There are big changes afoot for pharmacies both in Idaho and across the United States.

Starting July 1 in Idaho, if you have a short-term illness or something that can be diagnosed via an easy test such as a sinus infection, strep throat or a cold sore, instead of going to the doctor, you can get a prescription straight from your local pharmacist.

In addition, if you have something that has been previously diagnosed, such as asthma, you don’t have to return to your doctor for a refill of your prescription. That, too, you can get from a pharmacist.

This is all thanks to House Bill 191, which was passed into law by the Idaho Legislature last year.

YOU CAN JUST WALK IN

According to Dr. Jennifer Adams, the associate dean for academic affairs at Idaho State University’s College of Pharmacy, each year the Idaho Board of Pharmacy goes to the Legislature and asks for certain things that pharmacists be allowed to prescribe in the pharmacy. So pharmacists have been able to prescribe independently, for some things written into state statute, since the 1990s. For instance, pharmacists have been able to prescribe fluoride for several years.

“We have counties in the state of Idaho that do not have fluoridated water,” Adams said, “and so the dental community was concerned and wanting patients to have easy access to getting fluoride supplements for their children.”

Last year, at the urging of the Board of Pharmacy, the Idaho Legislature decided to greatly expand what the state’s pharmacists can prescribe.

“Last legislative session … there were a number of things that were brought forward from the Board of Pharmacy and the pharmacy community to our state Legislature and they passed those,” said Adams, who teaches the pharmacy law class at ISU and has doctoral degrees in pharmacy and education. “But there were some members of the Senate and the House Health and Welfare committees who said ... ‘Is there not a more efficient way of doing this other than each separate thing being brought to the Legislature?’”

So House Bill 191 was passed, allowing for the Board of Pharmacy to determine for itself in its rule-making process which items pharmacists could prescribe.

Still, there are only certain conditions pharmacists can prescribe for.

There are four cases in which pharmacists can prescribe medicine: for something that doesn’t need to be diagnosed; for something that is minor and will run its course (for instance, a cold sore), which is called “self-limiting” in the health care community; for something that has a simple test that can be done by the pharmacist (for instance, a strep test); or in instances of emergency.

FEWER REGULATIONS

In addition to letting pharmacists prescribe a lot more medications, the Board of Pharmacy was able to reduce some other regulations.

“One of the more important things to happen at the same time (as House Bill 191) was a reduction of regulation in the rule book,” Adams said.

Adams said that reduction has allowed increased access to health care for Idaho’s smaller communities.

“Really that’s what all of this is about,” Adams said. “We want to provide access to patients who would otherwise enter the health care system in another place. It’s fairly expensive to enter the health care system at urgent care or at an emergency room. If you have access through a pharmacy to be able to handle things that are minor or self-limiting then it’s not as expensive.”

Adams said there is also more room for innovation thanks to the change in regulations.

“We now have telepharmacies in the state of Idaho,” Adams said. “We have these broad allowances that have benefited communities.”

According to Wikipedia, “Telepharmacy is the delivery of pharmaceutical care via telecommunications to patients in locations where they may not have direct contact with a pharmacist.”

Patients can talk to a pharmacist via video conference and get their medications prescribed locally.

Adams said there are communities in Idaho that haven’t had a pharmacy in more than 40 years but now have a telepharmacy.

“They have access to pharmacy services and care that they would have had to drive a distance to get to before,” Adams said.

NEW COMPOUNDING STANDARDS

In addition to the changes at the state level, there are also big changes happening to pharmacies nationwide.

Compounding labs across the country are having to deal with and remodel their businesses to deal with a new regulation aimed at pharmacy safety created by the United States Pharmacopeia, which creates the regulations for pharmacies and their employees in the U.S.

One compounding lab in Pocatello is expanding its lab by 800 square feet and investing $400,000 to keep up with the regulations and keep compounding.

“It can be overwhelming, but I think the first thing you have to do is tell yourself this is what we do, this is who we are,” said Tori Shaver, the co-owner of Shaver Pharmacy, located at 235 S. Fourth Ave. in Pocatello. “Once you’ve decided that, then you need to commit yourself to doing it right.”

Shaver Pharmacy specializes in compounding, and when its owners Tori and his wife, Lorri Shaver, learned of the standard change, called USP <800>, which comes into effect in December 2019, they knew they’d have to make the upgrade.

“Compounding is making things from scratch,” Lorri said.

If you compound, essentially you can take a drug and put it into any form.

“If you have a child who can’t swallow a tablet and he’s 2, we might make (the drug) into a gummy or a liquid,” Lorri said. “Or … it’s really hard to give a cat medication, so we might make it into a cream … that you can rub inside the cat’s ear and then you’re not getting bit trying to pill a cat.”

And women all over the country are using compounded hormones that more exactly match their symptoms.

Shaver Pharmacy already specializes in sterile compounding, which is regulated by USP <797>, which has more stringent regulations and the environment is more controlled and tested than in general compounding.

Lorri said Shaver Pharmacy is the only pharmacy in Southeast Idaho that is accredited to do sterile compounding.

But USP <800> will be even more strict and will focus on keeping both the pharmacy employees and the patients safe.

“USP <800> moves into recognizing that these powders that … our employees work with, even though they’re beneficial to the patient because that’s what they need, can be hazardous chemicals to the people preparing them,” Lorri said.

According to Pharmacy Times Continuing Education, “Hazardous drug exposure is an issue of vital importance for pharmacists and pharmacy technicians. Abundant evidence has shown links between hazardous drugs and increased risks for cancer, teratogenicity (something that causes birth defects), and reproductive problems. USP General Chapter <800> provides standards for safe handling of hazardous drugs to minimize the risk of exposure to health care personnel, patients and the environment.”

Lorri, who teaches the compounding lab at ISU, said USP <800> is supposed to protect the public by making sure their medications are completely sterile, and it is intended to protect the pharmacists, who are routinely exposed to chemicals and substances that could be harmful for them, as well.

“When I have (my students) make capsules, I have them use food coloring powder, and I tell them, ‘This food coloring is your hazardous drug,’” Lorri said. “The lab is a mess, covered in rainbows. They have powder around their nostrils. They’ve been wearing gloves. It’s gone through two pairs of gloves. It’s all over their clothing. It’s all over the floor. And I say, ‘Now you’re going home to your 2-year-old and gonna give them a hug with those scrubs that you just wore.’”

USP <800> is there to put regulations in place to prevent such exposure from happening.

“This goes beyond pharmacy,” Tori said. “Pharmacy is just the first step in this because it’s the place where most of these drugs are prepared.”

These drugs, if they aren’t properly prepared and if workers aren’t properly protected, can expose anyone from delivery drivers to pharmacists to nurses to housekeepers and more.

“It’s all of health care,” Lorri said.

Some of the changes taking place at Shaver Pharmacy include rearranging much of the building. The compounding lab will move upstairs. The contaminated air from the compounding lab will need to be ventilated immediately outside. Employees will have to wear more protective gear. Hazardous materials will have to be incinerated instead of just washed down the sink.

“We’re the Boy Scouts of this,” Tori said. “We believe in doing what is required at the federal level.”

Tori said some compounding labs might “roll the dice” and not make the changes to their buildings. But they will likely be fined by the Federal Drug Administration and shut down for exposing their employees to the dangerous substances.

Tori said that adding that if some compounders decide to not make the upgrades and get out of compounding altogether, that only benefits Shaver Pharmacy.

AMAZON MOVING IN ON THE MARKET?

The news of Amazon entering into the pharmacy world was released last year.

This has some pharmacy companies feeling anxious, and according to Pharmacy Times, two grocery chains that contain pharmacies, Bi-Lo and Tops Friendly, are preparing to file for bankruptcy. Apparently, Amazon getting into the pharmacy market contributed to the bankruptcies.

The article in Pharmacy Times states, “Now that Amazon, with its acquisition of Whole Foods, has entered the brick and mortar arena, some of the older chains are being forced to find new ways to compete if they want to survive.”

It is expected that there will be some tension placed on the middle-men: pharmacies.

There is a term called the “Amazon Effect” — when Amazon infiltrates markets, brick-and-mortar stores start closing.

To offset the “Amazon Effect,” Lorri Shaver says Shaver Pharmacy is specializing in something that can’t be easily done: compounding. And after July 1, Shaver Pharmacy will take advantage of the new Idaho law allowing it to prescribe medications to patients.

According to Pharmacy Times, “With Amazon’s growth escalating, from 19 percent in 2014, to 20 percent in 2015, to 28 percent in 2016, jobs are being taken away from traditional retailers. Thousands of jobs are being lost across traditional retail in stores, supply chain positions, and headquarters facilities.”

Pharmacy Times reports that 2 million additional jobs in various sectors of the U.S. economy are expected to be lost over the next five years as a result of the “Amazon Effect.”

Could some of those lost jobs be in the pharmacy industry? It appears so.

OTHER CHANGES TO STATE RULES

Dr. Adams said the Idaho Board of Pharmacy has recently strengthened and preserved all of the state’s opioid-prescribing laws.

“Opioid abuse is a significant issue across the country and in the state of Idaho, especially in Southeastern Idaho,” Adams said.

The Board of Pharmacy last month put out a prescriber report that is sent to anyone who prescribes opioids. It compares each physician’s prescribing habits to other doctors in their same field and shows if they are an outlier or not.

According to Adams, when Arizona implemented this process, it saw a 10 percent reduction in the amount of opioids being prescribed.

“We want to make sure patients have access to pain medication when they need it but that we’re not over-prescribing and ending up with more opioids out there in the community that could potentially be used,” Adams said.

Patients can also get a partial prescription for opioids now if they only want a couple days’ worth of pills, so they don’t have leftovers in the house.

“If you don’t need it, you don’t have it, and you don’t have it in your home,” Adams said.

‘HUGE SHIFT IN HEALTH CARE’

Adams said health care professionals, namely doctors and pharmacists, can work really well together, and the new Idaho law is a great way to collaborate.

“When it comes to how we train health care professionals, the roles go hand in hand,” Adams said. “With a physician, they diagnose and they say what’s going on with their patients, and they have a lot of education on how to do that. Pharmacists get a little (of that type of education) but not a lot. And then on the physician side, they get some education about treatments and about what’s most appropriate, and pharmacists get a lot. It’s a collaboration, and we can work really well together.”

Lorri Shaver also commented on how collaboration with doctors can help patients.

Instead of going to five different doctors who each prescribe different things, some of which could be conflicting and unhelpful, starting July 1 you will be able to get everything you need from one pharmacist.

“A pharmacist … can look at all of that information, sit down with the patient and say, ‘This is kind of a duplicate therapy,’” Lorri said. And then they can help the patient get on a better medication regimen.

Adams said this should help with Idaho’s primary care physician shortage, adding that Idaho is a very dismal 49th out of 50 states as far as doctors per capita.

“It just allows another access point for people in our state to get access to services,” Adams said about pharmacists being able to prescribe.

Lorri said the state Board of Pharmacy is making Idaho a great state to practice pharmacy.

“(They are) making Idaho one of the best states in terms of pharmacists’ ability to practice,” she said. “And safety for the public.”

Lorri also touched on the changes coming from the Idaho Legislature and House Bill 191.

“It’s a huge shift in health care right now,” Lorri said.

Tori Shaver said that despite the stress of all the changes in the pharmacy world, he’s looking forward to the future.

“With the stress that we have because of these changes and what we’re trying to do, I would be under more stress if we were sitting here doing nothing,” Tori said. “Because I know the outcome.”

In response, Lorri said, “We would be a dinosaur.”