Using your pharmacist prescribing skills to navigate emergency supply.
On most days, community pharmacists will face at least one scenario where they are a ‘prescriber by default’, solving problems for patients ranging from out-of-date prescriptions, lost medicines, to travelling patients who left their scripts at home.
Ease of access and the convenience of pharmacists administering vaccination has proven a key contributor to the increase in influenza immunisation rates nationally. This has helped change community perceptions: that all people should consider annual influenza vaccination – something seen previously as mainly for ‘at risk’ people.
The accessibility of community pharmacists, their position as medicines experts and pharmacies’ extended hours of operation often mean patients will seek out a pharmacist first seeking ongoing supply of their essential medicines. However, regulations have traditionally limited the solutions a pharmacist can provide.
Some patients have an expectation that they are able to supply their pharmacist with a prescription some time after a medicine is supplied in an ‘owing’ scenario.
This expectation often exists for lower-risk, long-term, stable therapy. But while every state and territory has provisions to supply an ‘owing’ prescription upon request from an authorised prescriber, there is no legal provision for an ‘owing’ without prescriber authority.
For too long, there were few permitted options to support essential medicine supply following requests for ‘owing prescriptions’, placing pharmacists under undue and unreasonable pressure to break the law.
Originally introduced in 2012, PBS Continued Dispensing, supported by state and territory enabling regulation, allowed pharmacists to provide oral contraceptives and HMG-CoA reductase inhibitors (statins) in defined circumstances to support ongoing therapy. At the time, it was envisaged more medicines would be added to the list. But for the better part of a decade, nothing happened.
Then came the 2020 Black Summer bushfires and the coronavirus pandemic. Expanded PBS Continued Dispensing was progressively introduced in NSW, Victoria, ACT and South Australia in response to the bushfire crisis – with all other jurisdictions following the arrival of COVID-19 into Australia. This temporary measure is currently being reviewed with a view to it becoming permanent.
PSA National Board Director Dr Fei Sim said COVID-19 had been a game-changer for the supply of medicines:
‘How do we work around COVID-19? she asks. ‘How do we ensure access to medicines is happening in a timely manner? In a lot of small towns, pharmacists are the only point of contact for healthcare.
‘If a patient can’t get their blood pressure medicine or any medicine for their chronic health condition from a doctor, then continued dispensing from a pharmacist is an accessible option.’. But this form of structured prescribing arrangement requires more than a ‘tick and flick’ approach to supply. No two requests are the same. They demand pharmacists carefully consider patient therapy, personal circumstances, regulations and professional standards.
Three pharmacists explain decision-making approaches in common scenarios where emergency supply, including expanded PBS Continued Dispensing, may be considered.
Omololu Tayo, Owner, Cummins Pharmacy, Cummins, South Australia
Scenario: A male patient comes into the pharmacy with a prescription for Symbicort (budesonide) dated 2018. He is requesting supply of Symbicort to manage his ongoing asthma symptoms. You check his dispense history and My Health Record (including PBS history) but they do not show a history of more recent supply.
What do you do?
Answer: First, I would assess the patient’s asthma management so I know how urgent the request is. This includes how often he uses a reliever and his recent symptoms. Based on the information above, it seems likely he hasn’t been supplied Symbicort for nearly 3 years. This would mean emergency supply (including Continued Dispensing) is not an option.
If urgent, I would contact the patient’s GP and ask if the patient can have a new script for Symbicort and suggest for to doctor to see him first for a review. If the GP agrees, I would ask for an e-script so I can dispense. If the GP could not be reached, I would consider the need for supplying a reliever (e.g. salbutamol) and also ask the patient to see his GP as soon as possible.
This scenario more commonly happens when people run out of blood pressure medicines, or sometimes statins.
I would always check back with the patient’s doctor to see if I can provide an emergency supply or obtain an e-script.
Sabrina Imran MPS, Owner, Chemcare Wellness Pharmacy, Altona, Victoria
Scenario: A patient requests a single dose of quetiapine without a prescription. The patient is staying nearby and left her medicine at home, several hours’ travel away. You consult RTPM [SafeScript in Victoria] and My Health Record and the information given is consistent with those records.
What are your options?
Answer: Depending on prescriber availability, and how much longer the patient is likely to be away from home, I would choose the following options:
1. I would ring the patient’s doctor and request the GP to fax or email me a prescription for quetiapine to the pharmacy for this patient and I will then dispense it.
2. If the prescriber is unavailable, or the patient doesn’t have time to wait, then I can give the patient an emergency supply for 3 days – noting that, as the patient has only requested a single dose, one day’s supply may be adequate – and making sure there is enough time for the patient to get a prescription from her doctor.
3. Most conveniently, since I do have evidence the patient has taken the medication in the past 6 months I would be happy to do a Continued Dispensing if I can verify the patient is likely to be away from home for an extended period.
The amount supplied would depend on how soon the patient is returning home and how much remaining medicine the patient has at home, as well as likelihood of inappropriate use.
Susan Wild MPS, Owner, Molong Pharmacy, Molong, New South Wales
Scenario: A client asks for clarithromycin for Chronic Obstructive Pulmonary Disease (COPD) and promises to bring in a prescription for it within 2 days. The patient has no My Health Record but as a regular customer expects you to give him the medicine without a script (last supplied 6 months ago for a flare-up).
What do you do?
Answer: If the patient is a regular they would have a dispensing history and I could check for compliance and regular dispensing of COPD medications.
I could try and contact the patient’s doctor but if unavailable I would consult Therapeutic Guidelines, which recommends withholding antibiotic treatment for COPD patients in the community as the flare-up could have a viral cause.
Antibiotics are only recommended if there is an increase in sputum, if the sputum is yellow and if there is a fever.
I would ask about symptoms and if those three symptoms are present, the antibiotics of choice indicated would be doxycycline 100 mg daily for 5 days or amoxycillin 500 mg every 8 hours for 5 days.
If pharmacist prescribing was available (currently it is not), I could consider initiating 2 days’ supply until the patient saw the doctor.
Ideally, I would talk to the patient and suggest they continue using their COPD medication regularly as antibiotics do not often improve the outcome, and to see their doctor within 2 days.