Pharmacists Take Their Place on the Care Team

March-April 2018


Editor's Note: Lucinda L. Maine, PhD, RPh, is the executive vice president and chief executive officer of the American Association of Colleges of Pharmacy, the national organization representing pharmacy education in the United States. Pharmacy is the third-largest health profession, after nursing and medicine, with more than 300,000 clinicians practicing in community pharmacies, hospitals and many other health care settings.

Health Progress: First, tell us a little bit about your background and the American Association of Colleges of Pharmacy — and its role in the pharmacy profession.

Lucinda Maine: I assumed my position as executive vice president and CEO of AACP in July 2002. Prior to that time, I had been in senior leadership for the American Pharmacists Association (APhA) for 10 years and had also served in academic positions at the University of Minnesota and at Samford University [in Birmingham, Alabama]. It was the perfect melding of my professional experience — half in academia and half in association management.

AACP has been laser-focused on the continuous evolution of pharmacy education since 1900, when we were established as a stand-alone organization. Our most significant effort recently was helping our members complete the transition that resulted in all our graduates entering practice with doctoral-level preparation (PharmD graduates). We are the home of both faculty and administrators and serve both institutions and individuals with our programs and services. Our major annual gathering is our annual meeting, which now attracts over 2,000 participants annually.

How has the education of pharmacists changed over the last decade or so?
Pharmacy programs graduated students with a hodgepodge of degrees early in the 20th century. For that reason, AACP joined forces with APhA and the National Association of Boards of Pharmacy 80-plus years ago to create an independent accrediting body to oversee quality assurance in our programs of education. For the rest of the 20th century, that was the bachelor's degree, but there was much debate for almost 50 years that the Bachelor of Science was insufficient to equip contemporary graduates to serve as the medication-use experts in health care. Finally, consensus was reached in the early 1990s that all graduates needed to enter practice with the doctoral level of education. Expanding both the didactic and experiential education of pharmacy graduates has helped insure that our practitioners enter practice as patient-centered, team-ready clinicians.

The most significant change in the last decade or so is the expansion of interprofessional education for pharmacy, medicine, nursing and other disciplines. It is now a requirement for most of our accreditation agencies. This reflects the need for team-based care in practice in all settings of care.

What kind of training and education are pharmacists receiving in terms of painkiller meds — or meds in general?
The pharmacotherapeutics of pain management is a core component of PharmD education. That said, it is integrated into a wide range of courses/modules, so it is hard to quantify hours of coverage. In addition to understanding the role of pain management in acute and chronic illness, it is important for pharmacy graduates to understand the ethical, legal and communications issues associated with pain and its treatment.

With all the concerns about the opioid crisis, it doesn't seem like pharmacists are the go-to people for the media. Why is that? Why don't the media naturally gravitate toward the men and women who really serve as the natural gatekeepers for prescriptions?
The opioid crisis has SO many components that sorting out the optimal role for pharmacists is a bit challenging. Pharmacists dislike feeling like "drug police," especially because there are many patients with legitimate pain issues that need effective treatment. The role of pharmacists includes effectively managing initial quantities of opioids to prevent overuse and diversion; helping people titrate off opioids to other pain treatments, including over-the-counter products; assisting with drug takeback efforts; and promoting community education from elementary through senior adult populations. There is a lot of evidence that our profession has stepped up to the plate, but there is so much more to do.

One of the biggest changes in the profession is the expanded role of pharmacists as an integral part of the overall primary care team. Can you elaborate on that, talk a little bit about how it works and perhaps look to the future?
The most rapidly growing opportunity for pharmacists is work inside ambulatory care clinics where the monitoring and management of patients with one or more chronic conditions occurs in both public (veterans health care) and private-sector health systems. There is also an exciting project ending in early 2018 that has specifically studied how best to integrate pharmacists into private physicians' office practices. Wherever there are patients with one or more chronic conditions treated by medications, there ideally is a pharmacist who can collect information about how the person's current medication therapy is controlling their conditions (e.g., diabetes, hypertension, arthritis); make recommendations for modifications in therapy; and provide education to the patient to encourage adherence and changes in lifestyle as appropriate. This model of integration introduces efficiencies in primary care for other clinicians. It also helps those practices improve their quality measures, many of which are sensitive to optimal medication use.

Where does a pharmacist fit into the picture when it comes to monitoring a prescription? How do they manage what could be a difficult situation in terms of dealing with a physician?
There are a number of touch points for pharmacists in monitoring the appropriateness of medication therapy. Ideally, there is an opportunity for pharmacists to influence prescribing before it results in a prescription or drug order, which is easier to accomplish in the institutional setting. There are also opportunities for pharmacists to evaluate the right drug, the right dose and the right duration of therapy when a prescription is presented in the traditional community or ambulatory setting.

However, few prescriptions come with information about the indication for which the medication is being prescribed, and many drugs are used for multiple purposes. Including that information in the transmission of a medication order would increase pharmacists' ability to evaluate the appropriateness of a prescription, establish the goals of therapy in collaboration with the prescriber and discuss modifications that might help to optimize medication therapy for a given patient with the prescriber.

How is the role of the pharmacist changing as large retail drugstore chains seem to be changing the way they do business and expanding into areas such as walk-in clinics?
Pharmacists' roles have changed significantly in the last 20-30 years. It was most obvious in the hospital or institutional environment initially, because it was in those environments that pharmacists and other health care practitioners could work side by side on a daily basis, developing trust and appreciation for the unique contributions pharmacists make to those who are acutely ill. Twenty years ago, if you asked how many pharmacists were actively engaged in administering immunizations, the number would have been less than 50. Today, more than half of the licensed pharmacists are certified immunizers, and most student pharmacists receive immunization training in pharmacy school.

Retail clinics are a bit challenging in that there was always concern about channeling prescriptions from the clinic to the pharmacy department, violating self-referral laws and regulations. It is yet to be realized, but this environment has tremendous potential to increase access to care, including acute episodes of illness and management of chronic conditions.

Is there a role for pharmacists to play in controlling drug costs? Do drugstore chains or other big retailers have any leverage when it comes to pricing? Do they negotiate costs, and does that mean the huge chains are going to not necessarily control costs for consumers, but control costs for competitive marketing purposes?
AACP usually stays out of this area as it is incredibly complex. Pharmacists at the patient interface can play a role in identifying opportunities for cost reduction by using generic and therapeutic substitution. That said, the power resides disproportionately with insurance companies and pharmacy benefit managers.

Are American pharmacists taking on the medical advisory role that is common in European countries, where customers ask the pharmacist for advice about what to take for a cold, or how to treat a child's earache, for instance?
Pharmacists in the U.S. are the most accessible health professionals, located in virtually every community. They are educated to provide self-care advice for self-limited conditions, as well as knowing when to refer an individual who presents with symptoms that suggest a formal diagnosis and treatment beyond the point when over-the-counter products may be necessary.

Is the role of pharmacists becoming even more important as we switch from inpatient care to outpatient services?
The increased incidence of chronic conditions as the older adult population expands makes the availability of pharmacists' patient-care services in the outpatient setting extremely important. We do already see the expansion of practice in the ambulatory/clinic environment. Practice authority through collaborative practice agreements and statewide protocols are expanding the ability of pharmacists on the traditional community pharmacy platform to contribute more, as well.

Do pharmacists spend a lot of time helping/advising customers about generics, etc.?
Many times, the use of generics is a requirement of prescription benefit plans. Pharmacists do spend a lot of time communicating with patients about changes in therapy that hopefully will save consumers money while providing equivalent therapies and upholding the intended outcomes of care.

What about pharmacists in hospital pharmacies? Is that a different role or situation entirely?
Many of the responsibilities of pharmacists in the hospital are similar to pharmacists in other settings — reviewing medication orders for appropriateness and safety, interacting with other health professionals to coordinate care, educating patients about managing medications upon discharge. There are unique roles in the hospital setting — working in the ICU, emergency departments, surgical centers, etc. Inpatient pharmacists may also have enhanced access to more-complete patient information in electronic health records and to other clinicians during rounds.


Pharmacists Take Their Place on the Care Team

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