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- Issue 81: April 2009
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- Issue 75: September 2008
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Medication Continuance - What are the Issues?

Stephen Carbonara
From an Independent Professional Pharmacist Perspective

Issue 75: September 2008
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Medication continuance (aka: "Here you are, no tests today; would you like Nurofen Plus with that?") is a poorly constructed, publicly dangerous piece of propaganda aimed solely at protecting Guild members' domination of pharmacists' professional practice services.
It is so poor in fact and so bereft of clinical knowledge, that the Guild fails to appreciate that lives will be put at risk.
Rather than just appearing contrary, I will list that which I believe to be more appropriate guidelines for medicines provision below in my conclusion; however I will first deconstruct the issue as it stands.

The problems with this idea are numerous:

  • "Reduces unnecessary GP visits". -The Guild wants to reduce "unnecessary GP visits". How does the Guild decide what constitutes an unnecessary GP visit?
    Sounds like a brilliant sound-bite, however I do not believe pharmacists should have any kind of say in what constitutes an unnecessary GP visit.
    Do GPs collectively pass judgement on how many unnecessary pharmacy visits occur?
  • "Top 20 high volume chronic therapy medicines on the PBS". - The Guild's solution is to initially have the highest PBS-cost items eligible for medication continuance.
    What if a customer requests a supply of their regular Lipitor and Seroquel?
    How much time will then be spent in explaining that one item can be given but the other cannot!
    What if two different customers request a supply of their regular medicines, where one customer takes Lipitor and the other takes Lescol?
    How much time will then be spent in explaining that one customer can be obliged but the other cannot!
    Does this not exhibit some form of discrimination?
  • "Continuation of therapy for up to 12 months". - What happens at the end of 12 months? Haven't we only just delayed the inevitable?
    Customers will still eventually have to see their doctor!
    Won't this system just train them to be more lax with their (eventual) doctor's visits? Also, in theory a customer can present to 12 different pharmacies over 12 months and at each visit request a supply of their regular medicines!
    This therefore means that 18 months can elapse before any kind of consistent clinical review takes place.
    Is this wise if for example, in the case of Lipitor, a cholesterol and liver function test cannot be performed for this length of time?
    If I was the pharmacist at the 12 month mark, would I be allowed to even test blood pressure or test a finger-prick cholesterol level?
    What if my boss doesn't stock a finger-prick cholesterol monitor?
    I would sure hate to be the guy that propagates the last supply of an un-monitored medication that may ultimately result in a customer's liver damage!
  • "No extra cost". - Anyone who thinks that provision of an additional service does not incur a cost, is naive. If a boss employs me in a pharmacy where I am to provide a medication continuance service, and IF (and I stress IF) I agree to do so (highly unlikely), I will most certainly require some kind of remuneration for this additional service, either in the form of an increased hourly rate or on a fee-for-service basis.
    This is what I would call "danger money".
    I wonder if bosses will be happy to pay this.
  • "Not prescribing". - If this is not prescribing, it must certainly be some kind of quasi down-scheduling.
    Either way this poses a significant medico-legal risk in supplying items that, without proper monitoring, may cause harm to the consumer.
    If it is prescribing, then this assumes that the medico-legal risk is borne by the prescriber (or supplier) based on an appropriate risk/benefit assessment.
    If it is down-scheduling, then this assumes that the medico-legal risk is generally accepted to be of low-enough significance to allow consumer OTC access.
    How then can a defined medicinal substance exist in both of these associated drug categories, purely based upon the time frame in which it was sought? It is ludicrous to say that: "This item is prescription only, except if you don't have a prescription!"
  • "No extra training". - Before a health care practitioner can prescribe medicines, they receive training.
    Whenever a medicine is down-scheduled to S3, pharmacists often receive training and/or training materials.
    However if medication continuance occurs, all of a sudden no extra training is necessary???
    This is no way to sell a health reform strategy, particularly to medical practitioners.
    I do bet however that hospital doctors will have to complete extra training on how to deal with: Pharmacist's Incompetent Supplies Seen in Emergency Departments (or P.I.S.S.E.D. for short).

Medication continuance appears to offer a solution to an important health dilemma, however its real aim must be revealed.
It is a retrospective, counter-productive, discriminative, offensive, self-serving, oppressive and arrogant; not to mention dangerous, abuse of power inflicted on an unsuspecting public by the Guild in order to protect their “turf”.

In contrast, I believe that:

  • Clinical monitoring of prescription medicine treatments MUST occur and MUST be performed in a clinical setting, NOT in a shop.
    The writing of prescriptions and the supply of medicines must occur INDEPENDENTLY of each other.
    No one person should be normally allowed to both prescribe and dispense.
    Increasing access to medicines by diluting monitoring provisions will result in patient harm.
    Any health reform that purports to incur no cost to the health dollar is fundamentally flawed.
    Allied health practitioners CAN be appropriately (and robustly) trained to become prescribers and provide clinical services to patients.

  • The ONLY appropriate way to increase public access to subsidised medicines, is to increase the number of appropriately trained practitioners (GPs or otherwise).

Stephen Carbonara.

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