Prescription for Ferment

The use of prescription drugs has soared in the last decade, and the number of prescriptions issued in the United States is expected to rise 9% this year alone. For many diseases, drugs have supplanted other forms of treatment, such as surgery. The big issue is whether to include prescription drug coverage in Medicare--but it is not the only issue. Debate is also heating up in state legislatures and in Washington over who gets to prescribe drugs, and which drugs should be prescribed at all.

Two specific disputes involve California psychologists and optometrists. Both professions are pushing bills in Sacramento that would give them new authority to prescribe medications. The largest physician lobby in the state, the California Medical Assn., opposes both bills as medically risky. At least a healthy debate has been launched. Legislators should consider each bill on its merits.

The more carefully crafted bill, SB 929, by Sen. Richard Polanco (D-Los Angeles), would allow specially certified optometrists, in consultation with ophthalmologists, to prescribe antibiotics as well as some allergy and glaucoma medications. The medical lobby opposes the bill on the ground it could lead to optometrists overprescribing antibiotics. However, the California Academy of Ophthalmology tellingly does not oppose this bill, and there is no evidence of such a problem in the 33 states and the many nations that allow optometrists to prescribe some antibiotics. Polanco’s limited, careful measure deserves support.

The public need for the second bill, AB 1144, by Assembly members Sam Aanestad (R-Grass Valley) and Gloria Romero (D-Los Angeles), is less clear. Aanestad and Romero argue that their bill, which would allow a small group of trained psychologists to prescribe medications, would help rural areas and inner cities that have relatively few psychiatrists. However, the bill would limit prescription privileges to 10 psychologists who graduated from a now-defunct federal pharmacology training program. More troubling, the bill is vague. Rather than restricting psychologists to relatively safe drugs like the newest generations of antidepressants, it would allow them to prescribe and administer any “drugs for the treatment of disorders related to the practice of a psychologist.” This bill needs more thought.

There is also ferment on the federal level. Earlier this month, the Food and Drug Administration decided to consider allowing over-the-counter purchases of several popular prescription drugs to control allergies or cholesterol. The move came after Blue Cross of California lobbied the agency to grant over-the-counter status to the popular allergy drug Claritin. Consumers might find this convenient, but Blue Cross is clearly moved by cost factors. Should it succeed, the insurer could delete Claritin from prescription-drug coverage and probably reduce doctor visits by allergy patients as well. Currently, health insurers cover most of Claritin’s U.S. sales of $2.3 billion.

There is no indisputably clear mark dividing “safe” over-the-counter drugs that anyone can use without supervision from “risky” prescription drugs needing physician oversight. Consider, for example, the 2,500 reports of serious side effects and 79 deaths the FDA has associated with the use of over-the-counter and largely unregulated dietary supplements since 1993.

Legislators should proceed with caution. At a time when managed care companies are under increasing pressure to trim costs, there is a genuine danger that the lines will be drawn to benefit special interests more than patients.