Feature, Report, Therapies

A hard pill to swallow: oral medication prescribing rights for optometrists

Australian optometrists are not permitted to prescribe oral medication, in contrast to comparative countries where their counterparts have been prescribing them for years. Insight investigates why this is the case in Australia.

Optometrists in the UK have been permitted to prescribe oral medications since 2008. In New Zealand it has been since 2014, while in Canada, optometrists have lists they can prescribe from in different provinces. And in the US, 45 of 50 states have introduced legislation allowing optometrists oral prescribing powers.

But for Australian optometrists, their prescribing authority is limited to topical ocular medications such as eye drops and ointments, which can only be authorised by the country’s 4,135 therapeutically-endorsed optometrists. When it comes to oral drugs, all must refer patients to GPs or ophthalmologists.

Optometry Australia (OA), the profession’s national peak body, has strongly advocated to turn this around. It says the need to visit a second health practitioner for a simple prescription can mean additional patient cost as well as a loss of convenience. In some cases, patients will not access the oral medication, potentially putting their eye-health at risk.

For several years, the organisation has been calling for change – and recently reinvigorated its campaign. With Australia lagging behind comparative nations, it says it doesn’t have to look far for evidence supporting qualified optometrists to prescribe oral medications such as antibiotics, anti- inflammatories, and anti-viral agents.

However, if optometry is to successfully push for change, it will need to convince ophthalmology. That’s unlikely to happen soon, with both RANZCO and the Australian Society of Ophthalmologists against the move, stating that optometrists don’t not have the appropriate medical training and experience, which could compromise patient safety.

Slow but steady growth 

When New Zealand’s Medicines Act was amended in 2014, it gave registered optometrists with therapeutic accreditation the regulatory freedom to prescribe any medication that was within the scope-of-practice of optometry, as defined by the Optometrists and Dispensing Opticians Board (ODOB).

Dr Philip Turnbull, University of Auckland.

Authorities across the Tasman, including ODOB and the Ministry of Health, have tracked optometrists’ oral medication prescribing habits since 2014, and recently released data shows oral medication prescriptions are on the rise.

Dr Philip Turnbull and Professor Jennifer Craig, from the School of Optometry and Vision Science and the Department of Ophthalmology, respectively, at The University of Auckland, analysed NZ’s data.

“In the five years following the legislative change, more than half of eligible optometrists have had reason to prescribe an oral medication, and the proportion of oral medications continues to grow year-on-year,” Turnbull and Craig note in ‘Oral medication prescribing by optometrists in New Zealand’, published online in Clinical and Experimental Optometry in March this year.

They report that oral medications accounted for nearly 4% of scripts in 2019, or approximately 1 in 25 prescriptions. In 2020, it marginally surpassed 4% of scripts (4.03% compared to 3.88% in 2019).

A total of 53% of optometrists with prescribing rights – and who were registered at the end of 2019 – had prescribed at least one oral medication; 8.6% had issued more than 30 scripts.

“Interestingly, there wasn’t a huge rush to start prescribing, and the growth has been quite slow. The increase in independent glaucoma prescribing is much greater than for oral medications,” Turnbull tells Insight.

Most prescriptions in NZ were for antibiotics, which comprised 60% of all oral medications prescribed. Antihistamines made up 8.2%; antivirals made up 7.4%; and analgesics 2.2%.

Turnbull and Craig reported that, in the antibiotics class of medicines, azithromycin (which alone represented 39% of all prescribed oral medications) and tetracycline was prescribed for the management of meibomian gland dysfunction.

“Oral meds are almost entirely for managing dry eye, with smaller numbers for infections (bacterial, viral, toxoplasmosis), inflammation, and anti- glaucoma. There are also optometrists prescribing prophylactic oral anti- herpetic medication,” Turnbull says.

He says the advantage of allowing oral medication prescribing, at least in NZ, is a far wider range of medications.

“Drugs available in topical form and suitable for the eye are rather limited,” Turnbull explains. “It’s also useful for optometrists that work in hospitals or ophthalmology clinics, where they can consult with others, then prescribe any medication that is required. This is a big win for the patient, as they don’t need to rebook or pay extra.”

He says allergy is by far the biggest reason for an optometrist issuing a medical prescription overall and having access to oral and nasal spray anti- histamines are nice additional tools to have available.

“It’s important to also note that New Zealand doesn’t just have access to oral, but the law change meant drug modality doesn’t matter. We also have hospital-based optometrists prescribing injectable medications, such as Avastin, for example. They don’t actually inject the medication, which is currently out-of-scope, but by prescribing at the initial consult, they can ensure it is ready for the patient when they arrive for their injection,” Turnbull says.

“There’s also a low amount of skin ointments being prescribed too for treatments around the eye, which are better managed by an optometrist with appropriate tools and knowledge base, than a general practitioner, for example.”

In New Zealand, where optometrists have been able to prescribe oral medication for seven years, 4% of prescriptions by optometrists were for oral medications in 2019.

Significantly, authorities in NZ have neither been alerted to any out-of-scope prescribing of oral medications, nor have there been any reported adverse incidents specifically relating to optometrists issuing therapeutic prescriptions.

“This suggests that despite their newly granted authority to manage a broader range of ocular conditions, the optometry profession, as a whole, is practising appropriately and appears still to be referring and/or co- managing rather than independently managing cases requiring more complex therapeutic management,” Turnbull and Craig conclude.

Is Australia falling behind?

According to the latest Optometry Board of Australia data, 4,135 (60%) of optometrists in Australia are therapeutically endorsed.

Could those 4,135 optometrist’s skills be better deployed to meet community need? OA national president Mr Darrell Baker believes so. In July, he took the lead in announcing the organisation’s new policy platform on evolving scope- of-practice named ‘Working Together for Better Eye Care’. Oral therapeutics were among six areas OA is calling for change so the nation’s “seriously under-utilised” optometric workforce can combat urgent issues looming over the eyecare sector.

Darrell Baker, Optometry Australia.

“We believe it is in the interests of patients, communities and health system efficiency, to enable therapeutically qualified optometrists to prescribe oral medications relevant to their scope-of-practice,” Baker says.

“International evidence, including from New Zealand, also attests that optometrists prescribe oral medications safely.”

In its report, OA argues that the need to visit a second health practitioner for a simple prescription can mean additional patient cost as well as a loss of convenience.

“In some cases, patients will not access the oral medication, potentially putting their eye health at risk,” the report states. “These issues are more pronounced for rural and remote patients where there are fewer GPs, longer wait times, a lack of after-hours services and challenges accessing specialist ophthalmology services.”

It goes on to say that any decision to allow optometrists to prescribe oral medications would follow a detailed consideration of the public benefits and risks by the Australian Health Practitioner Regulation Agency and the Optometry Board of Australia.

According to OA, optometrists perform 10 million eye checks annually and are the first port of call for 80% of people.

“Increasingly, optometrists are treating, managing and triaging patients with eye disease, as well as filling gaps where there is not timely access to care. However, the skills of Australian optometrists continue to be seriously under-utilised compared to our counterparts in similarly developed nations,” Baker says.

“The only way we can get on top of Australia’s looming eye-health crisis is for optometrists to be supported to practise to their full scope to enhance patient access and increase the efficiency of Australia’s eye-health system.”

So, is Australia falling behind other nations, including New Zealand, parts of Canada, the US and the UK, that permit optometrists to prescribe oral therapeutics?

The answer, Baker says, is clear.

“We are still struggling with issues in terms of early identification of eye disease and access to treatment that were identified a decade or more ago – and many of them have arguably gotten worse.

“We must enhance how our eyecare systems work to meet the needs of our communities. This demands change and innovation. Yet, even with excellent evidence that highlights how optometrists are assisting to address serous eye health conditions in other advanced nations, the pace of change in Australia remains unacceptably slow. We are calling for faster progress in the interests of our communities.”

‘Proof is in the pudding’

Oral therapeutics was a presentation topic at Optometry NSW/ACT’s Super Sunday conference in 2018, and was meant to be at Optometry Victoria South Australia’s now-cancelled O=MEGA21 conference this month.

For a profession that doesn’t have prescribing rights, why is it important that optometrists in Australia are informed about oral therapeutics?

“Optometrists must have a good understanding of treatment options available for their patients to ensure they are putting in place the most relevant management plan and referral pathway for each presentation, and so they can support their patients in understanding what treatment options they may be offered,” Baker says.

Associate Professor Daryl Guest agrees. He is a long-time advocate of utilising his scope-of-practice to actively, but indirectly, prescribe oral therapeutics to patients.

The former University of Melbourne Eyecare Clinic director and retired owner of a multi-site practice in north-west Tasmania, Guest has been doing so since legislation was introduced in Tasmania to allow optometrists to prescribe therapeutics.

A/Prof Daryl Guest, University of Melbourne (retired).

“I’ve been prescribing oral therapeutics – through a GP – since the turn of the century. As a primary care practitioner, if I had a patient that would benefit from a six-to-12-week course of doxycycline, I couldn’t personally write a script, but I had a close working relationship with a GP in the same building, and I would knock on their door, and they would issue a prescription,” he says.

Guest, who will be stepping down as a member of the Optometry Board of Australia in October, estimates that he has co-ordinated 300 or more scripts, all signed-off by a GP.

“We’re not talking about sight-threatening disorders; we’re talking about non- sight-threatening conditions, such as meibomian gland dysfunction, and about the patient’s quality of life. We’re talking about anti-inflammatories to treat dry eye that hasn’t responded to conservative treatment.”

Guest says despite potential pushback from a section of organised medicine, prescribing oral therapeutics is generally not in the sphere of secondary or tertiary care, and predominantly should be handled by primary practitioners as part of community-based care.

This month, Guest had prepared to present a lecture titled ‘Orals: The next frontier’ at the O=MEGA21 clinical conference.

He says his lecture was not intended for recent graduates or early career optometrists who are both well-versed in oral therapeutics through their university training.

“I’m addressing those optometrists who are 15 to 20 years out in the profession, who didn’t graduate with therapeutics training but have since completed a therapeutics course. I’m saying to them: ‘Let’s remind you what the issues are when you’re prescribing a medicine that’s ingested orally rather than administered in the eye. It’s often the same molecule, but you’re giving it a different way’,” Guest says.

His lecture also discussed the issues around translating didactic knowledge of oral prescribing into everyday practice.

“I’m saying to those that have been practising for 20 years: Can you explain to the patient the possible side-effects of an oral medication, such as potential gastrointestinal reactions? Is the patient pregnant, or are they planning to get pregnant? Are they more likely to be exposed to UV, as some medications can make you more sensitive to the sun,” he says.

Guest also emphasises the importance of optometrists taking responsibility for medications they prescribe and working closely with pharmacists and GPs as part of a wholistic management approach.

Looking to counterparts in New Zealand, Guest says it is not unusual that optometrists may have been slow to begin prescribing oral medications when legislation was introduced in 2014.

“Optometrists are incredibly conservative. A similar pattern emerged in Australia when topical therapeutics were introduced. Initially, optometrists were very cautious to prescribe, but the younger generations are eager to utilise ocular prescribing rights including access to orals. They have said: ‘We want this’,” Guest says.

Optometry Australia’s 2040 project demonstrates younger generations of optometrists consider oral prescribing rights should form part of their future scope-of-practice.

Guest believes New Zealand’s decision to allow optometrists to prescribe oral therapeutics was, in part, based on business economics.

“Why did health authorities in New Zealand go ahead with legislation to allow optometrists to prescribe oral therapeutics? My theory is that the New Zealand health system was operating under significant financial stress, hence the need to better utilise resources and scope-of-practice. There is a strong health economics aspect, but notably, there hasn’t been any reported adverse events since optometrists began directly prescribing oral medications.”

“The proof of the pudding is in the eating,” Guest remarks.

Right of reply – ophthalmology 

RANZCO president Professor Nitin Verma says ophthalmologists are qualified medical practitioners with a long and comprehensive medical and surgical training course spanning over a decade and a half.

“As such, they are best placed to diagnose and treat the patient with eye disease. Part of their training involves the prescription of systemic medication that also requires extensive medical training, clinical judgement, and experience,” he says.

Prof Nitin Verma, RANZCO.

Verma says oral medicines are uncommonly prescribed in the management of most ocular conditions and – except in some disease categories – their use is generally not considered routine.

“When required, however, there are significant considerations including the choice of agent, dose, risk of adverse reactions and the management of co-morbidities. Additionally, there are a broad range of systemic and topical drug interactions and side effects that doctors are aware of and are capable of managing. Some of these could be associated with serious morbidity and could even be fatal. Ophthalmologists are prepared for this through their extensive basic medical and ophthalmic education which trains them to recognise and manage these events,” he says.

“Extending prescribing of oral medications to optometrists, who do not have the appropriate medical training, the experience and above all, do not have the need to prescribe oral medication routinely, could compromise patient safety.

“Finally, the responsibility of looking after the patient with an ocular problem needing oral medication does not stop at the prescription of the drug but also extends to having the knowledge and infrastructure to be able to handle the side effects and adverse drug interactions that could ensue. The reality is that the system is not set up for that and any adverse reaction in this regard could be very serious,” Verma says.

He says RANZCO cannot comment on the decision of other countries to allow optometrists to prescribe oral medication, except to say that each country has a different health system.

“To illustrate the point that the right to prescribe oral therapeutic agents is not needed, the data from New Zealand is self-illuminating. In 2019, only about 4% of prescriptions by optometrists were for oral medications, and the most commonly prescribed medication was an oral antibiotic. We believe that for ocular disorders serious enough to need oral antibiotics for their management, early referral to an ophthalmologist should be considered.

“In summary, RANZCO does not support optometrists prescribing oral medications and holds the view that in such uncommon situations where they are considered necessary for the reasons outlined above, involvement of an ophthalmologist in the management of the problem would be the appropriate course of action.”

A/Prof Ashish Agar, ASO.

Australian Society of Ophthalmologists (ASO) president Associate Professor Ashish Agar says organisation’s position is in alignment with the Australian Medical Association (AMA), as outlined in its 2019 policy document.

Its policy states that only medical practitioners are trained to make a complete diagnosis, monitor the ongoing use of medicines and to understand the risks and benefits inherent in prescribing.

“Only medical practitioners currently meet the high standards required by the NPS MedicineWise Prescribing Competency Framework in order to safely prescribe independently,” it states.

“The AMA therefore does not support independent prescribing by non- medical health practitioners outside a collaborative arrangement with a medical practitioner. Prescribing by non-medical practitioners should only occur within a medically led and delegated team environment in the interests of patient safety and quality of care.”

Further, according to its policy, the AMA recommends a system of mandatory referral to a registered medical practitioner where appropriate clinical criteria and outcomes are not achieved within a specific time frame.

“Oral agents can have, and have had, serious adverse effects including death, and so in the interests of patient safety, we agree with the AMA that they should only be prescribed by medical practitioners,” Agar says.

More reading

Expanded scope only way to tackle eye health issues, OA says

MBS Taskforce keeps controversial eye injection proposals in final report