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    Should pharmacists prescribe birth control?

     

    A clear need

    It is evident that there is a clear need for interprofessional collaboration to optimize patient care.

    Pharmacists will not replace physicians. Pharmacists work with patients to manage medications and triage them for required physician intervention.

    As stated in Oregon’s House Bill 2879 Section C, pharmacists will “[r]efer the patient to the patient’s primary care practitioner or women’s health care practitioner upon prescribing and dispensing the hormonal contraceptive patch or self-administered oral hormonal contraceptive.”

    Through team-based care and collaboration, physicians and pharmacists can and should work together toward the common goal of improved patient outcomes by the provision of quality pharmaceutical care.

    Jeffrey Fudin, PharmD, DAAPM, FCCP, FASHP is a clinical pharmacy specialist, Stratton V.A. Medical Center, Albany N.Y., and adjunct associate professor, Western New England University College of Pharmacy and Albany College of Pharmacy and health Sciences. He is an adjunct assistant professor, University of Connecticut School of Pharmacy. He is owner and managing editor of PainDr.com. He has no relevant disclosures for this topic. Contact him at [email protected].

    Lisa L. Dragic is a 2016 PharmD candidate at Temple University School of Pharmacy, Philadelphia Penn.

    Mena Raouf is a 2016 PharmD candidate at Albany College of Pharmacy and Health Sciences, Albany, N.Y.

    This commentary is the sole opinion of the authors and does not reflect the opinion of employers or employee affiliates. It was not prepared as part of Dr. Fudin’s official government duties as clinical pharmacy specialist.

    References

    1.     ABC News. Good Morning America. “Over-the-Counter Birth Control Available in Oregon, California to Follow.” January 2016. http://abcnews.go.com/GMA/video/counter-birth-control-oregon-california-follow-36077886. Accessed January 12, 2016.

    2.     Olis.leg.state.or.us. 2015. https://olis.leg.state.or.us/liz/2015r1/downloads/measuredocument/hb2879. Accessed January 12, 2016.

    3.     Colwill JM, Cultice JM, Kruse RI. “Will Generalist Physician Supply Meet Demands of an Increasing and Aging Population?” Health Affairs 27, no. 3 (2008):w232–w241.

    4.     Department of Professional Employees. “Pharmacists and Pharmacy Technicians: Facts and Figures.” 2014. http://dpeaflcio.org/programs-publications/issue-fact-sheets/pharmacists-and-pharmacy-technicians-facts-and-figures/. Accessed January 12, 2016.

    5.     Healthline News. “California to Let Pharmacists Prescribe Birth Control Pills.” June 2015. http://www.healthline.com/health-news/california-to-let-pharmacists-prescribe-birth-control-pills-062615. Accessed January 12, 2016.

    6.     Cdc.gov. Unintended Pregnancy Prevention | Unintended Pregnancy | Reproductive Health | CDC. 2016. http://www.cdc.gov/reproductivehealth/unintendedpregnancy/. Accessed January 12, 2016. Accessed January 12, 2016.

    7.      Acog.org. Over-the-Counter Access to Oral Contraceptives - ACOG. 2016. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Over-the-Counter-Access-to-Oral-Contraceptives. Accessed January 12, 2016.

    8.     Zeldis JB., et al. "STEPS: A comprehensive program for controlling and monitoring access to thalidomide." Clin Ther 21.2(1999):319–330.

    9.     Uhl K, Trontell A, Kennedy D. "Risk minimization practices for pregnancy prevention: understanding risk, selecting tools." Pharmacoepidemiology and Drug Safety. 16.3(2007):337–348.

    10.  Honein MA, Lindstrom JA, and Kweder SL. "Can We Ensure the Safe Use of Known Human Teratogens?" Drug Safety. 30.1(2007):5–15.

    11.  Cragan JD, et al. "Ensuring the safe and effective use of medications during pregnancy: Planning and prevention through preconception care." Maternal and Child Health Journal. 10.1(2006):129–135.

    12.  Di Pietro NA, Bright DR. "Medication therapy management and preconception care: opportunities for pharmacist intervention." Innovations in Pharmacy. 2014, Vol. 5, No. 1, Article 141. http://z.umn.edu/INNOVATIONS.

    13.  Chisholm-Burns MA, Kim Lee J, Spivey CA et al. “US pharmacists' effect as team members on patient care: systematic review and meta-analyses.” Med Care. 2010 Oct;48(10):923-33.

    14.  Van Wijk BL, Klungel OH, Heerdink ER, et al. “Effectiveness of interventions by community pharmacists to improve patient adherence to chronic medication: A systematic review.” Annals of Pharmacotherapy. 2005;39:319−28.

    15.  Steyer TE, Ragucci KR, Pearson WS et al. “The role of pharmacists in the delivery of influenza vaccinations.” (2004) Vaccine, 22(8),1001-1006.doi:10.1016/j.vaccine.2003.08.045.

    16.  Bpsweb.org. BPS Specialties | Board of Pharmacy Specialties. 2016. http://www.bpsweb.org/bps-specialties/. Accessed January 12, 2016.

    17.  Fudin J. “Nobody Knows.” December 2015.  http://paindr.com/nobody-knows/. Accessed January 12, 2016.

    18.  Gardner JS, Miller L, Downing DF, et al. “Pharmacist prescribing of hormonal contraceptives: Results of the Direct Access study.” J Am Pharm Assoc. (2003) 2008;48:212–26.

    19.  Community Preventive Services Task Force. “Team-Based Care to Improve Blood Pressure Control.” July 2014. http://www.thecommunityguide.org/cvd/cvd-AJPM-recs-team-based-care.pdf

    20.  Carter BL, Rogers M, Daly J, et al. “The potency of team-based care interventions for hypertension: A meta-analysis.” Archives of Internal Medicine. 2009;169:1748−55.

    21.  Odum L, Whaley-Connell A. “The role of team-based care involving pharmacists to improve cardiovascular and renal outcomes.” Cardiorenal Medicine. 2012;2:243−50.

    22.  Centers for Disease Control and Prevention. Collaborative Practice Agreements and Pharmacists’ Patient Care Services: A Resource for Pharmacists. Atlanta, Ga.: US Dept. of Health and Human Services, Centers for Disease Control and Prevention; 2013.

    23.  Carter BL, Ardery G, Dawson JD et al. “Physician and pharmacist collaboration to improve blood pressure control.” Arch Int Med. 2009;169:1996−2002.

    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.