Canadian Pharmacists Journal / Revue des Pharmaciens du Canada

The COVID-19 pandemic alongside increased patient demand, enablement of scope, and government funding has accelerated the need and demand for pharmacist prescribing in Nova Scotia.

A sequential explanatory mixed-methods study was undertaken to understand barriers and facilitators to pharmacist prescribing in Nova Scotia, Canada. This consisted of: 1) a cross-sectional survey and 2) semistructured, qualitative interviews with pharmacists practising in the community. The survey and interviews were designed using the Behaviour Change Wheel that encompasses the Capability Opportunity Motivation Model of Behaviour Change (COM-B) and Theoretical Domains Framework version 2 (TDFv2).

Of 190 survey respondents, the percentage who prescribed 15+ times/month increased from 49% before to 80% during the COVID-19 pandemic (P<0.001). Pharmacists identified knowledge, social norms/pressures, and rewards or consequences related to how and when to prescribe as facilitators (Knowledge, Social Influences, and Motivation TDFv2 domains, respectively). Barriers included the environmental context and fear of negative outcomes (Environmental Context and Resources and Beliefs about Consequences, respectively). Through the interviews, the presence of prescribing decision tools (Memory, Attention and Decision Processes) and a supportive organizational culture (Environmental Context and Resources) were facilitators. Worry was expressed about making mistakes (Beliefs about Consequences) and feeling significant pressure to meet patient demand (Social Influences) in a busy setting (Environmental Context and Resources).

Supports to better enable pharmacist prescribing are described, with key messages for pharmacists, pharmacy owners/managers, educators, advocacy bodies, regulators, and government identified.

Pharmacist prescribing has increased significantly over a short period of time. Environmental supports (e.g., time, space, access to patient records), government funding, peer support, and public awareness are needed to optimize and fully implement these practice changes.

Opioid toxicity continues to have significant morbidity and mortality in Alberta. Opioid agonist therapy is an effective treatment for opiate use disorder (OUD), with first-line treatment with buprenorphine-naloxone (BUP-NAL) being both highly effective and safe. Barriers to care limit access to treatment, and more access points for treatment are needed. Pharmacists in Alberta have a wide scope of prescribing authority and high accessibility. This study describes the barriers to care and the roles of pharmacists engaged in OUD treatment, and explores the potential for pharmacists to prescribe BUP-NAL to improve access to care.

Semistructured interviews were conducted with pharmacists from Alberta in January 2024. Key informants were identified using professional networks and the reverse snowball method, and continued until data saturation. Thematic analysis was conducted by 2 investigators using open coding.

Ten pharmacists were interviewed, and 4 major themes emerged: barriers to access OUD treatment, the current role of pharmacists in caring for patients with OUD, the future role of pharmacists as prescribers of BUP-NAL, and enabling pharmacists to prescribe. Patients experience many barriers to care, and a complex health system contributes to this. Pharmacists working with patients with OUD are highly knowledgeable and involved in assessing, managing, and monitoring therapy in a multidisciplinary capacity. Extending authority for pharmacists to prescribe BUP-NAL can improve access to care but must consider collaboration and social context.

Pharmacists are skilled and positioned to improve access to care for patients with OUD needing BUP-NAL.

Lyme disease is a bacterial infection transmitted to humans through bites from infected Ixodes species of ticks. Prophylaxis with a single dose of oral doxycycline following a bite from an infected tick reduces the risk of developing Lyme disease. Pharmacists in Nova Scotia (NS) were among the first in Canada to prescribe for this indication. The primary objective of this study is to describe experiences with pharmacist prescribing of prophylaxis after tick bites in NS.

A retrospective cohort study was performed using health administrative data 16 months before and after pharmacists were authorized to prescribe Lyme disease chemoprophylaxis (August 1, 2021). All dispensations of a single dose of oral doxycycline from a community pharmacy in NS were included. Data collected included prescriber type, date, and county of dispensation. Comparisons of dispensations were completed before and after pharmacists gained prescriptive authority and relative to other prescribers. Dispensations were described descriptively.

Over the study period, 12,549 single-dose doxycycline prescriptions were dispensed in NS: 3900 prescriptions were dispensed before pharmacist prescribing authorization for this indication occurred and 8649 were dispensed after. Pharmacists prescribed 61.3% of all single-dose doxycycline prescriptions following implementation of prescribing authority.

An increase in single-dose doxycycline prescriptions was observed in NS. Pharmacists have become the primary prescribers for Lyme disease chemoprophylaxis in the province.

Patients were willing to be assessed for chemoprophylaxis after tick exposure by pharmacists, and pharmacist prescribing for this indication suggests increased access to post-tick exposure care.

In February 2022, a novel antiviral for the treatment of COVID-19, nirmatrelvir/ritonavir (Paxlovid), was approved by Health Canada and made available to patients in British Columbia (BC). BC community pharmacists did not prescribe nirmatrelvir/ritonavir, but dispensing involved a detailed assessment with close attention to drug-drug interactions and patient monitoring. As the nirmatrelvir/ritonavir service was unique in BC, and not all pharmacists participated in the program, it is important to evaluate the perspectives of all the pharmacists who were affected so that lessons learned from the program can inform future pandemic planning and government initiatives.

A qualitative research study using key informant semistructured interviews was conducted. Community pharmacists with varying degrees of experience with nirmatrelvir/ritonavir were recruited using multiple methods of recruitment through e-mail and fax invitations and social media posts. Open-ended questions explored pharmacists’ experiences with the nirmatrelvir/ritonavir program, including barriers and facilitators to dispensing it, and recommendations for future pharmacy initiatives.

Forty-three community pharmacists participated in the study. Most participants were between the ages of 30 and 39 years and had practiced for less than 10 years. Thematic analysis yielded 36 codes that were organized into 3 overarching themes related to the following: learning; in-process experiences, supports, difficulties; and perceptions about the expanded scope of practice.

The following strategies may be helpful to consider including in future initiatives: preprinted forms, a hotline for peer support, slower rollouts, a single source for communicating changes, a patient portal, addressing the divisions between dispensary and clinical work, and having specialized positions to support future rollouts.

Lessons learned from the nirmatrelvir/ritonavir service included a slower approach to program initiation with additional training opportunities and more streamlined prescription options. Pharmacists also wished for better communication support and involvement in the planning of future initiatives.