Pharmacists’ Expansion of Scope

Illustration of pharmacists

Ontario becomes ninth province to allow pharmacists to prescribe for minor ailments

It’s been 16 years since Alberta became the first province to allow pharmacists to independently prescribe drugs, which include those in the assessment for minor conditions. Although the move met with initial resistance from the medical community, fears quickly faded as it became clear how much of “a huge untapped resource” pharmacists had been, remembers one Calgary family physician.

“I think it is fair to say that some people’s hair stood on end when it was announced. There were concerns about scope creep, continuity of care and loss of autonomy,” said Dr. Janet Reynolds, a family physician from Crowfoot Village Family Practice, which has a team-based approach to care which allows her patients access to interdisciplinary teams.

“And while no system is perfect, it’s safe to say that those concerns largely never materialized,” said Dr. Reynolds, who made her comments as a panel member in Choosing Wisely Canada’s webinar about the provincial government’s expansion of the scope of practice for Ontario pharmacists.

In January 2023, Ontario became the ninth province to allow pharmacists to prescribe for minor ailments. (Alberta pharmacists have the most comprehensive authority of any province or territory in Canada, having been able to independently prescribe Schedule 1 drugs since 2007.) The Pharmacist Prescribing for Minor Ailments (PPMA) program is intended to reduce the burden of minor ailment care on emergency departments, free physicians to spend time on the more complex care of their patients and, most significantly, allow patients to receive relief more quickly for minor conditions.

“It just makes sense to put patient needs as our focus. Why should my patient have to wait until Monday to see me when they can get their condition addressed with a prescription on Saturday morning?” said Dr. Reynolds.

The list of minor ailments for which pharmacists can prescribe was developed by a Minor Ailments Advisory Group (MAAG), comprising patient advisors, and experts in pharmacy, medicine, public health, health systems research and anti-microbial stewardship.

MAAG considered the parameters that would use the knowledge, skills and judgment of pharmacists in an integrated care model, while ensuring the delivery of safe, high-quality patient care, improving access to care in the community and the ability to reduce unnecessary emergency department visits.

The changes build upon pharmacy’s long history of assisting patients with minor ailments, assessing them and often recommending non-prescription therapies for their management, facilitating other self-care decisions, and/or referring patients to other health care providers when warranted.

Allowing pharmacists to prescribe was just the logical next step, one falling well within the profession’s scope, said Dr. Danielle Paes, Chief Pharmacist Officer at the Canadian Pharmacist Association. “This is something that we have been trained to do. This is right in our wheelhouse,” she said.

Pharmacy students are educated in the management of minor ailments throughout the course of their four-year Doctor of Pharmacy curriculum, says Dr. Nardine Nakhla, a clinical lecturer at the University of Waterloo’s School of Pharmacy. “This teaching is embedded in both the didactic and experiential components of the curriculum. We are confident that our program prepares students to assess and manage patients presenting with these ailments.”

“This is something that we have been trained to do. This is right in our wheelhouse”

In Ontario, a framework on general expectations for prescribing has been in place since 2012 when the Pharmacy Act, 1991 was updated to enable pharmacists to prescribe for smoking cessation. This included notifying the primary care provider after prescribing, providing the patient with the option of dispensing the medication at another pharmacy and assessing documentation expectations. These current regulations for prescribing, the standards of practice and code of ethics provide safeguards for the new authorities, and should address any concerns about collaboration, assessment, continuity of care and conflict of interest involvement, said Dr. Paes during Choosing Wisely Canada’s webinar.

To support understanding of this most recent scope of practice change, all pharmacists are required to complete an online module that reinforces the importance of referring patients to other members of the health care team for management of issues beyond their competence, as well as the need to continually self-assess one’s knowledge, skill and judgment necessary for the provision of safe and quality patient care.

But some reservations remain. During Choosing Wisely’s webinar, a physician member of the audience asked what reassurances could be provided to allay his concerns about patient safety. What if a pharmacist incorrectly diagnosed a cardiac issue as GERD? Or assumes a more serious condition is an uncomplicated UTI?

Dr. Paes said the expanded scope doesn’t put patients in harm’s way. “Pharmacists are cautious, guideline-concordant people. We are trained to be on the lookout for red flags and when we see one, we will move quickly to refer.”

Dr. Reynolds agreed. “I think we just need to have trust in pharmacists’ professionalism and training,” she said.

There is a growing body of research suggesting minor ailments are being dealt with appropriately by PPMAs. A study in the United Kingdom, where pharmacists have been allowed to prescribe for minor ailments since 2003, found low reconsultation and high symptom-resolution rates. In Canada, the RxOUTMAP study found pharmacist management of uncomplicated UTIs across 39 community pharmacies in New Brunswick was effective and safe, and resulted in high patient satisfaction. Of the 750 patients enrolled, clinical cure was achieved in 88.6 percent of those managed by a pharmacist compared to 91.1 percent for those managed by a physician, and there were no statistically significant differences in safety outcomes.

Empowering pharmacists to use their expertise to assess minor ailments has freed up her time to focus on patient care that can’t be delivered by a pharmacist, said Dr. Reynolds. “There is just so much to be gained in embracing the community pharmacist as part of the patient’s health care team.”

The Minor Ailments

As of the beginning of the year, Ontario pharmacists have been able to offer prescriptions for 13 minor ailments, including:

  • Allergic rhinitis
  • Candidal stomatitis
  • Conjunctivitis (bacterial, allergic and viral)
  • Dermatitis (atopic, eczema, allergic and contact)
  • Dysmenorrhea
  • Gastroesophageal reflux disease
  • Hemorrhoids
  • Herpes labialis
  • Impetigo
  • Insect bites and urticaria
  • Tick bites, post-exposure prophylaxis to prevent Lyme disease
  • Musculoskeletal sprains and strains
  • Urinary tract infections (uncomplicated)

Minor ailments are described as health conditions that can be managed with minimal treatment and/or self-care strategies. Additional criteria include:

  • Usually a short-term condition;
  • Lab results aren’t usually required;
  • Low risk of treatment masking underlying conditions;
  • No medication or medical history red flags that could suggest a more serious condition; and
  • Only minimal or short-term follow-up is required.

The Ontario College of Pharmacists (OCP) anticipates pharmacists could prescribe for six additional minor ailments by the fall of this year. In March 2023, the OCP Board approved proposed amendments to the Pharmacy Act that would enable pharmacists to prescribe for the following:

  • Acne (mild)
  • Aphthous ulcers
  • Diaper dermatitis
  • Vulvovaginal candidiasis
  • Pinworms and threadworms
  • Nausea and vomiting of pregnancy