[e-drug] prescribing and dispensing in one hand?

e-drug
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E-DRUG: prescribing and dispensing in one hand?
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Dear E-druggers,

There may be not many of us who complete a pharmacy degree and combine the
same with medical school (plus of course are in a position to also fulfil
the post-graduate obligations coming with using the diplomas). But for those who do, it can pose an interesting situation where authorities may be
challenged to grant or refuse licensing.

In a legislation project we were confronted with the scenario of a medical
doctor who happens to be graduated as a pharmacist as well. Now he likes to
practice medicine and open a pharmacy in country X. Should legislation
prohibit this as it may (easily) lead to supplier-induced demand/use of
medicines not in the interest of the patient, or in other words:

should pharmacy law state that prescribers are not allowed to have any
(commercial) linkage with the dispensing of medicines, segregate prescribing and dispensing? Is it always feasible?

We have found a bit of jurisdiction on it, but not much so far. Obviously we would not like to ignore the possible add-on effect of such a person, but have been reaching a conclusion as yet.

What are other countries experiences or solutions in terms of legislation
and pharmacy licensing?

hope to hear soon,

Pascal Verhoeven
Pharmacist
The Netherlands
verhoeven.pascal@gmail.com

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Dear E-druggers,

An interesting situation indeed. But then in a number of countries physicians are allowed to dispense where there are no nearby pharmacies. I believe in the UK this is still exists. In many developing countries where physicians are practising in area where the nearest pharmacy may be 5 to 10 km away, such clinicians maitain a well stocked "dispensing facility" which the clician, a nurse or another assistant would be dispensing. However, when
reveiwing the laws governing the practice of pharmacy they clearly state
that dispensing of prescription only medicine, contolled medicines and
narcotics must be done by the pharmacist and that the pharmacy can only be
opened in the PHYSICAL PRESENCE of the pharmacist. It is practically
impossible to be in 2 activities at the same time. In Oman the law
categorically prohibits a pharmacist to manage or run a medical clinic at
the same time s/he manages a pharmacy.

Ph. Qasim Ahmed Al Riyami
Assistant Dean for Training
College of Pharmacy & Nursing
University of Nizwa
P.O.Box 33 PC 616 Birket al Mouz; Nizwa
Oman
email: karafuu@gmail.com & qasim@unizwa.edu.om
tel: + 968 2544 6420

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E-DRUG: Prescribing and dispensing in one hand? (5)
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You are being too suspicious chasing an issue that does not exist (generally speaking). Pharmacists' passion to protect their patch is usually behind this sort of accusation.

In Australia there are around 100 doctors who have a license to dispense and supply medicines listed on the government pharmaceutical benefits scheme and this has never been raised as a problem.

The suggestion that doctors could create "supplier-induced demand/use of medicines not in the interest of the patient" can be equally levelled at pharmacist proprietors who buy product from manufacturer with sizeable inducements ranging from luxury holidays to a set of golf clubs to sell a particular range of proprietary medicines that does not have evidence based research to back up the benefit it can be to a patient.

How often does a pharmacist business owner tell the patient to go home and have a good rest because they do not need a proprietary medicine or for that matter a prescribed medication?

I suggest if you are going to question a doctor's ethics in owning a pharmacy business you do it after you are satisfied that the existing models of pharmacy ownership are in the best interest of the patient. As readers will know in many developed countries a pharmacist is required by legislation to own a business rather than a non-pharmacist. Surely this can lead to supply induced sale of medicines brought on by high stock levels purchased by the owner with valuable incentives as the reward.

Rollo Manning
Darwin NT Australia
E-mail: rollom@iinet.net.au

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E-DRUG: Prescribing and dispensing in one hand? (5)
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Respected E-druggers,

The situation in smaller countries with tougher laws is different.in India
80% of population spend money on healthcare out of their pockets. Health
insurance penetration is hardly 1.5%.

At every one of the half a million retail pharmacies you can buy the drugs
you require without any prescription. Tourists visiting GOA beaches buy lots
of proprietary medicines to take them home to get back travel costs.

In the name of creating access to drugs our state government officials give
out licenses and are paid off not to check pharmacist presence. Every doctor
having 4-5 beds has his own pharmacy albeit in alibi to recover entire
establishment expenses and to sell off the physician samples received.
Pharma and chemicals ministry wants to conduct a 45 day pro gramme for non
pharmacists manning the pharmacies, but health ministry says no. The drug
controller genarel of India comes under health ministry is responsible as he
heads a team of state drug controllers to ensure pharmacist presence in
retail pharmacies does not bother about it. The health ministry is yet to
recognize pharmacy as health profession. The education system is geared to
the needs of Industry. The community pharmacy division is barely six years
old in the mighty Indian Pharmaceutical association.

Nearly 20 mio people visit their nearest pharmacy to buy curative drugs from
people who do not have formal education either in pharmacy or medicine. Iam
trying to fight the situation by lighting a small lamp in the sea of
darkness through my fortnightly publication.Recently WHO india in
association of SEARPHARM FORUM conducted one day national conference on
Role of pharmacists in health care- challenges and opportunities- for a copy
of report pl mail me.

Members who wish to offer solutions to myriad problems facing India are
invited to work together.The Doctor has to perform the duties of pharmacist
and physician assistant.

Regards

Bhava Narayana
Editor
pharmed Trade News

--
Read Pharmed Online At
http://www.issuu.com/bhava

V.BHAVA NARAYANA
EDITOR&PUBLISHER
PHARMED TRADE NEWS
3-3-62A,NEW GOKHALE NAGAR
RAMNTHAPUR. HYDERABAD 500 013
INDIA
TEL 91-04027030681 MO 91-98495-51183
EMAIL pharmedtradenews@gmail.com
URL www.pharmedtradenews.com

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E-druggers,

I wish to provide my own two pence view on the issue of registered
pharmacist/physician going ahead to study medicine/pharmacy as well, and at
the same time wanting to practice both. Do I get it correct? In my view this poses a serious question of conflict of interest. I was taught during my pharmacy study days that there is clear seperation of roles between
prescribing and dispensing: one checks the other and in this way they work
together for the benefit of the patient - obviously to avoid mistakes,
especially in crouded clinical unit settings like we have in africa.

What I suspect can be acceptable is that such a person will choose to
practice either profession one at a time, perhaps deciding to practice
pharmacy this year and medicine the next year. In Uganda I have only seen
this year a couple of candidates who qualified in medicine enrolling for a
degree in pharmacy. I sense that we might see this happening the other way
around in the coming years. And I think it will be easier for the pharmacist since he/she will be earning as a ommunity pharmacy supervisor as he/she reads!

Let me at this early time add another point to this what I gues will turn
out to be seriouss and interesting discussion. I have seen nurses opting to
study medicine and qualifying to practice medicine. This to my recollection, has not raised any eyebrows at all. Is it because they are probably doing the SAME thing and yet they are supposed to be different professions? Is it acceptable that one practices nursing as well as practing medicine?

Richard Odoi Adome
Uganda
E-mail: rodoi@med.mak.ac.ug

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Hi all,

Pascal Verhoeven has raised an interesting side issue to the larger question of the desirability of separating prescribing and dispensing.

There is some empiric evidence for the policy stance that favours separation - see, for example, the abstract below from Birna Traps's work in Zimbabwe. This stance is standard WHO fare, and was also promoted at the Second International Conference on Improving Use of Medicines (ICIUM 2004) - "Although challenging, policies to separate prescribing and dispensing are feasible to implement and can result in lower costs to consumers and programmes and improved use of medicines" - http://mednet3.who.int/icium/icium2004/Documents/ICIUM2004PolicyAndProgrammeRecommendations.doc.

In South Africa, the 1996 National Drug Policy also included a clear policy statement: "Only practitioners who are registered with the relevant Council and premises that are registered and/or licensed in terms of the Medicines and Related Substances Control Act (No 101 of 1965) may be used for the manufacture, supply and dispensing of drugs. Medical practitioners and nurses will not be permitted to dispense drugs, except where separate pharmaceutical services are not available. In such instances/situations where dispensing by doctors and nurses has to take place, such persons will be in possession of a dispensing licence issued by the Medicine Control Council. Criteria for the granting of such licences will include inter alia, the application of geographical limits. Special concessions will be granted with regard to certain categories of providers such as occupational health services.. Proven competency of such persons to dispense drugs will be by virtue of the successful completion of a suitable training programme. All licences will be reviewed and renewed annually. These inspection functions will be delegated to the provinces."

This was codified in law, but immediately challenged by the medical profession. Finally, in 2005 the Constitutional Court struck down the "need" elements of the Regulations (in "The Affordable Medicines Trust v the Minister of Health and Others 2005 JOL 13932 (CC)"). As a result, medical practitioners and nurses have to complete a supplementary training course and apply for a dispensing licence, but all such applications are approved. There are currently about 8500 licensed dispensing practitioners (prescribers) in South Africa, and around 2400 community pharmacies in the private sector. In the public sector, almost all dispensing at clinics is done by nurses, in terms of a permit issued by a medical officer.

There is one more remnant of the policy in the Regulations governing the ownership of various types of pharmacies. Both community pharmacies and institutional (hospital) pharmacies in the private sector may not be owned by "an authorised prescriber". The legal construct runs along these lines: "Any person may .... own or have a beneficial interest in a community pharmacy in the Republic, on condition that such a person or in the case of a body corporate, the shareholder, director, trustee, beneficiary or member, as the case may be, of a body corporate .....is not an authorised prescriber".

However, where a single person holds both registrations - as a pharmacist and a medical practitioner (hence, prescriber) - then the regulatory authorities have allowed exceptions, provided that the person only practises one profession at any given time or place. A combined practice has not been allowed.

For details of SA law, visit the Medicines Control Council web site at http://www.mccza.com and the SA Pharmacy Council at http://www.pharmcouncil.co.za/

regards
Andy

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E-DRUG: Prescribing and dispensing in one hand? (9)
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Dear colleagues,

The situation in Nigeria is more or less the same.Majority of patients still pay out of pocket for health care. Most doctors in private practice have their own pharmacies and the patients are expected to buy their medications there.Since consultation fees is small, they try to compensate with profits made from the sale of drugs.

Despite efforts being made by regulatory authorities,we still have a long way to go.I think a wider spread of health insurance will solve some of these problems but we need enforcement of the regulations and education of all stakeholders.
   
Joseph Fadare
Physician/Clinical Pharmacologist
Nigeria
E-mail: dokita007@yahoo.com

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There is another angle to this discussion. Should pharmacy and dentistry training become post graduate degree speciliazations after undergraduate qualifications in medicine, in the same line with other medical specialities like paediatrics, surgery, obstetrics/gynaecology? Sounds like it would be relevant for clinical pharmacy/therapeutics , but not for other pharmacy subspecialities. Just another twist to the discussion
   
Atieno Ojoo
Technical specialist, Pharmaceuticals, UNICEF
E-mail: atisojoo@yahoo.co.uk

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I will also recommend E-druggers interested in this topic to search
E-drug archives using 'dispensing doctors' as search words. There is a
lot of information there, I have copied one of the messages, from
Richard Laing, below.

As Foppe says the Nordic countries have had dispensing doctors (DD) in
remote areas. They have been closely monitored and were only allowed a
small profit on the medicines. The law has been clear on separating
prescribing from dispensing so the DDs have only been allowed on an
individual basis. In Sweden, where the pharmacy sector is being
liberalised this year, I have been surprised to see that some
politicians, and of course the doctors, want to allow dispensing
doctors.

Some years ago Japan separated the two functions because of the high
cost of medicines and prices went down. South Korea also separated the
two functions, causing huge protests from doctors (initiated a strike).

Some of the medicine price studies done using the WHO/HAI methodology
have included survey of DDs and shown how negative it is on selection
and price (www.haiweb.org/medicineprices).

Here is Richard's message from 2003:

E-drug: Dispensing Doctors Monitor article
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E-Druggers have discussed in the past the issue of dispensing
doctors and rational drug use. There are 78 messages in the E-Drug
archives.

But I would like to draw to your attention the brief article in the
most recent Essential Drugs Monitor: "Dispensing prescribers - a threat to
appropriate medicines use?" Birna Trap, Ebba Holme Hansen. The
authors describe a comparative survey of prescribing by a group of
dispensing and a group of non-dispensing doctors in Harare,
Zimbabwe. The study identified major differences between the two
groups, with dispensing doctors prescribing significantly more
medicines, including antibiotics and injections, per patient than the
non-dispensing doctors.

To download the article using getweb send a message to
getweb@healthnet.org, leave the subject line blank and in the
message section write:

Begin
get http://www.who.int/medicines/mon/32_4.pdf
end

There is a longer article which is in Health Policy and Planning. The
url for this site is
http://heapol.oupjournals.org/cgi/reprint/17/3/288.pdf

Getweb does not work as the site requires signing in but as I think
Health Policy and Planning is one of the journals that makes its
articles available in developing countries you may be able to
download the article. If you cannot and are particularly interested in
the topic please e-mail me and I will send you a copy.

I think that this is an important topic with serious policy
implications.
The study looked at the many factors that could have been
associated with the dispensing doctors prescribing more drugs, more
injections more antibiotics and more mixtures. But at the end of the
day the authors concluded that being paid for dispensing affected
prescribing. This is consistent across all studies that I know of.

If this is the case, does it make sense to allow doctors to dispense if
there are pharmacies available to do the dispensing. If there are no
pharmacies available then should doctors be precluded from adding a
mark-up to the drugs and be limited to either charging cost price or at
most charging a fixed dispensing fee that does not change
irrespective of the numbers or cost of the drugs prescribed. If this is
not done the incentives are to the doctor to over prescribe.

The reverse issue also arises. What about prescribing dispensers?
Clearly pharmacists play an important role in advising about OTC
preparations but what happens when they "advise" on the purchase
of prescription medicines. I suspect that they will also be motivated by
potential profits to advise inappropriately.

My conclusion is that there are good reasons for the separation of
prescribing and dispensing functions. The challenge is to find
effective ways to enforce such a policy.

Richard Laing (Medical Officer)
Policy, Access and Rational Use
Essential Drugs and Medicines Policy
World Health Organization
CH-1211 Geneva 27, Switzerland
Tel 41 22 791 4533
Fax 41 22791 4167
E-mail laingr@who.int

Access Essential Drugs Monitor #32 at
http://www.who.int/medicines/mon/mon32.shtml

Kirsten Myhr
RELIS drug info&pharmacovigilance centre
Oslo, Norway
myhr@online.no

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Hi E-Druggers,

Here we are talking about dispensing doctors, but what about this new drive
towards prescribing pharmacists in the UK and US? I know there are
dispensing nurses but is there not a very real danger that the removal of
the separation of functions will destroy the pharmacy profession. Who will
take up the checking role? Will it be delegated to clinically competent
technicians? Why not then just make pharmacy diploma qualification?

If as a pharmacist I am able to supply any drug that a patient needs why
will I behave more ethically than a dispensing doctor? I am imagining the
scenario in which the prescribing pharmacist's employee (technician or
pharmacist) dispenses what he prescribes.

Regards,

Paul Lobb
Unaffiliated non-practising pharmacist (Zimbabwe)
E-mail: paul.lobb@gmail.com

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Hello all,

As a response to Paul Lobb's remark about the prescribing pharmacist: I am
not so sure that is a good idea either. But in the UK setting this
pharmacist prescribing seems to be fully protocolised and controlled in a
sense that the pharmacist is an extension of the doctors' hand. But there
also is a fundamental difference between diagnosing, prescribing and
dispensing. Doctors have usually not been educated to prescribe either
(perhaps only clinical pharmacologists have), but to diagnose.

Pharmacist do 'prescribe' in OTC, and especially in that field you see a lot
of unethical practices for often you see the too much and too expensive
syndrome. So, there indeed are certain things that pharmacists should not be
allowed to do either.

So, imho, we need to separate the two professional activities as much as
possible: Doctors diagnose, Pharmacist dispense (in the true meaning of the
word, the right drug for the right patient with the right information etc.).
That is what we both have been educated to do.

And what should be prescribed is a different discussion, that should be held
in the triangle patient, doctor and pharmacist.

Best regards,

Foppe van Mil
Pharmacy Practice Consultant
jwfvmil@planet.nl
The Netherlands

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E-DRUG: Stories on giving medicines to children
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Dear colleagues
   
Many times, including in this forum, we have discussed the challenges of not having age appropriate formulations of medicines for children, or not having dose administration devices, especially in developing countries. We have managed to express these challenges in the abstract, making reference to experiences.
   
I would like to bring in another angle to this discussion-that of our own personal experiences as parents, guardians, caregivers and health professionals.
   
As a parent/guardian/caregiver to a child, or having been a parent/guardian/caregiver to a child, it is likely that you will have given that child some form of medicine or observed the child being administered medicine by someone else.
   
I would like to capture stories on the good times when children took medicines with ease and the challenging times when children had difficulty taking medicines, whether it is by mouth, injection or other routes of administriation. What made it so good or what made it so difficult?
   
Would you be so kind as to share your real stories with me via email? Feel free to share experiences from older children, including adolescents too.
   
This is part of a collection to try and understand more the real end user challenges that are related to the lack of appropriate formulations of medicines for children or lack of devices for administration of medicine.
   
I would recommend that you reply specifically to me. Do not click reply as it will go to all,unless you want to.
   
Look forward to hearing from you soon
   
Atieno Ojoo, BPharm, MPH
Technical Specialist, Pharmaceuticals
Unicef Supply Division
Unicef Plads, Freeport
2100 Copenhagen
Denmark
Tel: +45 35 27 31 03
Fax: +45 35 26 94 21
aojoo@unicef.org
atisojoo@yahoo.co.uk
www.unicef.org/supply

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E-DRUG: Stories on giving medicines to children (2)
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Dear colleagues
  As a follow up to the message I posted on 25th April regarding your personal stories on the good and not-so-good experience with giving medicines to children, I wish to report that, so far, the response has been an overwhelming and deafening silence.
   
  This brings me to ask the next set of questions: Is this issue of lack of age appropriate medicines for children really an issue? So what if there are no age-appropriate formulations for children? are the adaptive and coping mechanisms working well? Is this really a problem at the end-user level? Sounds like its not! Just thinking loudly.
   
I welcome any response from those with experience and/or ideas.
  
Atieno Ojoo
  Unicef Supply Division
  Unite for Children
Atieno Ojoo <atisojoo@yahoo.co.uk>

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Dear Atieno,

It is disappointing that Atieno has not had any response to her call to
share experiences, thereby enabling learning from the daily challenges
experienced by those with direct responsibility for the care of sick
children.

Common sense argues that that the needs of children and their carers are not
well-served at present. We need to know about the gaps in provision of
usable formulations (and diagnostics), equipment (eg spacers for asthma
inhalers etc). What has changed for the better in recent times (eg FDCs),
and what is still needed?

This is such an important issue; it should not be allowed to fade out as it
will open the door to changing people's overall understanding of the need
for a culture of awareness of end-use issues, and all steps leading to this
(R&D, pricing/procurement, supply chain issues, training and rational use).

Even though people are extremely busy and don't always have time to focus on
additional tasks that are not part of the daily round of duties, lets hope
some will be able to respond.

Best wishes,
Philippa Saunders
UK
"Essential Drugs Project" <edp@gn.apc.org>

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Hi Atieno,

Personal experience : my daughter, who is now in her late twenties, has
never been able to swallow a tablet. I have always had to crush them
between two teaspoons and mix them with something fluid. She still can't
swallow tablets and continues to crush them herself even though she is now
an adult.

Giving her and her brother liquid medicine when they were babies was of
course always difficult as they would spit it out and I could never be sure
of whether they had taken the right dose or not.

Regina Hardardottir
H.R. Assistant
UNICEF Supply Division Copenhagen
Tel.: (+45) 35 27 32 15
Fax: (+45) 35 27 32 88
E-mail: rhardardottir@unicef.org

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Dear Atieno

We encountered problems with spironolacton oral solutions for children;
probably because of the infrequent need and therefore individual
preparation, concentration and labeling of the mixture is not always clear
which results in errors.

And of course the bad taste of the erythromycine oral solution hampers a
smooth administration.

Best wishes
Naomi Jessurun

Pharm D, hospital pharmacist
Pharmacovigilance coordinator Suriname

Academic Hospital Paramaribo
Flustraat 1 Paramaribo Suriname
E: hospitalpharmacy@azp.sr T: (597) 442222 ext 376
www.azp.sr
"N.T.Jessurun" <hospitalpharmacy@azp.sr>

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In Norway, where common bacterial infections in children are still
sensitive to phenoxymethylpenicillin, the doctors find the the bad taste
of the suspension or drops to be an obstacle to rational prescribing.
Therefore they sometimes write prescriptions for less suitable
alternatives, e.g. cephalexin (claimed to be the one with the best
taste). May be this is also driven by parents being less willing to try
ways of making the child accept the preferred choice
(phenoxymethylpenicillin) by e.g. put drops on a slice of bread with
jam.

Obviously, there is no incentive for pharmaceutical companies to try and
improve formulations!

Kirsten

Ms Kirsten Myhr, MScPharm, MPH
Head
RELIS Drug Info and Pharmacovigilance Centre
Ulleval University Hospital
0407 OSLO, Norway
Tel: +47 23 01 64 11 Fax: +47 23 01 64 10
myhr@online.no