Schedule 3: Use it or lose it


Schedule 3 - pharmacist holding out pill bottles

Many pharmacists are taking Schedule 3 medicines for granted, writes Phil Spyrou… which could end up costing the profession dearly.

Pharmacists across Australia are looking to expand the scope of their practice through professional services, but may risk losing access to a group of medicines they take for granted: Schedule 3.

It is widely acknowledged by those within the profession that clinical input from the pharmacist into the supply of Schedule 3 medicines has fallen by the wayside.

By law, the pharmacist should be involved with the provision of every schedule 3 medicine; the ‘involvement’ of the pharmacist can mean different things, depending on a pharmacy’s structure and culture.

Some pharmacists will say that overhearing the interaction between the patient and pharmacy assistant is adequate, and they will intervene if required. Other pharmacists prefer to speak with each client seeking a Schedule 3 medicine.

In my opinion, pharmacists should speak with every patient who seeks schedule 3 medications. Pharmacists have the appropriate training and skills to identify patients who need referral to another health professional and to identify patients who may be at risk of interactions by taking a Schedule 3 medicine.

Even in the most simple cases, pharmacists can counsel patients on the quality use of their medications.

Is it realistic, though, for a pharmacist dispensing 300+ prescriptions per day with only one dispense technician and no other pharmacist/intern available, to personally counsel every patient requesting a schedule 3 medicine?

At a bare minimum, adequate histories should be taken from the client seeking an S3 and then if supply is appropriate, counselling on safe use of the medicine should follow.

In many pharmacies, these conversations are not being had.

Examples include:

  • Supplying chloramphenicol without asking if there is any pain in the eye or visual disturbances. (The patient may have acute glaucoma and not bacterial conjunctivitis).
  • Supplying salbutamol without discussing the patient’s asthma symptoms. (What if the patient is having serious and frequent exacerbations?)
  • Supplying codeine preparations without asking what other medicines the client is taking or asking what type of pain is being treated. (The problem may be medication overuse headache/rebound headaches. Personally, I see too many headache sufferers who have never heard of this condition.)

 

There has been talk recently from the TGA of whether to up-schedule codeine to Schedule 4. The efficacy of over-the-counter codeine preparations is a debate for another blog post.

Nonetheless, it should be a message to pharmacists: use it or lose it! If as a profession we do not treat Schedule 3 medicines with the respect that they deserve, they may be taken away from us.

Three solutions that I propose to this problem are:

  • improving the layout of dispensaries, placing the pharmacist(s) permanently out the front;
  • investing in pharmacists/interns, thus reducing the workload on pharmacies with one pharmacist on duty; and
  • improved training for pharmacy assistants.

 

Phil Spyrou is a community pharmacist and author of the Headache Freedom blog (www.headachefreedom.com).

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7 Comments

  1. Bluebottle
    09/09/2015

    Good article Phil. Manufacturers see S3 as a black hole. Pharmacists forget that S3 products often provide better health outcomes, commercially benefit the business, are professionally satisfying to supply and grow customer loyalty. PPIs are going S2 because pharmacists forgot/refuse/couldn’t be bothered to supply them as S3s. Nuromol is a valid alternative to combined analgesics with codeine and is ours to own in the S3 department. Why are we not offering it to everyone who requests S3 codeine?

    • Phil Spyrou
      19/10/2015

      Bluebottle, thanks for your comment. I can see ibuprofen/paracetamol and paracetamol/metoclopramide preparations being used more in the future. Pharmacists are being educated through publications such as AJP and at conferences about the benefits of such formulations.

  2. Jarrod McMaugh
    12/09/2015

    My view on this is a little different, although I still think that S3 is not being handled correctly.

    The scheduling is a matter of the safety and appropriate access to the medication. This way of thinking about S3 as a category is not patient centred.

    Pharmacists need to be interacting with patients a hell of a lot more, and not just on S3 sales. S2, when a prescription is collected – all the time.

    Staffing needs to be designed to support the ability of the pharmacist to be out on the floor with patients. I’ve seen pharmacies that employ a ‘concierge’ pharmacist, and this is a great use of the expertise of the pharmacist to ensure that patients are getting the best possible care, regardless of the category.

    With regards to Bluebottle’s comment below – I think the lack of use of S3 is only partially due to pharmacists, and has a lot more to do with the companies promoting those products commercially.

    If you look at S4 – pharma companies employ quite a lot of manpower promoting these to doctors, both in the sales force, and the marketing force.

    When was the last time a pharmacist spoke to a pharma-representative about any S3 product without the representative focusing on sales figures, terms of trade, volume deals, etc?

    Pharma companies need to take a lot of the blame for the lack of use of S3 – if they aren’t interested in talking to pharmacists in a clinical manner, rather than a commercial manner, then they should expect pharmacists to be discouraged from using their products.

    • Phil Spyrou
      19/10/2015

      Hi Jarrod, thanks for your comment. We can definitely agree on the fact the pharmacists need to be interacting with patients more. I propose that any pharmacy dispensing more than 200 scripts per day have a second pharmacist available for interaction, consultations and services. Who could enforce such a measure?

      • Jarrod McMaugh
        20/10/2015

        Enforcement of any guidelines on pharmacist workload can only be done by the pharmacist and their employer.

        PSA, The Guild, PPA, The Pharmacy Board, and PDL all have guidelines on workload, based on prescription volume (and in some cases, patient interactions such as medschecks or professional service). No professional body is responsible for enforcing this though.

        Pharmacists are highly trained, ethical health professionals. We have the ability to critically assess our work situations and make judgements on the appropriateness of our work situation. If a pharmacist is working beyond their limit and not raising this with their employer, perhaps they are not fit to practice. If a pharmacist has an employee who is discussing workload with them, and they are not responding, then perhaps they are not fit to practice (and therefore own). Either way, doing nothing when workload is untenable is misconduct.

  3. James Lawson
    16/09/2015

    The grand experiment that is the S3 category of medicines demonstrates perfectly why allowing pharmacists to prescribe S4 medicines is a terrible idea.

    Here is our opportunity as a profession to demonstrate how we are able to safely and effectively handle the supply of restricted compounds, prescribing them in accordance with best practice guidelines.

    Yet instead, how many times to we see the pharmacy assistant behind the counter supplying Pharmacist Only Medicines with only the most basic of questions, if any at all, before telling the patient that ‘this just needs to be checked by the pharmacist?’

    The pharmacy profession at large is not ready to be given wholesale prescribing rights. One could argue that the problem is also compounded by the poor number of S4 medicines being down-scheduled to S3, but given the failure of the category in general to be treated with the respect it deserves, is it any wonder?

    Perhaps when the sale of S3 medicine is treated with the same due diligence and care as that of prescribing S4 drugs, we’ll see a bigger movement towards expanding the scope of pharmacy prescribing. Sadly the entire process of S3 medicine supply and entrenched attitude of the public towards this category of medicine would require a complete overhaul to accomplish this change.

    • Phil Spyrou
      19/10/2015

      Hi James, thanks for your comment. The answer definitely lies in more patient-pharmacist interaction as well as better training for assistants. Do pharmacists even need prescribing rights or just a stronger schedule 3?

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