On The Cover
Sonya Collins
With pharmacies in every town, and on nearly every city block, a pharmacist is often the most accessible health professional around. Americans never saw this more clearly than during the COVID-19 pandemic, when community pharmacy programs alone administered more than 270 million COVID-19 vaccinations from February 2020 to September 2022 and more than 50 million flu shots a year during that same period, according to a 2022 JAPhA study. But health care professionals would be remiss to suggest that immunizations are the only way in which pharmacists can make a significant impact on public health. With the right support, and payment for their clinical services, these community clinicians could be helping more patients quit tobacco, access HIV prevention and treatment, obtain and receive counseling on birth control, and connect to harm reduction services—all in the same place they pick up their prescriptions. Yet in much of the country, this role remains untapped.
“Pharmacists are accessible, they’re well trained, and it takes an average of 27 days to get in to see a primary care provider. That’s why we need pharmacists filling these gaps,” says Karen Hudmon, PharmD, a professor of pharmacy practice with a focus on tobacco cessation at Purdue University. “Pharmacists can have a massive impact, even in minor things. Small, widely implemented interventions can have a big public health impact.”
Immunizations
Nowhere else is the footprint of pharmacists in public health larger than in the realm of vaccines. A 2023 report from Global Healthy Living Foundation and consulting firm IQVIA found that members of the pharmacy team administered more recommended routine vaccines than physicians from 2020 to 2021.
During that time, most COVID-19, flu, and shingles vaccines were administered in pharmacies. The largest gains were seen in HPV vaccines, however. Fewer than 10% were administered in pharmacies in 2018; nearly 20% were given there by the end of 2021, according to the report.
Training to immunize is a critical part of pharmacy education from the beginning.
“Student pharmacists are trained on how to immunize early on in the curriculum, through the APhA Pharmacy-Based Immunization Delivery program, so they actually get certified while they are in pharmacy school,” said Gretchen Garofoli, PharmD, a clinical professor at West Virginia University School of Pharmacy. “By the time they’re in their third year and going out on rotations, they’re already giving vaccines to patients in the community.”
Increasingly, pharmacists not only need to be prepared to administer vaccines, but they must also be prepared to help patients distinguish between facts, misinformation, and conflicting information.
In the first major divergence in about 30 years, ACIP’s and CDC’s current recommendations for COVID-19 vaccines do not align with those of national medical associations, such as the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP). During this flu season, pharmacists need to be ready to explain that discrepancy and how patients can access the vaccine.
“ACIP and AAP recommendations used to be harmonized, but now they are not,” Garofoli said. “As health care practitioners, we need to know when groups don’t agree and why that happens. The evidence didn’t change. Only the recommendations did.”
HIV management and prevention
Pharmacists also control the spread of infectious disease through HIV management and prevention. As of 2023, more than 1 million people over 13 years in the United States and six of its territories were living with HIV. Pharmacists are well positioned to help patients manage the virus and avoid transmitting it to others.
Appropriate prescribing of and adherence to antiretroviral therapy (ART) is the cornerstone of keeping patients’ viral load undetectable and preventing transmission to others. But medication management of HIV brings significant challenges that pharmacists can help mitigate.
Research shows that inpatient HIV-related medication errors occur in up to 86% of patients. In this context, pharmacists are leading ART stewardship programs in hospitals.
Adherence to ART is also a major challenge for HIV management and care. A 2021 study in Advances in Therapy found that some 60% of patients with HIV who take ART have suboptimal adherence, defined as taking their medication less than 90% of the time. Forty percent of patients had poor adherence, taking their medication less than 80% of the time.
“Pharmacists make sure patients stay undetectable,” said Elizabeth Sherman, PharmD, an associate professor of pharmacy practice at Nova Southeastern University in Fort Lauderdale, FL. “Whether that’s through fixing medications, ensuring complete regimens, counseling on adherence, simplifying the medication regimen, monitoring labs, or identifying [drug] resistance as soon as it happens.”
In addition to helping patients manage and adhere to their medications, pharmacists are increasingly involved in the prescribing and management of PEP and PrEP and offering HIV testing.
As HIV has become a chronic, lifelong condition, Sherman said, “pharmacists have become part of the lifespan for people with HIV.”
She added that from pediatrics to geriatrics, people who are pregnant, and everyone in between, pharmacists are growing in what they can do and how they collaborate with other health care providers to achieve optimal patient outcomes.
“The pharmacy is a very nonstigmatizing setting for many interventions,” Sherman said.
Harm reduction
Pharmacists can also create stigma-free settings for harm reduction efforts regarding opioids. To start with, pharmacists can ensure that front-of-store and counter staff, such as cashiers and pharmacy technicians, are familiar with naloxone and know the appropriate way to respond when someone comes into the pharmacy seeking it.
When it comes to overdose prevention, the pharmacy team can also educate caregivers and loved ones on how to administer naloxone when needed.
“The person using drugs can’t reverse an overdose themselves,” said Anita Jacobson, PharmD, a clinical professor at the University of Rhode Island College of Pharmacy. “We want everyone in the community to be a first responder of sorts, just to have the knowledge and tools to recognize when somebody might be having difficulty as a result of an unregulated substance.”
Harm reduction means educating families and communities affected by opioid and other substance abuse about the signs and how to respond. Jacobson provides this education at libraries, town halls, schools, and through community organizations in her capacity as program director of the Community First Responder Program and Northeast Rural Opioid Technical Assistance Center in Rhode Island.
“Naloxone is a component of harm reduction, but for many unregulated substances, there isn’t a reversal agent,” Jacobson said. “We teach people how to recognize when a substance-related event has progressed to a medical emergency, when to call 911, and what you should and shouldn’t do while you wait.”
Harm reduction is not only about teaching the community how to respond to drug-related medical emergencies. Pharmacists are in a strong position to recognize substance use problems and connect patients with resources and care, whether it is syringe exchange programs or a path to stable housing.
“A lot of being a public health pharmacist is being a liaison and knowing how to help connect people to different services that are available,” Jacobson said. “Harm reduction is about triaging and connecting people.”
Opponents have argued that harm reduction initiatives that pharmacists are well equipped to lead enable substance abuse, but data contradict that. A 2022 study in Harm Reduction Journal by Krawczyk and colleagues shows that people who engage in harm reduction programs are five times more likely to seek treatment and three times more likely to stop using drugs than those who don’t engage in these programs.
Tobacco cessation
One in five U.S. adults report current use of a tobacco or nicotine product including cigarettes, e-cigarettes, cigars, or smokeless tobacco. In many cases, pharmacists are the health care provider most prepared to address this continuing public health challenge.
There are a number of ways pharmacists can help patients quit.
“Almost every pharmacy student is graduating well equipped to do this,” said Hudmon. “They may get more tobacco cessation training than providers in any other discipline.”
What’s more, patients seeking help quitting can see a pharmacist right away, Hudmon said, compared to the nearly 4 weeks on average they may wait to see their primary care provider.
But patients don’t have to actively seek help in order for the pharmacy team to make an impact. A study coauthored by Hudmon and published in JAPhA in 2018 found that when pharmacists and technicians were trained to offer quit-line referrals to patients in the pharmacy, the number of callers reporting referral from a pharmacy doubled.
“This is just by bringing in technicians, having them ask about tobacco use, advise patients to quit, and then refer those who are interested to the pharmacist or to 1-800-QUIT-NOW, which is an incredible resource that’s underutilized by every discipline,” Hudmon said.
In a current pilot program, Give Quitting a Shot, Hudmon and her colleagues are training pharmacists and technicians to assess tobacco use and a patient’s willingness to quit while administering vaccines. Previous research has demonstrated the efficacy of these types of interventions at health fairs, food pantries, and other events that serve low-income communities where tobacco use is highest.
“None of this has anything to do with prescribing,” Hudmon said. “It just shows that brief, minimal interventions can be wildly successful.”
When pharmacists can prescribe medications for smoking cessation, they can make an even bigger impact. Studies show that the majority of patients are comfortable discussing smoking cessation with a pharmacist, and abstinence rates on pharmacist-managed varenicline are comparable to those managed by other providers.
To help patients obtain those services, Hudmon and her colleagues at Purdue University and UCSF School of Pharmacy have built an interactive map, available at QuitSmokingPharmacies.com, through which patients can locate the nearest pharmacy offering smoking cessation services.
Birth control prescribing
This year, Michigan became the 35th state to grant pharmacists the authority to prescribe birth control. However, the number of pharmacists authorized to prescribe birth control still far outnumbers the number of pharmacists who offer it. Barriers to prescribing birth control include lack of reimbursement for consultations and little time or money to complete training requirements.
For pharmacists who want to prescribe birth control, national and state organizations—and companies—offer training and resources to prepare pharmacists to prescribe birth control in their pharmacies. Even schools of pharmacy in states where pharmacists don’t have prescribing authority, such as Florida, teach student pharmacists about contraception with an eye toward preparing them for practice in any state.
“Pharmacists may not always have prescribing authority, but we’re often the ones who can make birth control more accessible just by answering questions, counseling on correct use, and making sure patients know what options are available to them,” said Jasmine Cutler, PharmD, an assistant professor at the University of South Florida Taneja College of Pharmacy.
Pharmacists who do not or cannot prescribe can be advocates and advisors to patients seeking birth control by referring them to clinics where they can access prescription contraception and counseling them on OTC Opill. ■
A long-standing barrier to public health pharmacy
A 2022 study in JAPhA found that there were 15% more pharmacies than physician practices in low-income communities. These neighborhood health providers offer nearly twice as many operating hours as physician practices and are far more likely to accept Medicare Part D.
Figures like these underscore pharmacists’ prime position to improve public health, but one of the greatest barriers they face to this mission is receiving payment.
“Doing all of these things is great, but there is a pressing need for advocacy and policy to ensure pharmacists get compensated for these roles,” said Elizabeth Sherman, PharmD, an associate professor of pharmacy practice at Nova Southeastern University in Fort Lauderdale, FL. “It’s important that pharmacists continue to advocate for policy changes that match their expanding roles. That includes provider status and reimbursement for services. That needs to be universal.” ■