At my local Kroger grocery store there is a waiting area next to the pharmacy with a room that says Consultations. The waiting area is rarely used. There is only the occasional person whose prescription is being filled. The consultation room is generally only used for those occasions when a pharmacist administers a vaccine. It’s mostly a wasted space. There’s a saying I heard years ago that pharmacists are the most overeducated, underutilized professional in health care. They mainly supervise pharmacy techs who count pills and fill prescriptions. The consultation room could be used for so much more. In Britain, Canada and many other countries, pharmacists have more authority to dispense medications without a doctor’s permission.
Some states give pharmacists more dispensing authority than others. Kaiser Health News (KHN) wrote about an initiative in Montana. According to KHN:
Eleven states, including Montana, give pharmacists prescribing authority to some degree for medications such as birth control, naloxone, tobacco cessation products, preventive HIV drugs, and travel-related medications. The FDA has allowed pharmacists nationwide to prescribe the covid drug Paxlovid during the public health emergency.
A bill before the Montana Senate (SB 112) would expand the prescribing authority of Montana pharmacists. Montana has only one primary care physician for every 1,210 residents. Some physicians moved away, while other retired after Covid. There are counties in Montana with no primary care physician, but most at least have a pharmacy.
Supporters said the measure could help fill health care gaps in rural areas in particular, while opponents worried it would give pharmacists physician-like authority without the same education.
Who would those opponents be? It’s not like everybody would be required to consult with a pharmacist. Why expand the prescribing authority of pharmacists? Because according to a report by George Mason University’s Mercatus Center, there are approximately 228,000 primary care physicians spread across the United States. They aren’t evenly distributed. Some states have more than others. Cities have more than rural areas. Yet, even rural areas generally have pharmacies. According to the report, there are roughly 315,000 pharmacists spread across the U.S. Seniors especially visit pharmacies a lot; a lot more than they visit primary care physicians.
Pharmacists, who often work in grocery stores, “are open longer hours than most doctors’ offices, and no appointment is needed,” the authors of the Mercatus Center study wrote.
Under the bill, pharmacists could prescribe for patients who do not require a new diagnosis, for minor conditions, or in emergencies. They could not prescribe controlled substances.
In some areas of Montana patients must drive three hours to see a physician. In an emergency, pharmacists could triage patients before they are forced to travel long distances. I can see the potential for pharmacists to collaborate with doctors via telemedicine. Patients may come to the pharmacy where they consult with a pharmacist and talk to a physician on the phone to discusses their conditions.
SB 112 is modeled after a bill passed in Idaho. Tim Flynn, a pharmacist at an Albertsons grocery store in Meridian, Idaho, said the legislation lets patients be treated for minor conditions, such as urinary tract infections, when they can’t schedule a doctor’s appointment or get to an urgent care clinic.
Although a few states have expanded what pharmacists can dispense without a doctor’s prescription, it’s a patchwork of states on a piecemeal basis. Congress could pass legislation to create a consistent program across the country, allowing pharmacists to work up to the extent of their training. This could be done by creating a third class of drugs, called “behind-the-counter” drugs. Currently there are two drug classes. These are over-the-counter (OTC) and prescription drugs, sometimes called Rx drugs. The former are those drugs that are considered safe enough for consumers to self-medicate. Think Aspirin, Ibuprofen, Claritin and Prilosec, among numerous others. These were (aside from Aspirin) once prescription drugs that were switched to OTC. Rx drugs are those that can only be purchased from a pharmacy after obtaining a doctor’s prescription.
In countries such as the United Kingdom there are selected drugs that are behind the pharmacy counter. They are only accessible after a discussion with a pharmacist. For example, the drug maker applied to the FDA to have Lovastatin (for lowering cholesterol) switched from Rx to OTC status. Its application was rejected on three separate occasions. In the UK, Lovastatin is a behind-the-counter drug. After a pharmacist verifies consumers meet certain requirements, such as age 40 or above, have high cholesterol and understand the need for periodic liver enzyme tests, the pharmacist can dispense the drug.
The Consumer Healthcare Products Association, the trade association for OTC drugs, opposes the idea. They fear a risk-averse FDA would make behind the counter the de facto OTC class and stop switching Rx drugs to OTC. This is a legitimate concern. When facing tough decisions (which aren’t actually tough), bureaucrats at the FDA could easily punt and just slap drugs that should be OTC into the behind-the-counter class. Whereas OTC drugs sell for about 95% less than when they were prescription drugs, behind-the-counter drugs would likely not be as cheap. For the proposal to work, there would need to be provisions that forced the FDA to re-evaluate behind the counter drugs or (ideally) make them automatically switch to OTC unless an action is taken.
In the U.S. drugs like Sudafed are sold behind the counter to limit their use for methamphetamine and track who buys them but they aren’t technically from a third drug class. If done right a behind-the-counter class of drugs (hopefully as a step on their way to OTC status) could substantially boost patients access to care. For that matter, ramping up Rx-to-OTC drug switching would boost Americans access to care even more.