Alberta pharmacists soon will be able to write scripts
for schedule 1 meds, renew existing prescriptions and
administer vaccines. It all starts this fall under the
Pharmacists Profession Regulation Act. "The legislation
is largely structured around relationships," says Greg
Eberhart, registrar of the Alberta College of Pharmacists
(ACP). "The first thing to explicitly say is what pharmacists
can't do: prescribe controlled substances, like opiates
and barbiturates. The legislation isn't limiting with
respect to other drugs but it is limiting to the circumstances
and the framework with which a pharmacist may choose to
prescribe a drug." Alberta is the first province to pass
this kind of law and it hasn't been without controversy.
Many physicians are uneasy with the expanded scope of
practice bestowed upon their druggist colleagues. "I don't
agree with pharmacists prescribing and renewing meds without
the input of the attending MDs," says Dr David Yue, an
Edmonton FP.
The president of the Alberta Medical
Association (AMA), Dr Tzu-Kuang Lee, agrees. "Well,
obviously there are good things but there are also questions
regarding a move like this," he says. Those questions
include, who would be responsible for letting the physician
know a drug has been prescribed or changed and how soon;
who is responsible for the patient in the event of adverse
side effects; how the physician would find out the reason
why a prescription has been changed; and who is ultimately
responsible for the patient.
The ACP has been working together
with the College of Physicians and Surgeons of Alberta
(CPSA) to address physicians' reservations. Not everything
has been ironed out. "We are supportive of the collaborative
aspects of the plan and with the elements allowing pharmacists
to renew prescriptions," says Dr Bryan Ward, deputy
registrar of the CPSA. "We didn't support pharmacists
having the authority to initiate new prescriptions.
We think that in order to prescribe you need to be able
to diagnose — and we don't think pharmacists are
qualified."
A
NEW SCOPE
But pharmacists are already prescribing in a certain
sense, counters Mr Eberhart, be it recommending OTC
meds, adjusting dosages or referring patients to doctors.
With this new legislation pharmacists will be allowed
to adapt the prescription to the patients' needs —
that means adjusting the dosage, dealing with interchangeability
— and to give short-term extensions. Those who
do opt to 'really' prescribe — ie initiate treatment
— will be put on a clinical register and have to
prove they can do the job proficiently. "Those pharmacists
are going to have to demonstrate to our college that
they have fulfilled requirements that are prescribed
by our council so that we can ensure that they have
the appropriate training, experience and relationships
to perform those functions competently," he says.
Pharmacists who do write scripts
will have to work within their scope of practice and
not dole out drugs beyond the limitations of their competencies.
The prescribing will also have to focus on the needs
of patients. They're not looking to be doctors, assures
Mr Eberhart. "The purpose of this [legislation] isn't
for pharmacists to take on roles to assess and treat
conditions beyond that which they're not already trained
to assess," he adds.
A perfect example Mr Eberhart points
to is heartburn, something that pharmacists see on a
daily basis. Right now pharmacists have two options:
refer the patient to a doctor or suggest an over-the-counter
drug. "[With the new regulation] all of a sudden pharmacists
will be allowed to prescribe proton pump inhibitors,
which are the drugs of choice. They can prescribe it
and provide the appropriate monitoring," says Mr Eberhart.
WHAT
ABOUT THE DIAGNOSIS
And it's in the monitoring where some doctors' greatest
fears lie. "The new regulation states that pharmacists
can prescribe but will not diagnose," says Dr Hani Hadi,
a Calgary pediatrician. "This is counterintuitive: prescribing
medications implies that a clinical assessment has been
made." Dr Hadi's main misgivings are that pharmacists
don't have the time or diagnostic background to get
a full clinical history and physical exam. "My fear
is that this may consequently lead to the inappropriate
prescribing of medication," he says.
Dr Lee takes this one step further.
"Prescribing is only one link and trying to do it in
isolation may be problematic," he says, and fears that
the legislation might incite behaviour that may not
be conducive to good health.
Mr Eberhart acknowledges physicians'
concerns about initiating new prescriptions. "I think
right now we're seeing a lot of questions because there
is uncertainty about what this [law] means," he says.
The key to this legislation remains teamwork. "It's
about meeting the needs of the patient in a highly collaborative
environment where we respect relationships with other
health professionals and where we respect the expertise
of the pharmacist," he says.
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