Experts give a 21^st century forecast for pharmacy

What's in store for pharmacy in the 21st century? Change, change, and change. The pharmacist shortage will worsen, genomics will transform drug discovery, and senior care will become a dominant force in the profession.

That's the prediction from speakers at a Pharmacists Planning Service Inc. breakfast held at the American Pharmaceutical Association annual meeting in San Francisco.

Don't look for a major easing of the pharmacist shortage, warned Daniel Hussar, professor of pharmacy practice at the Philadelphia College of Pharmacy. Demographics and changing market conditions are stretching the ranks of pharmacists, nurses, and other health-care professionals. But while the profession remains at the mercy of an aging population and increasingly complex drug therapies, improving working conditions can significantly ease pharmacist shortages.

There is a very close interrelationship between pharmacist shortage and workplace issues,Hussar said. Working conditions can encourage or discourage pharmacists from entering specific work sites. Retail has been the big loser, he said, because working conditions in the retail setting are the most stressful in the industry. A growing number of pharmacy students who experience retail pharmacy firsthand during clerkships and part-time work are discouraged by the conditions and less likely to join the retail workforce after graduation.

They are willing to take a significant cut in pay in order to pursue opportunities that are more professionally fulfilling than retail pharmacy, Hussar explained. There comes a point when pharmacists, even newly graduated pharmacists, simply won't accept retail working conditions anymore.

To attract more retail pharmacists, employers must change the way they operate, Hussar said. The first step, he advised, is to curtail expansion in already-crowded markets. For some of the chains, the pharmacist shortage is self-inflicted,he said. Pharmacists are baffled at how these chains can open so many new outlets when existing pharmacies are so woefully understaffed.

Chains also need to make more effective use of technicians and technology to ease the pressure on pharmacists. Techs can be trained to handle third-party inquiries and other tasks as well as dispensing. He also called for more flexible work schedules, including job sharing, to bring more part-time pharmacists into the full-time work force and increase the number of female R.Ph.s in the retail sector.

On the regulatory side, Hussar called for state boards of pharmacy to consider whether another retail outlet is needed or whether there is already an abundance of facilities when approving new pharmacy licenses. Physicians and other prescribers should also be required to print scripts and include diagnoses in order to reduce callbacks and medication errors due to illegible handwriting.

Keeping an eye on genomics

Another area of change is new drug development. The 21st century has already produced a new driver in drug discovery:genomics.  A new group of products based on genetic engineering, monoclonal antibodies, and manipulation of specific molecular targets are already entering the market. With dozens of novel products already in the R&D pipeline, pharmacogenetics and pharmacogenomics are emerging as major new forces in the industry.

We're going to see a lot of new drugs simply from the searching of the human genome for more drug targets, said Kathleen Giacomini, professor of pharmaceutics at the University of California San Francisco School of Pharmacy. On a more complex level, she noted, individual genetic response to drug products is also poised to generate new therapeutic entities.

Teams at UCSF and other academic centers are examining membrane transport mechanisms, she noted. Genetic-based differences in membrane transport can impact drug activity. Researchers are looking at the genetic differences in membrane transporters, the functional significance of the variant transporters, and how genetic variation can affect clinical drug response. The answers depend on the drug and the transport mechanism.

SERT, the target for selective serotonin reuptake inhibitors(SSRIs), shows only 1.2% variation in amino acid base arrangement. MDRI, atransporter found in the intestine, liver, kidney, and brain, occurs in variantforms in 46% of Giacomini's sample population. Individuals with variantforms may respond to drugs differently,she said. Variations inmembrane transport may impact the blood level of the drug, which affects boththe side effects and the clinical effects.If the hypothesis survives,she said, future drug development might include product variations tailored tospecific genetic variants in the population.

Aging population will change pharmacy

Drugs designed to exploit genetic variation are still a possibility. Mark Sey, president-elect of the American Society of Consultant Pharmacists, believes geriatric pharmacy will become one of the mainstays of the profession. The population of elderly who are consuming vast amounts of prescription drugs is increasing,he said. The assisted-living population will increase dramatically for the foreseeable future, and most of them will be served by community pharmacy.

The aging of the population is already changing pharmacy. Older patients often consume multiple medications, Sey said. The problem: Increased drug use brings an increased risk of adverse drug events (ADEs). The highest risk population are those taking five or more medications. That's the vast majority of my population, including walk-in patients,Sey said. Studies suggest that at least 35% of elderly patients experience ADEs, he said, with a total bill approaching $170 billion annually. About 10% of ADEs result in hospitalization. And fully 90% of ADEs are preventable.

We need to give differential and more intense services to seniors, Sey said. If we don't attack this huge problem, somebody else will. If pharmacists don't provide the needed services, some other provider will.

Fred Gebhart

Fred Gebhart. A look at pharmacy trends for the new century.

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