Pharmacy Practice in the United States: A Comprehensive Overview

Introduction

From its very beginnings, pharmacy was considered the art of making medicines. Like most arts that originated in earlier times, it came eventually to be regarded as a science in the modern age (Wutoh 2). Throughout history, various cultures have practiced pharmacy by creating drugs "to treat illness, relieve pain, create euphoria and promote health" (Wutoh 3). All of the medicinal creations around the globe over the past millennium show that the making of medicines has been a universal process natural to humankind. Yet, in the United States, the science of pharmacy has taken a new trajectory — with the pharmaceutical industry representing a significant portion of gross domestic product. Pharmacy practice in the United States is not just an art or science — it is also a big business.

Nonetheless, while the usage and significance of medicines has differed from culture to culture, place to place, and time to time, one constant that has remained throughout the history of pharmacy is the special focus every culture has placed on medicinal substances. Today, in the United States, the science of pharmacy has risen to remarkable heights with a broad range of implications for those who develop drugs, those who administer them, those who use them, and those who oversee the legal aspects related to drug manufacturing. This paper examines the practice of pharmacy in the United States and discusses its many distinct aspects.

A Highly Specialized Science

As Rosemary Onuegbu points out, pharmacy practice in the United States is a highly specialized science with a wide variety of practice areas. One of the most common areas of pharmacy practice today — and the most likely place one goes to purchase self-care pharmaceuticals — is the community pharmacy, better known as the chain pharmacy. Chain pharmacies like CVS, Walgreens, and Kroger are familiar examples of community pharmacies. What sets them apart from other types of community pharmacies is the fact that they are corporately owned and typically operate brick-and-mortar locations across multiple states. They are the most visible from the roadside and usually the first place a patient goes when needing to fill a prescription. They represent, in many ways, the face of the pharmaceutical industry for most people: the friendly pharmacists working behind the counter to fill doctors' orders for patients.

Yet, in actuality, these pharmacies are only one small part of the practice of pharmacy in the U.S. today. Other types of community pharmacies also exist — such as the independent pharmacy, which is privately owned, usually by a pharmacist or a group of pharmacists (Onuegbu 10). There are mail-order pharmacies, franchise pharmacies, and department store pharmacies — but even these tell only a small portion of the story of pharmacy practice in the U.S. Still, the fact that today there is practically a pharmacy on every corner indicates how pervasive the pharmaceutical industry has become in American society.

How did the pharmacy industry become so large, expansive, and pervasive? Part of the reason is the change in the patient-physician-pharmacist relationship (Onuegbu 21). In the old model, the patient was at the center of the relationship. The patient would receive a prescription from his or her doctor and take it to the pharmacist to be filled. In the new model, the pharmacist is at the center of the relationship and communicates directly with both the physician and the patient, serving as an intermediary between the two. In other words, the pharmacist has taken on a larger role within health care. In today's pharmacy practice, the patient-oriented pharmacist must maintain a high degree of drug knowledge, strong communication skills, and the ability to gather and analyze information in order to "help sick patients cope with their feelings" (Onuegbu 22). To accomplish this, the pharmacist must be familiar with the full range of available drugs — both new and old — which can treat particular symptoms, and which options offer patients the least expensive solution for their particular ailment. Competition among drug manufacturers has made the pharmacist an important link in the industry-to-patient chain.

Another reason pharmacy practice has expanded into the industry it is today is that technological science has made extraordinary advancements that have allowed pharmacy to grow and develop in ways previously unseen. For example, within the overall pharmacy profession one can find multiple specialty practices. Nuclear pharmacy is one such specialty. It was, in fact, the first specialty practice to be recognized by pharmacy professionals (Gebo 9). This occurred in 1978, following the creation of the Board of Pharmaceutical Specialties two years earlier. It was not for another decade that the Board recognized a second pharmacy specialty (Gebo 9). This timeline illustrates how seriously the pharmacy industry takes its practice and how immensely high the standards are that all pharmacists must meet in order to be considered true credentialed specialists. It takes a considerable amount of time for a specialty to emerge, be proven effective, and be sufficiently distinct to require its own set of skills from a pharmacy professional.

What does a nuclear pharmacist do? As in community pharmacy, this practice centers on mixing and making drugs for patients. The nuclear pharmacist is tasked with more complex orders, however — such as "incorporating a radioactive isotope (like Tc99m) into a mildly pharmacologically active non-radioactive drug for disease state diagnosis" (Gebo 11). These drugs help physicians identify the nature of a particular problem in a patient's body. For instance, if a patient's heart is having trouble, a diagnostic test would be ordered by the doctor and the nuclear pharmacist would provide a radiopharmaceutical that allows the doctor to image the heart. As Busse, Chavanu, and D'Onofrio demonstrate, none of this would be possible without industrial pharmacy.

Industrial Pharmacy

Industrial pharmacy is comprised of several departments that exercise a variety of functions. The executive office of a pharmaceutical company oversees operations; the legal and compliance division ensures that the company adheres to FDA regulations; the research and development department conducts tests on new drugs to measure outcomes and effectiveness; and so on. It is a vastly large and multi-dimensional enterprise (Busse, Chavanu, D'Onofrio 10). Even a brief look at one aspect of industrial pharmacy gives a sense of how specialized nearly every aspect of the industry is today. A researcher employed by an industrial pharmacy company will utilize aspects of medicinal chemistry to make assessments regarding biological plausibility and toxicity before conducting human trials and fulfilling post-marketing commitments (Busse, Chavanu, D'Onofrio 10). From there, other employees reach out to pharmacists and physicians to promote the new drug to patients whose symptoms it targets. An extensive, interrelated web of sales, research, and healthcare is constructed — and it is this web that has allowed industrial pharmacy to play such a dynamic role both in how drug research is conducted and legislated (the pharmaceutical industry is a major lobbyist) and in how new drugs are marketed (Busse, Chavanu, D'Onofrio 14).

A closer examination of how drugs are produced within industrial pharmacy reveals a process far more complex than anything seen in human history prior to the advent of modern medicine. As Simon Wang shows, structure-based design of pharmaceuticals — such as nelfinavir (marketed as Viracept), used for HIV patients — plays a significant role in pharmacy practice in the U.S. today. Structure-based design begins with the preparation of a protein model. Seeds or "decoys" are then used to prepare a virtual screening database for docking, scoring, and ranking. This is another highly specialized form of drug manufacturing and testing that takes place in industrial pharmacy, well behind the scenes of the friendly neighborhood pharmacist at the corner drugstore.

Fragment-based drug design is another process pharmacists engage in when manufacturing a product. It involves utilizing a binding site comprising multiple binding pockets, crystallographic screening, designing a lead compound around a core template, and the growth of a single fragment (Wang 10). Such intricate operations are a far cry from the grinding of herbs and collecting of natural substances traditionally used in medicinal form thousands of years ago in ancient cultures around the world (Wutoh 3). As Wang demonstrates, a great deal of pharmacy practice in the U.S. is highly scientific and demands deep knowledge of chemistry and molecular biology. Yet this is just one aspect of industrial pharmacy. Another side of this practice is marketing — the way new drugs are advertised on television, regulated by FDA authorities, and sold to potential clients, physicians, and pharmacists around the country. Industrial pharmacy is a substantial network of multifaceted components, each specialized within its own area to produce maximum results for the company and for the consumer. If nuclear pharmacy was the first "recognized" specialty in pharmacy, it may be fair to say, more than thirty years later, that nearly every aspect of pharmacy practice is "specialized" in the sense that each places unique demands on those who pursue careers in their respective fields — whether one is a nuclear pharmacist, a researcher, a drug designer, or a community pharmacist.

Conclusion

Pharmacy practice in the United States offers a wide range of choices, opportunities, and specialized fields of service. In the U.S. today, pharmacy has achieved the status of a science — thanks in no small part to the centuries of accumulated study that preceded it as well as the technological developments of the 20th century. While someone unfamiliar with pharmacy might assume that the local pharmacist at the neighborhood corner drugstore represents the entirety of the profession, a more detailed examination reveals a far more complex, dynamic, evolving, and specialized field of medicine. Pharmacists can engage in research, manufacturing, regulation, sales, networking, administration, and direct patient care. In short, there is no single face or representation of pharmacy practice in the U.S. that can do justice to the full scope of the field — even if the community pharmacist remains the most commonly recognized figure. Behind the scenes, pharmacy practice has developed into a highly specialized discipline upon which millions of people depend.