The recent experiences of pharmacists dealing with the challenges of the COVID-19 pandemic will help to inform practice into the future. One aspect of practice that has been highlighted at this time is the pharmacist’s role in managing medicine supply and declining to supply on certain occasions.
PDL is aware of complaints to pharmacy owners as well as the regulatory agencies about declining the supply of OTC or prescription medicines. This issue has been the subject of regulatory investigation for pharmacists in the past, however the number of complaints and investigations has significantly increased in recent months when compared to PDL’s historic reporting data.
It is understandable that extreme anxiety and fear of COVID-19 are factors for some client’s poor behaviour. However, the PDL Professional Officers believe some formal complaints may have been prevented if clear and consistent messaging was provided to the client. This messaging might include signage and printed information available for display and distribution. Appropriate verbal communication between clients, pharmacists or pharmacy staff may have also prevented the escalation of some matters to a formal complaint.
A proportion of recent complaints relate to decisions by pharmacists to decline supply of salbutamol inhalers and hydroxychloroquine or an inability to supply influenza vaccines. Other cases involved declining supply of multiple quantities or repeats of medicines in the early phase of the COVID-19 crisis and prior to the government advice to limit dispensing to one-month supply.
Historically, complaints of this nature have included requests for OTC cough suppressants and antihistamines as well as prescription medicines including benzodiazepines and opioids.
PDL supports pharmacists who are practising professionally and believe supply should not be provided because of the risk of harm or a lack of indication or efficacy.
Suggestions if declining the supply of a medicine:
A thorough understanding of the patient history and treatment plan is vital.
- You may choose to decline to supply a verified prescription for high doses or large quantities of certain S8 or S4 medicines, or for frequent supply of anabolic steroids. Such a decision requires all appropriate information being gathered from the patient and perhaps the prescriber.
- While it is a frequent comment that a client demands an item be supplied, there is no obligation for a pharmacist to comply if they have concerns about any aspect of the request, even if the prescriptions are non-PBS or have been supplied in the past.
- Review of the approved indications and dose guidelines is important, and a decision is made independently of the direction or demands of the prescriber or patient. If a pharmacist is concerned about the risk of harm, dependence or diversion, then it is within their professional obligations to decline dispensing. Alternatively, deferring supply until such time as discussion about a treatment plan or specialist review would be an option.
Communication needs to be clear and appropriate.
- Extra time may be required for the pharmacist to ensure there is less confusion, misunderstanding or allegations of discrimination. If the pharmacist decides that supply is not appropriate, then a clear explanation should be provided of the reasons for this action and alternative options provided to the client. It should be clearly explained that any decision is based on concerns for a person’s health and wellbeing.
- Care should be taken to ensure there is no allegation regarding illicit or inappropriate use of the medicine.
Documentation is always important.
- Thorough documentation should always be made of the advice provided and reasons for any decision to decline supply. Good records will assist pharmacists to defend any allegations or complaints.
- Any decision must be on an individual patient basis, referenced against current guidelines or resources, able to be explained and justified and always documented.
Pharmacists may be unable to supply:
Regarding recent cases of requests for supply of OTC salbutamol, pharmacists should inform clients of the regulatory changes, the reasons for these changes and the limitations the changes place on pharmacists when assessing a request for OTC salbutamol. These changes require pharmacists to clarify the diagnosis and treatment history of the client to the best of the pharmacist’s ability and with the engagement of the client. Pharmacists should use their professional judgement and discretion in this assessment and balance the risks versus benefits of supply or denial of the supply. Referral, preferably written with clear explanation of issues, to a doctor for review should be provided to ensure continuity of care.
Hydroxychloroquine, dexamethasone or the next potential COVID treatment
While it’s now less common to receive a prescription for hydroxychloroquine compared to the recent past, the pharmacist again needs to consider the regulatory changes, the reasons for these changes and the limitations the changes place on pharmacists when assessing a prescription. If the prescriber is a GP, and records are not able to confirm prior supply or the diagnosis, then contact with the GP may be required.
Requests for other medicines touted to be of benefit for the management of COVID-19 will undoubtedly occur in the future. The same professional considerations should apply whenever presented with a prescription intended for an unapproved indication.
The high demand for influenza vaccines this year has seen shortages and clients struggling to secure a vaccine for administration by a pharmacist or medical practitioner. There have been complaints, including regulatory investigations, where it is alleged pharmacists will not supply a vaccine from stock on hand. PDL believes that these complaints are ill-founded and based on misunderstanding or miscommunication. If stock is not specifically allocated to either a pharmacy vaccination client or prescription patient, then supply of the available vaccine should occur. If all vaccines are specifically allocated to clients, this should be communicated clearly to ensure no misunderstanding by the client. Examples may include “there is no stock available for dispensing at the moment”. The client could be asked if they would like to be contacted once a vaccine becomes available. It is not appropriate to advise clients that unallocated vaccines are being prioritised for those clients vaccinated in a pharmacy.
While limited supplies and time of year may see a decrease in influenza vaccine requests, the same considerations will apply if or when a coronavirus vaccine becomes available. The benefit of hindsight from the 2020 vaccination season should be incorporated into any planning for pharmacist supply or administration of a new vaccine.
Call 1300 854 838 if this topic raises any concerns for you. PDL membership includes 24/7 access to speak with a Professional Officer for immediate advice and incident support, Australia-wide. Please leave a comment or question for our Professional Officers via the blog.