Just Ask Your Pharmacist?

The notion of behind-the-counter drugs that could be sold without a prescription but only by directly consulting with a pharmacist has been tossed around quite a bit by the FDA lately. It's an interesting and somewhat controversial proposition, and apparently the FDA isn't "ready to make any kind of decision."

The AMA is openly opposed to the plan, saying that pharmacists will not necessarily have the required information to do what amounts to prescribing medication. And, in certain contexts, they're right.

One thing that puzzles me is which drugs, exactly, are being proposed to be made "behind-the-counter" (or BTC for short). Some suggestions from the Forbes article include varenicline, Pfizer's new blockbuster smoking cessation drug, the antiviral drug oseltamivir, and cholesterol-lowering statins.

What the hell are they thinking?

There's already a precedent for BTC drugs; pseudoephedrine. America's favorite cure-all for cold symptoms has been behind the counter for some time now to combat methamphetamine production. Many pharmacists have used this as an opportunity to provide additional counseling to patients wishing to purchase pseudoephedrine products, making sure that there are no reasons the patient should avoid PSE or that another product might not suit the patient better. I've discouraged many patients from purchasing PSE in favor of other treatments for cold symptoms in cases when PSE would've been unhelpful, an opportunity I might not have had if PSE were still on the pharmacy floor. And Plan B is essentially a BTC drug, too.

Varenicline makes a little bit of sense, but giving community pharmacists the power to dispense antibiotics or antivirals without a prescription would be a nightmare. Patients would be rushing the counter at all hours, ignorant of the growing problem of antibiotic resistance and demanding amoxicillin every time they sneezed. Pharmacists would be ridiculously overloaded and unable to handle the demand. What's more, most pharmacists only have minimal training in diagnosis and are unable to order lab tests. It isn't our job to diagnose illnesses; it's our job to design, review, and optimize drug therapy. The AMA is right when they say pharmacists shouldn't be throwing around statins any more than statins should be over-the-counter (which has been suggested). Who's going to make sure patients taking statins get regular liver function tests if they can just walk into the drugstore and buy a box of Lipitor on a whim?

I don't object to the idea of BTC drugs, but if the NCPA is going to push for BTC, it needs to have a very clear idea of what it wants to accomplish. Many drugs would be inappropriate for pharmacists to dispense without proper communication between the dispensing pharmacist and the patient's primary care physician. This basically rules out any drug that is taken long-term for chronic conditions. No meds for diabetes, high blood pressure, hypothyroidism, osteoporosis, asthma...the list could go on.

So what could a pharmacist conceivably dispense as a BTC? We're basically looking at short-term therapies. Painkillers? Absolutely not; your corner drugstore would be full of drug seekers from dawn to dusk. Non-narcotic migraine medications like Imitrex could be okay. Oral contraceptives could be a good idea. Anti-nausea drugs like promethazine would be reasonable, but treating symptoms like nausea without investigating their cause is potentially dangerous. But all of these drugs have side-effects, interactions, and contraindications. Pharmacists would have to be very careful to conduct thorough patient evaluations to prevent irrational overprescribing of drugs--which is already a problem with patients who see multiple doctors. Imagine having to factor in multiple pharmacists. Most pharmacists are already sufficiently troubled by patients who won't use the same pharmacy for every fill. And would Corner Drugstore really give pharmacists the time and staff that they'd require to conduct the patient evaluations that they would need to dispense these medications responsibly?

The jury is still out.