Pharmacists’ prescribing: A hill to die for?

Issue: BCMJ, vol. 50, No. 6, July August 2008, Page 290 Editorials

The recent sitting of the BC legislature resulted in numerous legislative changes that at first glance appeared to be deep incursions into the practice of medicine, presumably in response to public pressure for improved health care access. 

This legislation should come as no surprise given the prior throne speech in which promises were made to enhance the scope of practice of existing health care professionals and expand patient access and choice of health care professionals. 

Bill 25, the Health Professions (Reg­ulatory Reform) Amendment Act, does much to enact the throne speech promises. Expediting licensing of foreign medical graduates is one of the bill’s intents, but it is dampened by a lack of BC training programs and resources. The low fruit of the legislation pertains to pharmacists’ prescribing, or as the BC College of Pharmacists prefers to call it, “adapting a prescription.”

Pharmacists have for many years been allowed to dispense drugs, “contrary to the terms of a prescription.” This allows pharmacists to substitute generic drugs and make adjustments to account for packaging, etc. A wider interpretation of the old legislation is now being contemplated. In addition, the wording of the new legislation adds the words, “renewing a prescription.” 

Far more disconcerting is another legislative change to the old act, which defined a “practitioner who is allowed to prescribe” as a person authorized to practise medicine, dentistry, podiatry, and veterinary medicine, to now also include “a class of persons prescribed by the minister.” 

In other words, the Minister of Health will now be able to authorize pharmacists to independently prescribe. Independent prescribing poses a number of concerns about pharmacists being able to make a  diagnosis. The College of Pharmacists of British Columbia has therefore wisely sidestepped this issue but is proceeding with rules pertaining to “adapting a prescription.” 

Adapting a prescription includes:
• Changing the dose formulation or regimen of a new prescription (including a new prescription for ongoing care) to enhance patient outcomes.
• Renewing a previously filled prescription for continuity of care.
• Making a therapeutic drug substitution within the same therapeutic class for a new prescription to best suit the needs of the patient. 

Pharmacists who adapt prescriptions must abide by seven fundamental elements before doing so:
• They must show individual competence. This means that pharmacists should not adapt a prescription for any patient unless they have appropriate knowledge and understanding of the condition being treated and the drug prescribed.
• Pharmacists must have appropriate information. The decision would have to withstand a test of reasonableness and the pharmacist must be able to justify the adaptation.
• Pharmacists can only adapt an existing prescription.
• Appropriateness of adaptation must be shown, and in particular, it must be shown that the adaptation is in the best interest of the patient.
• Pharmacists must obtain patient consent and explain to the patient any possible risk of an adaptation.
• The adaptation must be documented and this documentation must contain the rationale for the decision.
• Pharmacists must notify the original prescriber as soon as reasonably possible.

As you can gather from the long list of adaptation criteria, it is likely that the busy community pharmacists will think twice before renewing or adapting a prescription. If one considers that pharmacists will also incur  liability and expose themselves to a potential loss of pharmacist/physician collegiality, widespread prescription adaptation for the most part is more theoretical than practical. 

Physicians can do much to make the current legislation imperatives redundant. This includes authorizing appropriate prescription refills on the original prescription, educating patients about the purpose of and need for follow-up vi­sits, and collaborating with the patients’ pharmacist to ensure best practice.

It does not appear that this is a hill that anyone has to die for.  

Willem R. Vroom, MD. Pharmacists’ prescribing: A hill to die for?. BCMJ, Vol. 50, No. 6, July, August, 2008, Page(s) 290 - Editorials.

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