Using executive action, governors in many states can use a relatively untapped means of reducing the cost and improving access to prescription drugs for their citizens.
This action is known as standing orders. They’re pre-written, clearly defined medication orders and instructions from a licensed medical practitioner to ancillary licensed healthcare practitioners, such as pharmacists.
Classifying prescription-only versus over-the-counter is a federal prerogative. But defining the scope of practice of state-licensed healthcare practitioners is a state prerogative. Unfortunately, expanding the scope of practice of non-physician healthcare practitioners is often easier said than done.
The various licensed health professions jealously guard their turf, and resist surrendering authority to competitors. This usually leads to long and contentious legislative battles pitting lobbyist against lobbyist, sometimes taking years to resolve. The standing order provides a way around that.
More than half the states use this tactic to get around the Food and Drug Administration’s prescription-only classification of the opioid overdose antidote naloxone. The standing order makes it easier for the people who use opioids — or those who care about those people — to get access to naloxone while saving the time and expense of a doctor’s office visit.
The state’s public health commissioner or chief medical officer (if this person is also a licensed medical doctor) fills the role of the prescribing physician for anyone requesting naloxone from a pharmacist by issuing a statewide standing order.
There are other workarounds. States where the chief public health official is not a licensed physician have expanded the scope of practice of licensed pharmacists so they can prescribe naloxone.
This problem should have been solved already. For a couple of years now, the FDA has invited the makers of naloxone to request a reclassification of the drug to over-the-counter, even though the FDA Commissioner can order the reclassification without being asked. None of the drug makers have shown interest. The urgent need to reduce overdose deaths drove the states to craft the above workarounds.
Similarly, despite the fact that the American College of Obstetrics and Gynecologists, American Academy of Family Physicians and the majority of reproductive health providers have, for years, called for hormonal contraceptives to be available over-the-counter, the FDA has failed to act.
As a result, 11 states and the District of Columbia have expanded pharmacists’ scope of practice so they can prescribe oral contraceptives — saving many women the inconvenience and expense of a doctors’ appointment. And in late 2019, California allowed pharmacists to prescribe pre- and post-exposure prophylaxis for HIV.
Currently more than half the states plus the District of Columbia have state public health commissioners or chief medical officers who are also licensed medical doctors. Governors in those states have the standing order arrow in their executive action quiver. Their public health officers serve in the executive branch at the pleasure of the governor. They can issue standing orders for several other medications in addition to the order already issued for naloxone.
Examples include prescription-only smoking cessation drugs, non-sedating/low sedating antihistamines, decongestants, corticosteroids and oral fluoride. All 50 states allow pharmacists to administer vaccinations. A standing order can be issued to allow pharmacists to perform and interpret Tuberculin skin tests.
Women can buy and take over-the-counter pregnancy tests. Pharmacists should be given a standing order to perform swab tests and cultures, and administer common prescription medicines for strep throat and influenza.
None of these standing orders compel pharmacists to dispense a drug if they are uncomfortable doing so. Pharmacists can always refer the patient to a physician. Likewise, none of these orders prevents a patient from seeking the advice and prescription of a licensed medical doctor.
But a more liberal use of the standing order provides a way for governors to improve choice, expand access and reduce the cost of healthcare for their residents while bypassing special interest haggling down at the state legislature.
It lets governors take some positive action while Washington continues to drag its feet.
