to your information? Having your personal information out in another area leaves it open to the possibility of someone having access to it who shouldn’t.

Pharmacists are highly trained professionals and know their stuff. I do trust them in what they do, but the area of prescribing is something they should not be involved in. It isn’t that I don’t trust their judgment, because I do: I am married to one!
 
Bruce Miller works at the Victoria General Hospital in Halifax, Nova Scotia. He has worked in the social services and health care field, specifically with the psychiatric population, for more than 20 years. He now does mental health-oriented public speaking and stand-up comedy. He can be reached at encouragingspeaker@gmail.com or via his Website, www.thenakednut.ca.

Jennifer Hood, industry spokesperson:
What do you do when you run out of medication? What if you don’t have a family doctor and can’t wait for hours in the emergency room? In many Canadian provinces, you can go to your pharmacist.

Over the past decade, the Canadian health care system has changed. Many Canadians do not have a family doctor and for those that do, it can take a long time to get an appointment. Emergency room wait times have been reported to be up to 30 hours. When you need your prescriptions renewed or have questions about your medications, your pharmacist can help.
Pharmacists have at least four years of university training in medication therapy and management on top of basic science. Because they have the training, more and more governments are allowing pharmacists to prescribe most medications (except for narcotics).

Your pharmacist cannot diagnose you, but he can help you with medication issues. Sometimes you need a prescription renewed, and sometimes you just don’t feel right and think it may be because of the medications you’re taking. In these cases, your pharmacist might renew your prescription or adjust your dosage in consultation with your doctor. The pharmacist will document the information and update your doctor on what was done.

It’s important that you shop around and find a pharmacist that you like. It may help to find one who has a good understanding of mental health issues. Once you find “your” pharmacist, keep going to him. He’ll keep records of your medications and your medication history, and will be able to identify any potential medication-related problems before they happen. He can also help ensure you don’t run out of your medication just because your prescription needs to be renewed.

Pharmacist prescribing is already legal in some provinces in Canada and is being discussed in others. Around the world, pharmacists have been allowed to prescribe for years. Talk to your pharmacist to see what he can do for you. 

Jennifer L. Hood is a communications specialist with the Canadian Pharmacists Association. She has worked in communications and marketing in the health care sector for more than five years.