A Brief History of Pharmacy in the US
Key takeaways:
The 1800s brought the first pharmacist licensure requirements, the first pharmacy school in the U.S., and the first pharmacy journal in the U.S.
The modern U.S. pharmacy quickly evolved in education and practice to reflect advances in drug development and manufacturing as well as patient needs, culminating in a 6-year doctor of pharmacy degree and the pursuit of direct patient care activities.
To remain relevant and continue providing value to the healthcare system, pharmacists must develop new models, expand on existing ones, and ultimately be capable of demanding fair reimbursement for the services they provide.
The history of U.S. pharmacy is as fascinating as that of any other facet of medicine. Let’s look back a few centuries and find our way to the modern era.
U.S. pharmacy in the 18th and 19th centuries
America’s first licensed pharmacist was Louis Dufilho, Jr., who opened a pharmacy in New Orleans in the early 1800s. Now a museum, it features displays of medications common during that time. These medications were often based on Louisiana Voodoo culture, which has its roots in West Africa and was furthered by Haitian immigrants to New Orleans. Medications containing narcotics were also common. Tampons, for example, were dipped in opium and belladonna plants to treat menstrual cramps.
The United States Pharmacopeia (USP) was formed in 1820 by a group of physicians concerned about the poor quality of medicines in America. They published the first national, uniform set of guidelines for medicines and medical preparations. Throughout its history, the USP has focused on uniform standards for the quality of medicines, and, to this day, the USP is one of the most widely respected standards organizations in the world for medications, foods, and dietary supplements. Standards also have now expanded to include practice standards, like USP 797 on the compounding of sterile preparations, or USP 800 on the handling of hazardous substances.
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The Philadelphia College of Pharmacy, America’s first pharmacy organization and first pharmacy school, was founded in 1821. Its graduates eventually began calling themselves “pharmaceutists” to distinguish themselves from untrained apothecaries. The original curriculum, culminating in a graduate in pharmacy (Ph.G.) degree, required 2 years of classroom work and a 4-year apprenticeship. Coincidentally, this matches the 6 total years standard these days to obtain a doctor of pharmacy degree (PharmD).
In 1825, the school founded the first English-language pharmacy journal, named the Journal of the Philadelphia College of Pharmacy. The journal mostly focused on what would be considered compounding today, but it also contained articles on “materia medica,” which means the therapeutic effects of substances and their form and function.
U.S. pharmacy, from the 20th century to today
Modern American pharmacy can be divided into four eras. These eras reflect the evolving nature of pharmacy practice in response to patient needs and advances in medicine, pharmaceutical manufacturing, and research.
The “soda fountain” era: 1920 to 1949
Pharmacy education during this period evolved from short courses and apprenticeships to degree programs lasting 3 or 4 years. The American Association of Colleges of Pharmacy (AACP) developed a pharmaceutical syllabus in 1910 that helped standardize pharmacy education across the country.
This was also the time during which the 6-year doctor of pharmacy degree was first proposed to elevate the profession and place pharmacists firmly in the realm of healthcare professionals. Oddly enough, though, this proposal was fiercely opposed by both pharmacy educators and deans of pharmacy schools. The reasons cited included the cost of implementation, lack of preparation, and opposition by the medical schools housed at the same universities.
Rapid advances in pharmaceutical manufacturing reduced the need for compounding, which had been a large part of the pharmacist’s role, resulting in an identity crisis as pharmacists sought to find their role in healthcare. Pharmacies profited from front-end sales of medicinal alcohol, which were exempt from Prohibition laws, and from soda fountains. What began as a device to provide fountain drinks (often with caffeine and cocaine) to cure ailments in the mid-19th century evolved into a central theme of the drugstore, especially during Prohibition.
Ethical standards of the time actually barred pharmacists from discussing medications with patients, and they were supposed to inform patients that medications should only be discussed with their provider.
The ”lick, stick, pour, and more” era: 1950 to 1979
Pharmacy education continued to evolve as pharmacy leaders acknowledged that a 4-year degree was insufficient to prepare students to enter practice. The doctor of pharmacy degree was formally proposed in 1950, but, because of continued resistance to its creation, a compromise was struck to establish the 5-year bachelor of pharmacy program.
This period also is marked by the divide between nonclinical and clinical activities, a topic that continues to stir heated opinions. The biggest rift was (and remains) between dispensing and nondispensing activities — hence, the “lick, stick, pour, and more” era.
By 1950, only 25% of prescriptions were compounded, and, thus, the majority of prescriptions were dispensed as commercially produced products. Ethical standards at this time still prohibited pharmacists from discussing medications with patients, and, while it might be shocking by today’s standards, many prescription labels didn’t list the drug name, because there was a commonly held idea that labeling the vial would violate the physician-patient relationship.
Eugene White is widely credited for his significant contributions in transforming pharmacy practice during this period, from one focused on no-questions-asked dispensing, soda fountains, and lunch counters to one focused on patient care.
In the inpatient setting, hospital satellite pharmacies were piloted and expanded. This made hospital pharmacists the provider of sterile compounded products, unit-dose medications, and drug information. Previously, these services were provided primarily by nurses working on the floor.
The pharmaceutical care era: 1980 to 2009
While the University of Southern California was the first pharmacy school to adopt an all-doctor-of-pharmacy curriculum in 1950, the AACP rejected a proposal to make it the standard entry-level degree as recently as 1985. However, in 1989, the Accreditation Council for Pharmacy Education (ACPE) published an intent to make the doctor of pharmacy the standard by the year 2000.
This era was when patient counseling became a more widely adopted and mandated pharmacist activity. The Omnibus Budget Reconciliation Act of 1990 required patient counseling. A study conducted shortly after its passage confirmed that the legislation increased the frequency that pharmacists counseled patients.
Nondispensing activities also expanded. The American Pharmacists Association launched its immunization program in 1996, and, by 2004, about 15,000 pharmacists and pharmacy students were trained immunizers. Pilot projects in the 1980s began for what would eventually become medication therapy management (MTM). The Medication Modernization Act, passed in 2003, created Medicare Part D and mandated MTM services to be included in Part D benefits. This mandate led to the realization that pharmacists would finally be able to become more involved in the direct management of patients.
The post-pharmaceutical care era: 2010 to the present
The first pharmacy residencies were accredited in 1963, but they really took off in popularity recently. As of 2018, 29% of all pharmacy students were pursuing a residency — double the rate compared with just 9 years before.
Pharmacists have continued to expand into other areas, like population health management, and, for quite some time, there has been a push for provider status, which would allow pharmacists to bill Medicare Part B for patient care activities.
Pharmacist-led immunization services have also continued to grow. Today, all 50 states allow pharmacists to immunize, and pharmacists play a central role in managing vaccine-preventable disease (such as COVID-19).
MTM, on the other hand, continues to struggle with poor reimbursement. So, while it has been expanded and still holds a lot of potential for the advancement of pharmacy, it faces challenges that pharmacists must work to overcome before it can have its full impact.
Throughout the COVID-19 pandemic, pharmacists have provided coronavirus testing and immunization services. Legislative changes have allowed pharmacy technicians to also provide both COVID-19 testing and a wide range of immunizations, broadening the capacity of the U.S. healthcare system to respond to the increased pressures it faces. As of November 9, 2021, close to 163 million doses of the COVID-19 vaccine have been given in retail pharmacies.
What’s next?
Pharmacists currently provide myriad benefits to our public health, and growing these services will become an increasingly key part of the pharmacist’s role. This includes playing larger roles in reducing drug costs amid an aging population and an explosion of high-cost specialty medication.
To do this, pharmacists must be reimbursed not only for dispensing but also for cognitive services and must be able to demonstrate both the financial and clinical benefits of the services they provide. Pharmacists must also shift further away from dispensing, which itself has seen declining reimbursement and continues to evolve with robotics and expanded pharmacy technician roles.
Pharmacy education must change to meet these needs, with a greater emphasis on topics like pharmacogenomics, health economics, and public health.
The bottom line
Pharmacy has been an ever-developing profession for nearly two centuries and has to continue evolving to thrive in an ever-shifting healthcare landscape. Starting from the 1820s, when the first pharmacist licenses and pharmacy schools were founded, until today, with the advent of pharmacogenomics and population health management, pharmacists have played a central role in the country’s healthcare system.
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