Pharmacy First

As of January 1, 2023, pharmacists in Ontario are allowed to prescribe medication for 13 minor common ailments.¹ Similar changes are planned in British Columbia.² The move is intended to empower pharmacists to use their skills, improve patients’ access to care, and reduce the workload of primary care physicians and emergency departments. These objectives are admirable, but why has it taken so long?

Across the 13 Canadian provinces and territories, the variation in pharmacists’ scope of practice is striking,² especially so for prescribing. Although all jurisdictions but one (Nunavut) allow pharmacists to renew or extend prescriptions for continuity of care, only Alberta allows a pharmacist to initiate independently a prescription for any schedule I drug. The number of conditions for which Ontario pharmacists can prescribe (n = 13) is modest compared with those in Alberta, who can prescribe for 58 of the 59 conditions listed in a comparative chart prepared by the Canadian Pharmacists Association.³ Why is there such a difference?

Pharmacy practice in Canada is evolving from a technical supply function to a more clinical cognitive role. This parallels practice changes across many other countries, especially in the developed world. The variability in the extent of these changes across countries may reflect differences in pharmacy training, but this is not the case for variations within a single country such as Canada.

Until recently, the general separation of prescribing and dispensing functions was hailed as an important safety net for patients, removing potential conflicts of interest and also the potential for prescribing errors to reach the patient. However, a shift toward a greater prescribing role has been occurring incrementally. Although the word “prescribe” is often understood to mean “write a prescription for a schedule I drug to be dispensed by a pharmacist”, pharmacists have for many years been prescribing over-the-counter (OTC) medications. The first step to increase their prescriptive authority came with the deregulation of many previously schedule I drugs to OTC availability. Evaluations demonstrated that this steady increase in the number of often-potent OTC medications that pharmacists can prescribe or recommend was both safe and well accepted by the public. This expanded role has resulted in greater public awareness of pharmacists’ expertise in medicines.

For a fundamental paradigm shift in role to occur, three things must be in place: governmental need, societal acceptability, and evidence of benefit,⁴ all underpinned by professional aspiration and expertise. It is therefore interesting to speculate whether existing jurisdictional variation is due to differing needs across provinces or inconsistent interpretation of research evidence. Is it right that in some provinces the public does not have such easy access to care provided by prescribing pharmacists?

Other questions come to mind, presenting a fascinating research agenda. Does the hypothesis outlined above hold true for Canada? To what extent are these new roles actually being used in practice? Is the public now more dependent on medicines, given their increased availability through pharmacists? Research from the United Kingdom has demonstrated the efficiency and effectiveness of minor ailment schemes,⁵ but is there similar evidence from Canada? If not, should there be, or can evidence from other, arguably similar, jurisdictions be used as the basis of new provincial policies?⁶ Furthermore, to what extent are these new authorizations being implemented in the hospital sector, and what is the benefit? Pharmacists are highly trained experts in medicine, and it is right that their skills should be utilized for the benefit of all patients. As leaders in our profession, we should be lobbying for all pharmacists to practise to their full scope of practice.⁶