Nguyen 1 The Power of Prescribing Why pharmacists should do more than dispense medications Have you ever wanted

to go straight to the pharmacy to get a certain medication but had to go through the hassle of getting a prescription from the doctor first? Well, maybe you wont have to go to the doctors first. The job of a pharmacist is to prepare medications, fill doctors prescriptions, and counsel patients about the proper use of medications (jdpower.com). Pharmacists have an in-depth knowledge of the chemistry of various drugs and how they react in humans, and also how drugs interact with each other (about.com). The schooling to become a pharmacist takes about four years of schooling and a PharmD, or doctorate of Pharmacy degree, is required. So if a pharmacist has to go through all this work and schooling, and has this extensive amount of knowledge on the medications they are dispensing, why cant they dispense them to patients without a prescription?1 Even though pharmacists do not have the background or education of a doctor, they should still be able to have the power to prescribe to patients. Prescribing Programs The FDA has proposed to create a third drug category where pharmacists are able to dispense drugs for nonprescription use. Also, with being able to dispense certain drugs, pharmacists can be of more use by recommending certain medications regarding medical results or appropriate drug therapy. If people can come into pharmacies to ask pharmacists for advice on their medical condition(s), it should make sense that a pharmacist can dispense medications needed to treat those conditions. The FDA has already given their official proposal for this predicament in the Federal Register where they go in depth

The rhetorical situation is whether or not pharmacists should be able to prescribe medications. A primary audience would be pharmacists who want more power within their field. A secondary audience would be doctors who would feel threaten by pharmacists taking some of their power away and patients who would benefit from advanced-practice pharmacists.

Nguyen 2 even in establishing a new paradigm to support how this third drug category would work. Also, a public hearing for the issue took place to get the input of interested public members. Society feeling the need to have pharmacists to have a bigger role besides just dispensing the drugs and/or medications is the social context of this issue. I believe that pharmacists should be able to dispense medications and drugs to patients because it will be more convenient and will put pharmacists more into use in the medical world. Three states have already successfully implemented a prescribing program for pharmacists that include additional education and heavy collaboration with physicians. Some countries, even the United States, already allow pharmacists to prescribe some medications. Especially in the United Kingdom, pharmacists can legally prescribe a range of medicines previously prescribed only by medical practitioners, but of course, its to a certain extent. In the United Kingdom, they progressively and highly publicized their prescribing rights to pharmacists across the country. There are already steps being taken to get pharmacists on the path to prescribing which I think will lead to bigger roles in the future. In the states within the United States that allow the practice, pharmacists prescribe with the collaboration of a specific practitioner and within a defined protocol. Personally, I think that with the limited training and education, having a practitioner by their side within a structured program makes pharmacists prescribing more reliable and reasonable. For example, in the state of Washington, pharmacists intending to prescribe must file a protocol agreement with the Washington State Board of Pharmacy and the agreement is good for up to two years. The protocol agreement must include what type of prescriptive authority decisions the pharmacists is allowed to make; the types of diseases, drugs, or drug categories involved; the general decision criteria or plan the pharmacist will follow when making decisions; and the pharmacists plans for such activities as documentation and communication with the authorizing practitioner (National Association of Boards of Pharmacy Newsletter Vol 41 #6). In the United States, there are collaborative

Nguyen 3 drug therapy management programs that exist in 75% of the states in which these programs allow qualified pharmacists working within in a defined protocol to assume responsibility for performing patient assessments, ordering laboratory tests, and selecting, initiating, monitoring, and adjusting drug regimens. This is in a very confined structure, but it shows how there are small projects letting pharmacists prescribe. Having this organization and structure will limit the mistakes made from the limited training pharmacists have and the collaboration with a specialized practitioner will make sure that what the pharmacist is doing is correct. This gives pharmacists more power and more use in the medical field besides just dispensing and consulting the drugs. Potential Problems With every idea comes its flaws and of course, this idea has its potential speed bumps. The collaborative practice environment poses many challenges with everything that it needs to be successful. Firstly, pharmacists must find a physician willing to work with them collaboratively and the physician must refer patients to the participating pharmacist. Another bump in the road is that pharmacists may find it difficult to gain access to patient medical records since they dont have that power necessarily. Documentation must be shared in a timely yet secure manner in the collaboration and pharmacists face a big challenge in being reimbursed for their non-dispensing services. According to the National Association of Boards of Pharmacy Newsletter (Vol. 41 #6), a survey of advanced-practice pharmacists in North Carolina and New Mexico said that the reimbursement is one of the largest barriers to program success. The pharmacists were well regarded and high in demand with their important services but they were getting no reimbursement from the government which is why the model of advanced-practice pharmacy wont succeed. While some physicians are all about the collaborative program with pharmacists, some are not. Some physicians perceive some aspects of advanced-practice pharmacy as threats to their authority.

Nguyen 4 Basically, they dont want to share and/or let go of their power in the medical world. But, according to an article written by Ernest Dole, Pharm.D., PhC, BCPS, FASHP, physicians usually support the idea once they understand that the arrangement is collaborative and capitalizes on each professions strengths. Especially in areas of primary care where the number of physicians is dwindling, leaving large groups of the population medically underserved and the workforce strained to the breaking point. It is obvious that the medical field needs more pharmacists to prescribe simply because there arent enough physicians to provide for the number of people needing medical attention. Advance-practice pharmacists have a deep knowledge of drugs and their impact so they have a niche in caring for patients who need to have their medication modified than patients who need an initial diagnosis according to Matthew Murawski, Ph.D., associate professor of pharmacy administration at the College of Pharmacy and Pharmaceutical Sciences at Purdue University in West Lafayette, IN. That means the idea of collaborative prescribing requires both the physician and pharmacists so the physicians authority isnt jeopardized. Other concerns include patient safety and economic incentives, particularly in a retail pharmacy setting which the pharmacists could be the prescriber and dispenser. Having pharmacists as prescribers means more people having access to patient records which to some people could make them a little uncomfortable. Establishing a pharmacy practice-wide vision of how pharmacists as prescribers fit into the overall future of health care, and how to reconcile with that vision with the visions of other health care providers, particularly other prescribers could also be a challenge to the societal mindset. We are so used to seeing pharmacists as only the dispensers of drugs and not as people we can go to actually get the medications ourselves. Lisa Nissen in her commentary discusses how pharmacist prescribers would be best placed within the health care system and what they can provide with the greatest value. A pharmacist prescribing is of great value because patients wont have to make a trip to the doctors for a prescription and then the pharmacy, they can just make one trip to the pharmacy for their medication.

Nguyen 5 Additional Information For many years, pharmacists were known as the people that carry out the message on the slip received from the doctor about what medication should be taken to treat that medical condition, but over the recent years many people have been advocating allowing pharmacists to prescribe the drugs as well, creating easier access to certain patients that need it. In a commentary by Lisa Nissen, a professor at the University of Queensland in Brisbane, Australia, she describes pharmacists as not having a core skill in prescribing but having key foundations that exist within their profession training that can help develop the skill of prescribing. In another article, C. RichardTalley, editor in chief of the American Journal of Health-System Pharmacy, believes that specific skills and credentials should be required for pharmacists to obtain the status of prescribing which is on the same idea as Nissen, but he emphasizes more on how pharmacists will need to be on the skill level of nurses or physicians. For the states successfully having pharmacists prescribe, most pharmacists are clinical pharmacists and have gone through additional education that is equivalent to that of a physician assistant. Many people assume that pharmacists prescribing could be a bad idea because they are not at the level of physicians, but if they go through the additional training and gain the proper knowledge then they are more than capable of prescribing. In Talleys article he compares practitioners to pharmacists through the Social Security Act which was trying to get pharmacists reimbursement on the federal level. He discusses how nurses and other practitioners became able to prescribe which is mainly through the Act in which those are eligible for Medicare part B payment, which pharmacists are not eligible for. According to the editorial, they have tried to amend the Act to include pharmacists but have failed multiple times. How nurse practitioners obtained provider status may be a model pharmacists should emulate to get more power in certain states. There is an either-or fallacy in his argument because he reduces that the only options for

Nguyen 6 pharmacists is to get trained to the level of nurses and practitioners or not at all whereas Nissen gives more and realistic alternatives. The act has been tried to pass for the last eight years but it has died in committee every time. The American Society of Health-System Pharmacists hopes to make progress at the state level stating that it is not necessary to wait for federal legislative breakthrough in order to make progress with other payers, such as state Medicaid programs. Pharmacists already have provider status in a number of programs, which eventually may lead to universal provider recognition. I think that if they start at the state level it can slowly flow into the federal level. Its true, the pharmacists will need something to pay them in their services and the government should be able to provide them that. Giving the pharmacists to prescribe medications to patients is what the future is calling for. I believe that having some sort of power for pharmacists to prescribe will be more beneficial than detrimental. Three states within the United States have already successfully allowed it and many more states are on their way to granting the same privileges. Even in Europe, many countries have some form of prescribing program for pharmacists. Its clear to see that it is only going to get more innovative and accepted from here. Maybe theyll add the additional education to prescribe within pharmacy programs but its too far to tell what can happen.

Nguyen 7 Works Cited Talley, C. Richard. "Prescribing Authority for Pharmacists." Prescribing Authority forPharmacists. American Journal of Health-System Pharmacy, n.d. Web. 09 Mar. 2014. <http://www.ajhp.org/content/68/24/2333>. Nissen, Lisa. "Pharmacist Prescribing: What Are the next Steps?" Pharmacist Prescribing: What Are the next Steps? American Journal of Health-System Pharmacy, n.d. Web. 09 Mar. 2014. <http://www.ajhp.org/content/68/24/2357.full.pdf%2Bhtml>. Glatter, MD Robert. "Should Pharmacists Prescribe Prescription Medications?" Forbes.Forbes Magazine, 11 May 2012. Web. 09 Mar. 2014. <http://www.forbes.com/sites/robertglatter/2012/05/11/should-pharmacists-prescribeprescription-medications/>. Santiago, Andrea. "Pharmacist Jobs - Career Overview and Prospects for Pharmacist Jobs."About.com Health Careers. About.com, n.d. Web. 09 Mar. 2014. <http://healthcareers.about.com/od/healthcareerprofiles/p/PharmacistJobs.htm>. "Summary." U.S. Bureau of Labor Statistics. U.S. Bureau of Labor Statistics, n.d. Web. 09 Mar. 2014. <http://www.bls.gov/ooh/healthcare/pharmacists.htm>. Lane, Kimberly S. "Federal Register Vol. 77, No. 39." Gpo.gov, n.d. Web. 13 Apr. 2014. <http://www.gpo.gov/fdsys/pkg/FR-2012-02-28/pdf/2012-4597.pdf>.

Nguyen 8 "Pharmacist Jobs - Career Overview and Prospects for Pharmacist Jobs." About.com Health Careers. N.p., n.d. Web. 12 Apr. 2014. <http://healthcareers.about.com/od/healthcareerprofiles/p/PharmacistJobs.htm>. "Pharmacist Prescribing: Is Collaborative Practice a Path of the Future?" - News. N.p., n.d. Web. 13 Apr. 2014. <http://www.nabp.net/news/pharmacist-prescribing-is-collaborative-practice-a-path-of-t he-future>. "Rating: Loading ... Is Prescribing the Next Step in the Evolution of Pharmacy?" ASHPInterSections RSS2. N.p., n.d. Web. 13 Apr. 2014. <http://www.ashpintersections.org/2012/05/is-prescribing-thenext-step-in-the-evolution-of-pharmacy/>. "Advanced-practice Pharmacists: Practice Characteristics and Reimbursement of Pharmacists Certified for Collaborative Clinical Practice in New Mexico and North Carolina."Advanced-practice Pharmacists: Practice Characteristics and Reimbursement of Pharmacists Certified for Collaborative Clinical Practice in New Mexico and North Carolina. N.p., n.d. Web. 13 Apr. 2014. <http://www.ajhp.org/content/68/24/2341.short>. For further information: Diigo Library