Rx for Drug Misuse: Pharmacists’ New Role : Health: Beginning Jan. 1, the druggist must consult with the patient every time a new or changed prescription is filled.

If you’ve never come face-to-face with the pharmacist at your local drug store, get ready for a big surprise.

Beginning Jan. 1, pharmacists throughout the state will emerge from behind the counter to assume a role that could well change the face of pharmacy services and greatly influence how Californians take their medicines.

A state Board of Pharmacy regulation will require pharmacists to consult with every patient who receives a new prescription or a refill that has changed.

The regulation is a bold tactic designed to address the widely acknowledged problem of patient misuse of prescription drugs, which is thought to cost billions of dollars annually in preventable side effects, hospitalizations and prolonged illness. Reaction from health-care providers has, however, been mixed.

“We’ve got pharmacists on both sides of the issue,” says Giny Herold, assistant executive officer at the state Board of Pharmacy. “We’re looking at a real change in pharmacy services in the state.”

Opponents question whether pharmacies are set up to provide consultations. Some of the specific concerns include:

* Confidentiality: Will the pharmacist and patient have a place to confer if privacy is desired?

* Will customers end up waiting in long lines to receive prescriptions if the pharmacist is tied up in long consultations?

* Will the pharmacist have enough information about the patient and the other medications that patient might be taking in order to provide an accurate consultation?

* Will this expansion of pharmacy services cause economic hardship for facilities already hard hit by medical cost-cutting, like public hospitals already suffering from serious staffing shortages?

* Will the state be able to enforce the regulation and measure its effectiveness?

Many of these concerns are dwarfed by the larger problem that the regulation is attempting to address, Herold says.

“There are a number of reports that indicate substantial medical costs due to mismanagement of prescription drug use,” she says. “And there are an incredible number of hospitalizations relating to the lack of knowledge people have about taking multiple prescriptions.”

According to the National Council on Patient Information and Education, a consumer education group on prescription drug issues, up to half of the 1.6 billion prescriptions dispensed annually in the United States are used incorrectly.

Misuse can lead to prolonged illness, avoidable side effects, increased hospitalization, absences from work and overuse of health-care services.

Misuse is especially acute among the elderly, who often take multiple drugs for various ailments.

According to a USC study reported earlier this year, one out of five people 60 or older has an adverse reaction to a prescription drug, ranging from nausea to difficulty breathing.

Other studies have shown that up to 25% of hospital and nursing home admissions of elderly people are related to misuse of prescription drugs.

The problem is not limited to the elderly. A review of 10 studies on children’s medicine use showed 46% did not take the medicines correctly, according to the National Council on Patient Information and Education.

Whether the responsibility for taking medications falls on the physician, patient or pharmacist, physicians have taken much of the blame for poor communication with patients.

In one study, only 19 of 221 patients interviewed said their doctors had asked if they had any questions about the drugs, according to the National Council on Patient Information and Education. Some patients said they felt too intimidated and rushed to ask questions.

“Doctors get dinged for not communicating with patients better,” says Christine Pahl, staff coordinator of the California Medical Assn., which opposed the consultation regulation. “But we’re trying to do things better. Maybe this (regulation) will bring health-care providers closer together instead of being so fragmented.”

The intent of the regulation is to encourage pharmacists to fill the void that sometimes exists between physicians and patients. The USC study found that only about 36% of the respondents received drug information from a pharmacist.

For example, pharmacists have much more education than physicians regarding the 2,000 prescription medications on the market.

Pharmacists sometimes have a unique opportunity to coordinate a patient’s use of medications. For example, many individuals take several drugs prescribed by different doctors. If the patient fills all prescriptions at the same pharmacy, then potential problems with drug interactions can be spotted.

In addition, a patient with a prescription for several refills is not likely to see the doctor between refills. But the patient will see the pharmacist for each refill, allowing the pharmacist the opportunity to assess whether the drug is being taken correctly and whether it is causing any problems.

But Mike Nichol, an assistant professor at the USC School of Pharmacy, questions whether the consultation regulation will be effective if patients are getting prescriptions filled at various pharmacies without any coordination.

Patients might benefit enormously by using just one pharmacy, Nichol adds. “If an individual gets all their drugs at a single pharmacy, they would have coordinated care.”

Pharmacists, however, would be expected to object to any alteration of a free-enterprise system, such as a regulation mandating that patients choose one pharmacy to fill all prescriptions. Likewise, at least some pharmacists do not support the consultation regulation because it restricts their freedom to do the job as they see fit.

“I think most pharmacists feel (patient consultation) should be part of the job and it shouldn’t have to be mandated. But we recognize that there are pharmacists out there not doing it,” says Cindy Hespe, vice president of professional affairs for the California Pharmacists Assn.

The regulation has also been strongly criticized by members of the California Assn. of Public Hospitals because of fears it will impede services.

The group supports the notion of consultation, says Terri Thomas, a lobbyist for the association. “But we feel that, within the limits of their budget and staff, (public hospital pharmacists) provide as much consultation as they feel is necessary. To regulate the public hospitals at a time when they have been cut hundreds of millions of dollars is going to impede our ability. Our waiting rooms are totally overburdened as it is.”

Thomas says member pharmacists are also concerned about the logistics of providing consultations to patients discharged with prescriptions.

Moreover, she says, the regulation will raise the question of whether pharmacists can be held liable for problems stemming from use of medications. Pharmacists will not be required to document consultations, but she suggests that many may do so in case of a subsequent lawsuit in order to verify that they counseled the patient or that the patient refused consultation.

But, says Harris of the Pharmacy Board, “that liability exists now. There has been a lot of case law where the pharmacist has been charged with failure to consult.”

Just how the regulation affects consumers will, in all likelihood, vary widely, experts suggest.

“A lot of it depends on how it’s implemented,” Nichol says. “If the pharmacist takes a real aggressive stand on it, people will notice.”

Some pharmacists, particularly those at independent neighborhood pharmacies, are already doing patient consultations, says Patty Harris, executive officer of the state Board of Pharmacy. But larger, high-volume drug store chains might face radical changes in the way they do business.

“The independent mom-and-pop stores often do this consultation,” Harris says. “That’s why they can compete, because . . . the larger, high-volume chain stores often don’t have the time to consult.”

Most experts predict that the law will be embraced by consumers, even if it means a longer wait to pick up a prescription.

“It’s kind of like you break the ice, and everyone likes to get that information,” Nichol says. “I don’t think many people will turn down the opportunity for consultation.”

What’s Covered, What’s Not

Under a state prescription-drug regulation, effective Jan. 1:

* At minimum, pharmacists must discuss directions for use and storage of prescription drugs, the importance of compliance with these directions, precautions and relevant warnings.

* The regulation covers patients who receive a new prescription or a refill that has changed, outpatients filling prescriptions in hospital pharmacies, and inpatients being discharged with prescriptions.

* Not covered are hospital inpatients, nursing homes dispensing medications to inpatients and mail-order pharmacies.

* Patients have the option to refuse the consultation.