Ontario is picking up nickels in front of the steamroller of antibiotic resistance
Letting pharmacists prescribe antibiotics is inviting doom
The Toronto Star published an opinion piece yesterday on something that I alluded to a few days ago:
Pharmacists can now prescribe antibiotics for common infections — but this may hurt our health-care system in the long run.
[..]
Canada is already over-prescribing antibiotics, and it’s contributing to a larger public health problem known as antimicrobial resistance — when illness-causing microorganisms like bacteria become resistant to the drugs used to treat them. Antimicrobial resistance is a serious concern; the Centers for Disease Control and Prevention estimates that well over a million people died from it in 2019 alone.
Pharmacists are now allowed to prescribe some drugs for common conditions other than covid, such as hay fever, pink eye, cold sores, etc. The idea is that by allowing patients to access care at pharmacies, since many Canadians do not have timely access to medical care, they can receive faster care while also preventing people from going to the emergency room.
I’ve been hearing about the risks of antibiotic resistance for years, although I’m by no means an expert. The WHO considers it one of the biggest threats to global health, food security and development today.
As the Star correctly points out, many of the costs of over prescription are externalized and not borne by either the patient or the pharmacist:
The health cost of antibiotic over-prescription is not borne by the individual who gets a prescription. An unnecessary prescription for a urinary tract infection has no significant impact on the health of the antibiotic’s user, barring adverse drug reactions.
There are trade-offs to any policy. I’m not convinced the government has either noticed the trade-offs or considered whether they are worth it or not. This is essentially a technical debt decision: Ontario is implementing a policy in the short term that will have costs in the future. Even worse, the costs are nonlinear. Letting Canada’s health care system collapse is obviously bad, but can be solved over time. That period of time might be years with many, many unnecessary deaths, but allowing microbes to develop resistance to antibiotics puts modern society at risk. As the WHO states,
Antibiotic resistance is putting the achievements of modern medicine at risk. Organ transplantations, chemotherapy and surgeries such as caesarean sections become much more dangerous without effective antibiotics for the prevention and treatment of infections. - source
Canada’s health care system may go through a period where Canadians cannot access health care, but the alternative is much worse and irreversible. I don’t claim to be an expert on health care, but I can see that there is a trade-off involved here that I am not convinced the government has considered. As Taleb would put it, pursuing small gains with large risks is like picking up nickels in front of a steamroller.
Conflict of interest?
Further from the article:
Community pharmacists also earn dispensing fees when filling prescriptions. It is a conflict of interest if a person prescribing drugs can collect revenue from dispensing the drug. While patients are under no obligation to fill their prescription at the same pharmacy they receive it from, it’s likely the majority will.
Conflicts of interest are not new to health-care professionals. For example, physicians bill the Ontario Health Insurance Plan for services they can order and provide for patients. Unethical conduct is known to occur where money and patient care collide — and the incentive to prescribe drugs has never before been made so explicit in Ontario
The Star’s big expose today is that pharmacists earn money when they provide services. According to the source they’ve linked, the potential earnings from over prescribing is $8.83 per patient (higher in rural areas). I find the idea that any pharmacists would be enticed by $8.83 per patient to be implausible, especially considering that the pharmacists also need to do work in order to dispense the drugs. They need to speak with the patient, diagnose the problem, measure and package the drugs, explain usage, etc. None of this is particularly difficult, but the cost of drugs is regulated as well, and the fees go towards paying for the pharmacists time. The big scoop here apparently is that pharmacists are incentivized to get paid for their work.
A bigger problem in my opinion is that pharmacists really have no skin in the game. It’s the same issue that walk-in clinic doctors have. There are too many people to treat to spend any real amount of time with them and their incentives are to turn people over quickly to either get through the work load or make more money on seeing more patients. A patient who has received a prescription (or drugs directly from the pharmacist) is a happy patient because they feel they have had their problem solved. A happy patient goes away, and the doctor/pharmacist will likely never see them again. If they do see them again, they can fall back on not seeing the whole medical history, it was an idea, go see your family doctor, etc. There’s no incentive to solve problems, but to just make problems go away.
Back when I had a family doctor, his opinion was that bronchitis was wildly over-diagnosed. Its symptoms are quite commonly seen by walk-in clinic doctors, and its easy to give drugs (that in many cases don’t work) to make the patient go away. His opinion was that often the symptoms would go away by themselves in a few days, drugs or not, but giving out the drugs made the patient feel better and made the doctor’s lives easier.
Even better, at least here there is no feedback loop between actions doctors take and outcomes, except in egregious cases of malpractice. A patient taking antibiotics they don’t need poses (generally) no harm to the patient, and the doctor generally doesn’t care if it worked or not.
What about Paxlovid?
I must now reconcile what I’m arguing here with my last article on pharmacists dispensing Paxlovid against covid. Paxlovid of course is not an antibiotic and doesn’t have the same downstream effects of obsoleting modern infection control, although it might have a similar effect on covid itself.
That being said, we shouldn’t forget as well that covid is incredibly dangerous for older adults. Urinary tract infections are uncomfortable or painful, and if left untreated can cause worse complications, but covid kills. Paxlovid leads to a 44% drop in risk of hospitalization or death in adults 50 or over. There’s an obvious benefit there with potential costs. It’s also probably generally easier to diagnose covid, as opposed to many of the other conditions. Patients have access to rapid covid tests, while it would likely not be possible for a pharmacist to distinguish between a urinary tract infection and something much worse. Therefore, it’s much easier to judge whether Paxlovid would have an impact versus some of the other drugs, and the potential impact is much higher.
This is the sort of trade-offs that need to be considered. Paxlovid has considerable upside with smaller downsides. “Common conditions” treatment has a small upside, and while it will usually have no considerable downsides, some of the possibilities are devastating to modern society. I don’t really trust the government of Ontario to have considered these trade-offs ahead of time, and I gather they’re just trying to make it look like the problem is going away.