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    Should pharmacists prescribe birth control?

     

    Who’s watching for interactions?

    As Dr. Ashton mentioned, hormonal contraceptives do not come without risk. Furthermore, hormonal contraceptives carry several drug-drug, drug-food, drug-natural supplement interactions where their efficacy is reduced by CYP3A4 inducers, including phenytoin, phenobarbital, St. John’s Wart, carbamazepine, and some antibiotics, such as those in the rifamycin class. Conversely, certain drugs such as macrolide antibiotics could elevate toxicity as a result of diminished metabolism.

    Many of these interactions require additional counseling and backup contraception. Often these cases are not brought to the attention of those who prescribe the birth-control pills, a consideration that Dr. Ashton did not address.

    Furthermore, various estrogen-based contraceptives induce CYP1A2, leading to potential interactions with commonly prescribed medications such as ciprofloxacin, tizanidine, and olanzapine, all of which do not generally fall within the bailiwick or expertise of any conventional prescribers.

    Even if such prescribers were proficient in evaluating these pharmacokinetic issues, they would be far less likely to be aware of the drug combinations, particularly if, for example, an antibiotic or antifungal were prescribed by a dermatologist and the hormonal therapy by an OB/GYN.

    Having the pharmacist prescribe hormonal contraceptive will not only increase access; it will also help ensure that selection of these medications is safe and appropriately effective, and will mitigate several risks, including drug interactions.

    Study findings

    A study in Washington State evaluated the impact of pharmacists who prescribed hormonal contraceptives.18

    The study evaluated 26 community pharmacists and 214 women enrollees. Pharmacists identified women at risk of unintended pregnancy and offered to evaluate them to determine whether they could safely use oral contraceptives, contraceptive patches, or the contraceptive vaginal ring. Interested women self-administered medical and contraceptive history questionnaires.

    Pharmacists measured weight and blood pressure, and were allowed to provide hormonal contraception, including oral contraceptives, the contraceptive patch, and the contraceptive vaginal ring.

    Study interviewers followed up with women by telephone at 1-, 6-, and 12-month intervals. Of the study participants, 195 women (91%) were prescribed hormonal contraceptives by participating pharmacists. After 12 months, 70% of women responding to an interview reported continued use of hormonal contraceptives.

    This study demonstrated that pharmacists can efficiently and safely screen women for hormonal contraceptive therapy and select appropriate products. In addition, almost all respondents expressed willingness to continue to see pharmacist prescribers and to receive other services from them.

    The healthcare team

    When pharmacists are members of healthcare teams, they improve patient health and decrease costs.13

    The Community Preventive Services Task Force also found strong evidence that when a pharmacist is included on the team, team-based care can improve blood pressure control.19, 20

    Additional research has shown that when physicians and pharmacists work together using medication therapy management (MTM), patients’ chronic conditions improve.21-23

    Jeffrey Fudin, PharmD, DAAPM, FCCP, FASHP
    Jeffrey Fudin, PharmD, DAAPM, FCCP, FASHP is a clinical pharmacy specialist, Stratton V.A. Medical Center, Albany N.Y., and adjunct ...
    Lisa L. Dragic, PharmD Candidate 2016
    Lisa L. Dragic is a 2016 PharmD candidate at Temple University School of Pharmacy, Philadelphia Penn.
    Mena Raouf, PharmD Candidate 2016
    Mena Raouf is a 2016 PharmD candidate at Albany College of Pharmacy and Health Sciences, Albany, N.Y.

    12 Comments

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    • Anonymous
      Pharmacists are highly-trained, skilled healthcare professionals (or they should be). RPh's in Oregon complete 5 hours of CE training before they're allowed to go through the process with a patient leading up to the dispensing of birth control pills (BCPs). (Questionnaires, checking vital signs, etc. are involved in the process.) If, after becoming a RPh and going through the supplementary training, you still don't feel qualified to dispense BCPs...well, it reminds of the old saying, "if you can't take the heat, stay out of the kitchen." We have the knowledge-base to do many other things than dispensing and basic counseling. Utilize what you've been taught. Seek out additional information if you need to. We have an opportunity to improve the healthcare of millions of women nationwide, who otherwise would go without. We are the most accessible healthcare professionals, with 300,000 RPh's nationwide. We need to think outside the box. We need to get outside of the comfort-zone of our 4 walls. If you are truly held back by religious beliefs, you should hand the situation off to a colleague who can help the patient. Otherwise, do your job of providing the best healthcare possible for your patients. We can do at least as good of a job as FPs and GPs, who are currently the primary dispensers of BCPs.
    • Anonymous
      I cannot concur more with the last respondent on 1-31-16. The argument proposed by Jeffery Fudin is both absurd and offensive. It further fractures primary care, treats pregnancy as a disease, and lacks any basis in reality. I have worked in both the VA as a clinician and at a major chain and can tell you the difference is day and night. A clinically trained pharmacist at the VA (with prescriptive authority and clinical priviledges) could do this, but in the retail setting this is out of place.
    • KyleElwood
      Dr Jennifer Ashton's commented that the blood clot risk with hormonal therapies are one reason why pharmacists should not be prescribing hormonal birth control products. My experience does not support this. As a pharmacist, I always ask each patient who is receiving a hormonal birth control product whether their provider discussed the risk for blood clotting with them. I would estimate that at least 50% said that they did not or did not cover the issue adequately. I tell them how to recognize the symptoms of such an event and what to do about any signs that suggest it may be occurring. I also discuss phlebitis, as well. With appropriate added education for the pharmacist and if employers provide appropriate time allowances (perhaps time issues should be mandated by Board of Pharmacy)...pharmacist involvement in this area of prescribing can be successfully implemented.
    • [email protected]
      Did any pharmacist tweet Ashton back to let her know that the laughable ones are the same that correct the crap she writes everyday. Pharmacists, it's time we stand up and defend the profession. We have the most drug therapy knowledge in the healthcare field and still sit there for the others to belittle our knowledge when the PAs and the NPs they have there can't write a jack of prescription, including some of the MDs. We kiss too much ass that's why the profession is where it is now.
    • Anonymous
      I would never say pharmacists are not qualified to do this in the proper setting, but this is how it will go down. Corporate community pharmacy COLLABORATIVE practice agreements have only one goal in mind – sales and profit at any cost. Collaboration: A working practice whereby individuals work together to a common purpose to achieve business benefit. A physician signs off on a Board of Pharmacy Approved Collaborative Practice Agreement/Protocol. What does he do from then on and for what amount of compensation? The pharmacist then gets an e-mail from his employer two weeks before this goes live stating this is another mandatory pharmacy service that everyone must execute on. The email includes a link to a two hour “payroll neutral” online tutorial that takes 8 hours to complete if you really read it, and a schedule for next week where you must attend, one of two, live eight-hour payroll neutral classes on your day off. The class consists of an assistant-assistant district manager quickly reading a power point presentation and telling you that you will just incorporate this into your work flow just like any other prescription, MTM, flu/zostavax/pneumonia/hepatitis shot, cholesterol/thyroid/blood pressure test, nasal/throat strep-influenza swab, customer service satisfaction survey, and then kicks you out the door. There is never a legitimate competency test at the end. You’ll be very lucky if they then don’t say you also have to go out and beat the streets to set up and provide “payroll neutral “, “contraception clinics” on your day off at your local schools, gyms, car dealerships, and senior centers. From then on the already buried pharmacist is subjected to further increased workload, no increase in staffing or compensation, increased personal and professional risk and liability, with the only incentive being, wait for it… yet ANOTHER quota and key performance metric that they must meet to avoid being disciplined and terminated. The corporation from then on takes all the proceeds and continually states that there is no money budgeted for appropriate staffing. Why would State Boards of Pharmacy commission a pharmacist workplace survey that results in 120 pages of complaints and warnings from nearly every pharmacy survey respondent, and then approve more pharmacist prescribing while not doing a thing about existing working conditions aka patient health and safety? The survey respondents that begged the Boards in their own survey for relief from workloads and quotas (key performance metrics) never see any action even though the NABP issued a resolution against performance metrics (NABP Resolution 109-7-13) which has since been adopted by most US state boards of pharmacy. Anyone using quotas and metrics in pharmacy are therefore going against good practice standards set out by our major regulatory body, and still nothing is done. hxxp://www.doh.wa.gov/Portals/1/Documents/2300/2014/690290.pdf It is unprofessionally dumbfounding every time this naive pushing for more “prescribing” services in the retail setting is proposed and dumped on pharmacists without any mention of additional staffing and compensation requirements. This, “we can do more for even less” phenomenon always seems to come from a group of epidemiologists, or some academic type non-retail, clinical pharmacy specialist, part-time, adjunct assistant/associate professor that has one of those, “clip board in one hand and a coffee cup in the other” jobs, or the touchy feely project of a couple of Pharm.D. candidates that likely have never worked a 13-hour lone pharmacist shift in any setting. If you find yourself in pharmacy or pharmacy school wanting to do what physicians do, change programs and get yourself a heap of liability insurance and a 9-5 clinic complete with a staff of receptionists and medical assistants, see your appointments in a private exam room, perform the exams, order the labs, create a complete and ongoing patient practitioner relationship and follow-up schedule, and then send the patient’s prescription to a pharmacist for review and dispensing. More liability and work with no additional or appropriate staffing, for no extra compensation, no wonder EVERYBODY expects EVERYTHING for FREE from Pharmacy. It is a myopic bunch that is pushing for pharmacists to prescribe contraceptives, and you can be sure none of those pushing for this will ever have to perform this in the retail conditions and settings described above.
    • Anonymous
      I say let the lawmakers pass the laws to help the access and demand problems. Pharmacists are not physicians, but can do this. But board of pharmacies please see that we succeed well by requiring in-depth training that ends with a test. A hard one that ensures we both know and can do what this article just said we did. I am flat as a pancake under my current retail load and am interested how this will be incorporated. My fear is our companies herding us through an eight hour class, handing us a certificate, plastering this new service on the reader boards and giving us an extra tech hour to handle it with. I will be watching for the future article about how this rollout is going in Oregon and California. Possibly an interview with the director of Oregon's BoP about the issues they are facing in making this a reality.
    • Anonymous
      I'm in favor of BOP to have competency testing requirement before an interested pharmacist can prescribe OC. OC is just a start, it will expand to other drug classes. Retail pharmacy practice is dominated by a handful of big chains. Any pharmacies that want to have OC services need to fund to educate their pharmacists to bring their competency up to date and ensure their continuing competency. A few hours of online or correspondence courses will be insufficient. They also must provide time to practice (i.e. assessment, monitoring, follow-up...) It can't be an added duty to the daily 300 Rx. OC's are hormonal products that can do weird things to the endocrine system in individuals. We all had a cursory overview of OC pharmacology and endocrine pathophysiology in pharmacy schools. Answer for yourself, how much time did you and your professors spend on this drug class? Are you really competent enough in prescribing hormonal agents (OC) for your own loved ones (e.g. wife, child-bearing daughters or granddaughters? By the way, I am a pharmacist.
    • Anonymous
      For obvious reasons NO. The lawyers are just waiting for more liability for pharmacist. There is a reason OB/GYN's are decreasing in numbers. LIABILITY.300 scripts a day by yourself and screening for OC's. The professors have lost their minds. Ask them if they would work for a chain for 12 hours doing 300 scripts without a break and give immunizations doe MTM, and now screen for and prescribe birth control pills. Those that can, do. Those that can't, teach. Maybe I will become a lawyer.
    • Mr. HWretzel
      Prescribe BC's??? Are they nuts? As has been stated, where is the time pressured pharmacist going to perform an examination? What about undue weight gain from fluid retention? What about follow up exams for breast and uterine cancer? Blood clots? Is the pharmacist REALLY capable of determining the correct combination for the patient? What about determining what to prescribe in case of certain side effects? If the medical community is bitchin' about a shortage of doctors. why not look to the real source of the problem: the insurance companies who continuously reduce payments to healthcare providers. while. every year they report increased profits in the billions!
    • [email protected]
      I'm not sure if you are a pharmacist but those are dumb questions you are asking if pharmacists can prescribe these birth controls pills. YES we can, today's pharmacists have Pharm.D and are more therapeutically educated than PAs and NPs but these two groups do prescribe crap they don't know much about and we have to correct them every time. So don't chicken out and don't belittle pharmacists.
    • Anonymous
      The simple answer (and it's so simple that an academic will never understand it) is: NO. How can already time-challenged pharmacists take the appropriate amount of time to appropriately assess the appropriateness of this therapy and just where are they going to conduct pelvic exams? The Washington State study that's cited did not reflect real world working conditions. Also, let's not forget that dosing O/Cs is more art than science (evaluating the "femininine" characteristics of the patient to determine the estrogen/progesterone ratio to use). Finally, are you going to be happy to see your malpractice insurance premiums go from the pittance they are now to something more like an OB/Gyn pays? Don't even get me going about the drug interaction thing. Most evaluations fall victim to the "ENTER to bypass" that keystroke fatigue brings upon us. Morning-after pills? Sure. But for a pharmacist to maintain a modicum of professional standards of practice that an MD must follow would require major re-engineering of the practice site. All to fill one measley RX. Stupid, stupid, stupid...
    • Anonymous
      No, for all of the reasons listed in the previous comments. How in the world can a pharmacist in a retail setting possibly accomplish an exam? Not to mention who is going to pay for the increased liability insurance? Ironically, today's local paper featured an article about a woman who had a stroke due to OCP. I would not want to be the pharmacist responsible for that after a 2 minute consultation (which is all the time the retail corporate world would budget). As a previous poster remarked- only someone in the academic world who has never worked a retail job/ had liability insurance would think this was a good idea. I did NOT go to medical school, I went to pharmacy school and as such I'm not compensated or trained for this kind of prescribing.