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Should Pharmacists Prescribe?

Published June 20, 2012 1:34 PM by Renee Dahring
The FDA recently announced a proposal to allow pharmacists to prescribe some medications. Much to the surprise of no one, a well-known physician organization has issued a statement opposing any such changes. Many reasons are given, ranging from "only licensed doctors" can prescribe medications to "this would cause a breakdown in the relationship between the patient and the physician," "it will lead to fragmented care," and by golly ALL prescribing should be supervised by a physician. Stop me if you have heard this before (or if you are laughing too hard).

The comments are even more interesting to read than the article I found on this proposal. This is where the usual suspects show up. Accusations of financial motivations on the part of pharmacists are rampant, while ironically quite a few MDs posted about their own fears of losing revenue should prescribing authority be expanded to include pharmacists. And sure as the sun comes up in the east, there are quite a few of what I like to call the "there goes the neighborhood" type remarks. The commenters are complaining that once the door was opened by allowing NPs and PAs to prescribe, it was only a matter of time before other professions would jump on the bandwagon and want in on the prescribing action, too. Sprinkle in a few snide comments about "undermining our authority" with a side of some veiled insults belittling the educational preparation of pharmacists and the audacity of a PharmD using the title "doctor," and things are really starting to sound familiar!

After reading the statement from the physician organization, I thought it would be a good idea to also read the actual Federal Register notice. I quite frankly don't see where they are proposing quite what the MDs fear (unlimited pharmacist prescribing). Rather, they are attempting to open a discussion about the wisdom of requiring an office visit for refills for certain chronic medications and whether or not in some situations, the office visit can actually be a barrier. An example is patients with asthma going without rescue inhalers and ending up in the ER. Also, there is some discussion of patients answering a series of questions on a computer that uses algorithms for diagnosis of some conditions.

The full notice can be found here. The response from the American Academy of Family Practice is here.

Now, it's not my intent to get on the case of the physicians, but rather to ask how we as NPs and PAs feel about this proposal. Do we have the same sort of gut reaction as the MDs, or are we more open to the idea of rethinking the current system? Now that the proverbial shoe is on the other foot, do we feel threatened too?

I welcome your comments and discussion. This could be very interesting.

 

19 comments

I personally am of the opinion that only a licensed physician should be permitted to prescribe any medications.  

NP's, PA's or Pharmacist s do not have the training or clinical experience. In my opinion, unless they work under the direct supervision of a physician, writing scripts should be prohibited.

Kay October 14, 2013 7:28 PM

as a 5th year pharmacy student I already know more than a nurse practitioner. You went to nursing school for goodness sake. Give me a break about you knowing jack crap

poop tooth October 7, 2013 2:16 PM

Pharmacists that want to prescribe should go to medical school or PA or NP school. They are not trained as clinicians. They do not do clinicals treating patients. The preperation they recieve is to compound and make drugs not to taylor treatment to a patients needs. A pharmacist has no business in the treatment arena.

Michael Jacobs, Nurse Practitioner - FNP, Summit Urgent Care July 5, 2012 10:27 AM

El Paso TX

-I'm in pharmacy school. I did 4 years of undergrad, and I'm doing 4 years of pharmacy school. To work as a clinical pharmacists many do residencies (up to 2 years to specialize) = 10 years. Last year of pharmacy school is rotations at HOSPITALS including critical care, cardiology, infectious disease, ambulatory care, internal medicine, etc. I spend 4 years in school learning TREATMENT not counting pills. I think the most qualified person to prescribe is a PHARMACIST

Linda August 7, 2012 6:11 PM

I wholeheartedly agree with V Eucario!  Medicine needs to be team based and ALL teams members cooperate,  No turf issues. I would love to have a pharmacist who would be part of my team, and we could look at the appropriate medications together, or I prescribe based on the pharmacists best recommendation.  It would make it so much better for our patients.  Pharmacists have the best knowledge on medications than any of us, including doctors.  After all, they spend a lot of time in school for this, a heck of a lot more than my 3 semesters of pharmacology and pharmacotherapeutics.  Back in my day, there was no genomics, either.   Let's support the new paradigm of medicine.

Paula, Family Practice - PA-C July 8, 2012 12:58 PM
MI

An then comes pharmacotherapy. Why do we see so much therapeutic failure? Why do patients tend not to get better? This is something that we, as clinical pharmacists, ask time after time. The problem is that drug therapy/pharmacology is so involved, that it takes a career in itself to fully understand. Disease states change the conditions that will cause the body not to respond. Pharmacogenomics are also involved which will change the pharmacokinetic profile. Look, if prescribing is as simple as looking up a drug, then people will respond and get better... But this does not happen because prescribing is not as easy as looking up drugs of choice in a handbook. The Bill on PharmD prescribing is NOT based on diagnosing. The intention is to have a health care format that is working well in the UK and France. The MD does the diagnosis and the PharmD will prescribe (more like engineering a therapeutic plan) after the diagnosis is made. This will solve many of the problems of lack of practitioners. Again, there will be no "single" person doing the diagnosis and prescribing. NPs and PAs monitor the patients based on assements.  

V Eucario, PGx Pharmacotherapy - PharmD July 7, 2012 7:26 PM

In response to Lucy's post on 7/5:

She wrote, "In order to have my prescriptive authority, I needed to have more than just advanced pharmacology.  NPs need to understand disease process, assessment and anatomy/physiology and differential diagnosis."

I'm currently in my MSN PNP program, and my friend who is in his final year of his PharmD program has had extensive education, more than just advanced pharmacology, on a variety of disease processes, A&P, etc in both his undergraduate and graduate program. I believe that with the education that PharmD students attain in their 8 years of schooling, this is a topic that is long overdue in discussing.

I too agree with others who have commented that PharmD's are underutilized and could be a benefit to the healthcare team, having more prescriptive authority.

Kyleen, RN July 7, 2012 10:23 AM

If the pharmacist's are held responsible for their actions, and are able to follow up when the plan of care they directed does not work--Then okay. I am concerned that this might lead to pt's not receiving appropriate follow up care. I think we can all agree that one plan of care does not fit all. There is an element of trial and error for some pt's.

Melinda , , FNP-BC urgent care July 6, 2012 3:25 PM
Portland OR

I have had the privilege of working with two clinical pharmacists specializing in psychiatry that I would feel 100% comfortable being granted prescriptive authority.  Both of these PharmD's have completed residency in psychopharmacology and I have witnessed them accurately interview and diagnose clients while applying knowledge of physiology and medication interactions, previous trials, and both on and off label uses of medications.

Rachel Karbowski, Psychiatry - APN July 5, 2012 8:40 PM
NJ

I smell opportunity for the smart PA or NP to be on the team that studies this issue.  The AAFP wrongly states in their discourse that only doctors are qualified to prescribe and are disingenuous in their response.  It exemplifies a case of our strongly held societal beliefs that only "doctors" are qualified to practice medicine and highlights the inability to change.

The FDA is being innovative.  I support studying the questions the FDA proposed.  They have valid questions and concerns.  Remember that in the 1950's and 1960's diphenhydramine was available by prescription only.  We now have other antihistamines available without prescription.  I understand the FDA proposal as a precursor to studying what other drugs may eventually be available without a prescription.  I agree with Jaclyn that some drugs may be safe to dispense without a prescription such as an albuterol inhaler, if the patient has documented asthma.

Pharmacists are under-utilized and do not work up to their licenses.  They are more than pill counters and should be part of the health care team working together for the good of our patients.  So, I say, go for it!  Extra training may be necessary and I am willing to bet if we look at curriculum of pharmacy schools some are already adding in assessment classes and general physical exam classes.

However, I would like to see independent practice for PA's before the pharmacists gain  prescribing rights.  Perhaps we could be their collaborating "supervisor" rather than MD/DO's.  

Paula, Family Practice - PA-C July 5, 2012 7:34 PM
MI

The FDA proposal does not allow Pharmacists to prescribe every known medication.

In fact there is no prescribing at all. It is a new class of drugs that were originally prescriptions, named "safe use" or "behind the counter" or such.

If I am reading other sources correctly, it seems the AMA is knee-jerking as usual.

----------------------------------

Janelle Derbis, of the FDA's Office of Special Health Issues, said the FDA is concerned the AMA's resolution does not accurately represent the agency's intent in its proposal.

"FDA is not proposing to change who can prescribe and or dispense prescription drugs," Derbis said. "Rather, the FDA is proposing to explore a flexibility in allowing certain OTC products to be dispensed with conditions of safe use."

- Fox News (PS, Fox is an untrustworthy "news" channel for anything politics)

Mark D. July 5, 2012 6:59 PM

I think that pharmacists, especially PharmDs are very knowledgable about medications. But their education does not include learning to assess and diagnosis. Maybe for refills under certain conditions such as rescue inhalers, in a collaborative arrangement with the original provider/prescriber, maybe limit them to one refill to tide patients over until seen by licensed provider.  But for new problems, new medications, I say ABSOLUTELY NOT!

In order to have my prescriptive authority, I needed to have more than just advanced pharmacology.  NPs need to understand disease process, assessment and anatomy/physiology and differential diagnosis.

I also agree, granting pharmacists prescriptive authority shouldn't occur until NPs have the ability to work to independently in all states to the full level of our education.

Lucy Vara APN, FNP-BC, Cardiology - NP, Private Physician Clinic July 5, 2012 4:03 PM
Knoxville TN

I don't feel that they shoudl be allowed to prescribe. I agree that there needs to be some HX & assesment before any medication such be prescribed.

I love that the gov thinks this is a goo idea, but they allow the states, hospitals, insurance industry & physicians block NP from practicing up the the level that we were trained.

Kim, APN July 5, 2012 2:03 PM
Naperville IL

I have just completed my advanced degree for adult nurse practitioner in New Jersy. I have read the comments but not the FDA recommendations. I am in agreement with the NP'S  right to  autonomy in precribing medications I disagree with the state of Jersey on collaborative privileges. It is also my determination that affordable health care is everyone's contribution even the pharmacists. They cannot diagnose but it would be benefical for the public if they can refill medications that the person has been on for chronic conditions. Certain requirements such as refills only for a specific amount of time and EMR of the refill sent to the HCP. I know I would appreciate the convenience of refills without having to pay a copay. Everyone complains about the cost of doing business and the lack of time that can be afforded to patients. A program like this would free up a non essential office visit.

Jean Bruno July 5, 2012 1:45 PM
NJ

Pharmacists are very valuable regarding their knowledge of drugs.  I am however uncertain regarding the conditions that pharmacists would be required and/or asked to prescribe and how much history and information would need to  be  ascertain.   Additionally ,if a pharmacists are prescribing who would be required to follow-up and monitor the patients?  Would they require a collaborative agreement and /or contractual relationship with a physician? I continue to support the pharmacists input as a collaborative  partner.  However, with the information provided I don't think it is fair to agree and/or disagree.

Gianetta Norwood, Oncology - FP-C July 5, 2012 11:22 AM
IL

Pharmacists that want to prescribe should go to medical school or PA or NP school. They are not trained as clinicians. They do not do clinicals treating patients. The preperation they recieve is to compound and make drugs not to taylor treatment to a patients needs. A pharmacist has no business in the treatment arena.

Michael Jacobs, Nurse Practitioner - FNP, Summit Urgent Care July 5, 2012 10:27 AM
El Paso TX

Pain Management at Allina Hospitals, Anoka, MN are managed by, evaluated by and under the direction of Pharmacy Supervisor. Pharmacists prescribe narcotics and other medications. NP's are under the direction of the Director of Pharmacy-NOT Nursing, NOT Physiciains although a physician signs the privileges but not involved otherwise. NP's recently resigned over this arrangement and lack of autonomy in their decisions and practice.

lois, Pain Mgmnt - CNP, Hospital July 3, 2012 5:39 PM
Anoka MN

Last week, we followed the landmark Supreme Court ruling on the Affordable Care Act , which allowed one

July 2, 2012 4:22 PM

One day closer to perfect health drugs, and one day closer to the end of all healthcare power squabbles.

Len June 23, 2012 10:45 PM

On the bright side, we know its not just us!

I think it is a great idea for things like rescue inhalers, anti-fungals, stable conditions, and acute but familiar issues where the patient knows what it going on and the office visit is a expense-based formality. As long as a PCP is established and that have been seen in the last year for follow-up, I am in favor of an additional layer of access for patients. The pharmacists and their employers could be less enthusiastic since it may mean more training and certainly more liability.

I admit though, I will be miffed if they get nation-wide, independent additional privileges before NPs get the basic ones we should already have. Make that double miffed if they don't have to knuckle under a collaborative agreement while we are still fighting to get out from under ours.

Jaclyn Engelsher June 21, 2012 7:44 PM

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    Occupation: Nurse Practitioners and NP Recruiters
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