The pharmacist physician
2
Editorial The pharmacist physician The National Association of Boards of Phar- macy has passed a resolution (80-8) requesting the creation of "an 'exempt legend drug' category which shall be dispensed only by pharmacists" to be "utilized for all drugs as an intermediary step between the current classifications of legend and over-the-counter drugs." In several states similar proposals are being introduced into the legislatures for the express purpose of enabling pharmacists to dispense certain medications without a physician's prescription. In Florida, for example, legislation authorizing pharmacists to prescribe passed the Florida legislature on May 14 and was signed into law by the governor on May 24. Section 465.186 of the Florida statutes makes "available to the public upon the order of a pharmacist" certain drugs that a formulary committee will recommend as acceptable for a pharmacist to dispense. In ad- dition, the legislation specifically recommends that certain medications, such as "lindane in any strength," be authorized by the formulary com- mittee and permits the committee to develop dis- pensing procedures under which the pharmacist may refill his prescription. Pharmacists began to practice medicine in Florida on Oct. I, 1985. The fundamental question being addressed is the right to practice medicine. The dispensing of phar- macologic agents is obviously the final step a prac- titioner takes after properly evaluating and diag- nosing disease. The privilege of dispensing a lim- ited number of restricted medications is equivalent to legislatively granting pharmacists limited med- ical licenses. Several questions immediately come to mind. Have pharmacists been adequately trained in clinical diagnostic skills? Will the pharmacist step from behind the counter so that he may physically From the Division of Dermatology, University Of South Florida. examine each patient before he makes his diag- nosis and prescribes medication? Will the phar- macist keep complete medical records on each of his patients? There is no question that pharmacists are a vital element of our health care delivery system. Nev- ertheless, the ability to evaluate medication phar- macologically does not by any stretch of the imag- ination equate to the ability to practice clinical medicine. One additional point should be raised for our consideration. Hydrocortisone (0.25% and 0.5%) preparations are currently available over the counter because the Food and Drug Administration (FDA) presently has them in tentative final mono- graph status. Medications that are in tentative final monograph status are not specifically approved by the FDA for over-the-counter sale but are rather permitted to be sold over the counter if the man- ufacturer assumes the liability. It is only by issuing a final monograph that the FDA approves the over- the-counter availability of a product. (This may seem a moot point, but if you speak with persons at the FDA they do not say that their agency has approved over-the-counter hydrocortisone. They will tell you that the FDA is presently studying the subject and has issued only a tentative final mono- graph on it.) The legal status of a tentative final monograph " is that of a proposed rule."* The resolution of the National Association of Boards of Pharmacy requests that a "category be utilized for all drugs as an intermediary step between the current classifications of legend and over-the- counter drugs." It seems that these medications are currently in such an "intermediary step" rec- ognized by the FDA as tentative final monograph status. It does not, unlike the resolution requests, *Federal Register, vol. 48, no. 27, p. 5852, Feb. 8, 1983. 817
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Transcript of The pharmacist physician
Editorial
The pharmacist physician
The National Association of Boards of Pharmacy has passed a resolution (80-8) requesting thecreation of "an 'exempt legend drug' categorywhich shall be dispensed only by pharmacists" tobe "utilized for all drugs as an intermediary stepbetween the current classifications of legend andover-the-counter drugs." In several states similarproposals are being introduced into the legislaturesfor the express purpose of enabling pharmacists todispense certain medications without a physician'sprescription. In Florida, for example, legislationauthorizing pharmacists to prescribe passed theFlorida legislature on May 14 and was signed intolaw by the governor on May 24. Section 465.186of the Florida statutes makes "available to thepublic upon the order of a pharmacist" certaindrugs that a formulary committee will recommendas acceptable for a pharmacist to dispense. In addition, the legislation specifically recommends thatcertain medications, such as "lindane in anystrength," be authorized by the formulary committee and permits the committee to develop dispensing procedures under which the pharmacistmay refill his prescription. Pharmacists began topractice medicine in Florida on Oct. I, 1985.
The fundamental question being addressed is theright to practice medicine. The dispensing of pharmacologic agents is obviously the final step a practitioner takes after properly evaluating and diagnosing disease. The privilege of dispensing a limited number of restricted medications is equivalentto legislatively granting pharmacists limited medical licenses. Several questions immediately cometo mind.
Have pharmacists been adequately trained inclinical diagnostic skills? Will the pharmacist stepfrom behind the counter so that he may physically
From the Division of Dermatology, University Of South Florida.
examine each patient before he makes his diagnosis and prescribes medication? Will the pharmacist keep complete medical records on each ofhis patients?
There is no question that pharmacists are a vitalelement of our health care delivery system. Nevertheless, the ability to evaluate medication pharmacologically does not by any stretch of the imagination equate to the ability to practice clinicalmedicine.
One additional point should be raised for ourconsideration. Hydrocortisone (0.25% and 0.5%)preparations are currently available over thecounter because the Food and Drug Administration(FDA) presently has them in tentative final monograph status. Medications that are in tentative finalmonograph status are not specifically approved bythe FDA for over-the-counter sale but are ratherpermitted to be sold over the counter if the manufacturer assumes the liability. It is only by issuinga final monograph that the FDA approves the overthe-counter availability of a product. (This mayseem a moot point, but if you speak with personsat the FDA they do not say that their agency hasapproved over-the-counter hydrocortisone. Theywill tell you that the FDA is presently studying thesubject and has issued only a tentative final monograph on it.) The legal status of a tentative finalmonograph " is that of a proposed rule."* Theresolution of the National Association of Boardsof Pharmacy requests that a "category be utilizedfor all drugs as an intermediary step between thecurrent classifications of legend and over-thecounter drugs." It seems that these medicationsare currently in such an "intermediary step" recognized by the FDA as tentative final monographstatus. It does not, unlike the resolution requests,
*Federal Register, vol. 48, no. 27, p. 5852, Feb. 8, 1983.
817
818 Lober
however, specifically recognize the pharmacist nordoes it give the pharmacist dispensing authority.
The National Association of Boards of Pharmacy resolution requests that pharmacists be legislatively granted limited medical licensure . Flor-
Journal of theAmerican Academy of
Dermatology
ida has enacted such legislation and other statesare considering similar proposals. If pharmacistswish to practice clinical medicine, they should berequired to go to medical school.
Clifford Warren Lober, M.D., Tampa, FL
ABSTRACTS
Effect of naloxone on menopausal flushes, skintemperature, and luteinizing hormone secretion
Tulandi T, Kinch RA, Guyda H, et al: Am J ObstetGynecoI151:277-280, 1985
A hypothesis that an opioid mediated the "hot flash" vasodilatation of the :skin as seen in menopausal women isdescribed and contradicted in this report.
P. G.A.
Oculocerebrocutaneous syndrome
Wilson RD, Traverse L , Hall JG, et al; Am JOphthalmol 99:142-148, 1985
Brain-eye-skin lesions are found in this birth defect. Theskin lesions are focal hypoplasias and accessory tags.
P. G.A.
Altered skin elastic fibers in hypothyroidmyxedema and pretibial myxedema
Matsuoka LY, Wortsman J I Ditto], et al: Arch InternMed 145:117-121, 1985
These authors find elastic tissue in skin to be damaged anddecreasedin these myxedemas , probably not due to infiltrationby the glycosaminoglycan .
P. G.A.
Vulvar sweat gland carcinomas
Wick MR, Goellner JR, Wolfe JT III , et al: ArchPathol Lab Med 109:43-47, 1985
A review of the subject is presented with five new cases.About 10% of vulvar carcinomas are related to the sweatglands, and each has its own morphology and prognosis.
P. G.A.
Wheelchair cushion effect on pressure and skintemperature
Seymour RJ, Lacefield WE: Arch Phys Med Rehabil66:103-108, 1985
More studies of pressure-induced ulcers of the skin arewelcome. This clever report concerns padding on wheelchairs.
P. G.A.
The diagnostic value of antihistone antibodies indrug-induced lupus erythematosus
Epstein A, Barland P: Arthritis Rheum 28:158-162,1985
Finding antibodies to histones , the authors argue, is support from the laboratory for the diagnosis of drug-inducedlupus erythematosus, provided, of course, that the clinicaldiagnosis is tolerable. This support is valid especially if thedrug suspected is procainamide. These statistical decisionmaking devices are useful; no doubt, however, in a givensingle case the precise diagnosis may remain obscure, in fact.
P. C. A.
Soluble mediators from mononuclear cells increasethe synthesis of glycosaminoglycan by dermalfibroblast cultures derived from normal subjectsand progressive systemic sclerosis patients
Whiteside TL, Worrall JG, Prince RK, et al: ArthritisRheum 28:188-197, 1985
Fibroblasts from patients with scleroderma produce muchmore glycosaminoglycan than do normal fibroblasts whenstimulated by natural factors from mononuclear cells. Theproblem remains murky.
P. G.A.
