The Two Roles of a Community Pharmacist: Medication Dispenser and Counselor

Counseling is one of the most important job functions for a community pharmacist as so many things can be discovered, fixed, and addressed. Although one of the biggest barriers to thorough counseling at every encounter is time, community pharmacists can pinpoint situations where counseling may be more necessary and even beneficial for their patients.

One of the most eye-opening things that I have ever learned about health care was an anecdote told to me by a community pharmacy preceptor during my APPE rotations. He said that many prescribers truly believe that their patients take their medications correctly every single day. Maybe it is because these prescribers think and believe the best of their patients; or maybe it is just because they have never been exposed to the fact that patients are not adherent with their medication regimens.

Since learning this, I have always practiced pharmacy with the following mindset—medication that is taken always works better than medication that is not taken. 

Prescribers are at a disadvantage because they only see half of what community pharmacists can see. While they know what they prescribed and when, they cannot see the other details such as the fill date, pick up date, and copay. One issue is that the medication may never get picked up by the patient, and the prescriber would have no way of knowing.

During the dispensing process, pharmacists can see trends and pinpoint opportunities for counseling. While asking every patient what questions they have for the pharmacist is a great starting point, it is sometimes necessary for community pharmacists to actively engage patients with more targeted questions.

For example, I recently noticed that a patient was picking up their 30-day supply of Vraylar (cariprazine) every other month, rather than monthly. The next time I saw the patient, I made a point to ask them some questions about the medication. By asking targeted questions, without judgement and assumptions, I discovered that the patient was having difficulty affording the medication and so they were only taking it every other day rather than daily as prescribed. The patient seemed very embarrassed to discuss the cost, but if they had made these comments, we would have realized there was a problem sooner. I helped the patient sign up for the manufacturer coupon card and contacted the prescriber to get a 90-day prescription instead, and the result was a prescription that was well within the financial means of the patient.

Although I was able to help this patient, the prescriber had no idea that the cost was an issue for the patient, and the patient never divulged to the prescriber that they were taking only half as many doses due to the cost.

Not only did this interaction help the patient in this instance, but it also demonstrated to the patient that I had their best interest in mind. In the future, they will hopefully feel more comfortable coming to me with any concerns regarding medications or other mental health issues which may arise.

Trust with patients is built over time but increases with each positive interaction between the pharmacist (or technicians) and the patient. 

Another advantage of the community pharmacist is that the patient’s full medication list is available all in one spot, whereas various prescribers may not have full med lists if the patient does not provide that information, and EMR systems do not connect.

Many psychiatric medications have severe interactions with other commonly prescribed medications, and the pharmacist is in the perfect position to evaluate that risk. For example, many antipsychotics cause QT prolongation, so azithromycin could be a dangerous choice.

Serotonin syndrome is another adverse event that needs to be evaluated when multiple medications that increase serotonin are used. Tramadol and dextromethorphan are often prescribed for short term use but could greatly increase the risk for serotonin syndrome if the patient is taking multiple SSRIs or SNRIs, among others. 

Pharmacists are key in evaluating interactions such as these, especially in this specific patient population. 

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