Dispensing Hope: How Pharmacists Are Advocating for Abortion Access

In 2022, the US Supreme Court ruled on Dobbs v Jackson Women’s Health Organization, revoking the constitutional right to abortion established 50 years ago in the landmark Roe v Wade decision. As of June 2022, the right to access abortion services returned to the states—and their elected representatives—to determine who is granted that protection.

'Abortion pill' as listed in dictionary / Casimiro - stock.adobe.com

Since then, a patchwork of ever-changing state legislation has blanketed the nation. These shifting laws have created confusion and complications for patients and health care providers alike, resulting in unrest among abortion advocates over the issue of access. And political momentum surrounding abortion has kept up in federal courts as well: In the coming months, the Supreme Court will hear arguments aimed at narrowing access to the drug mifepristone, a type of abortion medication used in more than half of all abortions performed in the US.¹ In April, the Supreme Court is further slated to hear arguments that will determine whether hospitals are obligated to provide abortions to patients in crisis.²

Some abortion advocates have gone as far as to describe emerging state legislation, as it restricts women’s rights to make decisions about their own bodies, as draconian.³ And while there are statutes that reflect this definition—such as those in one state that bar physicians from speaking about abortion with their patients or risk a lawsuit—many states have enacted laws and regulations to demonstrate their commitment to protecting women’s reproductive rights. Even in states where access is limited, advocacy organizations such as Planned Parenthood—which offers resources for gas, flights, travel, meals, and childcare expenses to those who must travel across state lines to obtain an abortion—have worked to circumvent restrictions.⁴ Committed to their responsibility to serve patients, pharmacists have also emerged as prominent health care actors to ensure patients have access to the reproductive care they need.

The FDA approved mifepristone in 2000, in a decision that the organization noted was made based on safety and effectiveness data from clinical trials in the US and France.⁵ Conditions of the approval, however, required that only physicians could give the drug to women. This typically occurred in a series of 2 in-person doctor appointments: At the initial visit, women would be given mifepristone, and they would then return 2 days later to take misoprostol, a combination regimen that has since been considered the standard of care for medication abortion treatment. For women who lived far away from an abortion provider, the decision granted women access to a safer and more private abortion experience.

In 2021, the FDA amended the original approval of mifepristone to accommodate for the constraints of the COVID-19 pandemic by permanently removing the in-person dispensing requirement associated with the drug. The amendment also broadened the scope of who could dispense mifepristone to include brick-and-mortar pharmacies, so long as pharmacists completed a certification process to do so. Just days after this certification process was finalized by the FDA in early 2023, CVS and Walgreens, the 2 largest drugstore chains in the US, pledged to become accredited and sell mifepristone in states where abortion was still legal. On the brink of implementing the move that could expand access for millions, Walgreens is reportedly in the “last stages of finalizing certification.”⁶

In the United States, 90% of Americans live within 5 miles of a pharmacy,⁷ which unlike physicians’ offices or hospital settings, offers a familiar and comfortable environment for patients to ask questions and discuss their concerns about medication. Alongside an increasing reliance on prescription medications in the US, many patients find themselves forming trusting relationships with their pharmacists: Between 2015 and 2018, nearly 50% of the US population used at least 1 prescription drug, while 24% used 3 or more, and more than 10% used 5 or more.⁸ As they apply to the abortion landscape, factors like convenience, familiarity, and trust uniquely position pharmacists to serve patients.

“We know that pharmacists have always been listed fairly high in the trustworthy side of things, and accessing any kind of care, including medication abortion, involves trustworthiness,” said Don Downing, PharmD, professor emeritus of clinical pharmacy at the University of Washington in Seattle. “Women have voted with their feet in accessing reproductive health services from pharmacists in Washington state for quite a long time now. And there are going to be some women who say, ‘I know my pharmacists better than I know anybody else. I trust them. And in this very personal decision, I feel comfortable in asking them to help me with this.’”

Downing, a longtime advocate for reproductive health, has dedicated much of his career to broadening pharmacists’ ability to serve patients in this area of care. In 1998, he worked to develop the nation’s first pharmacist-provided emergency contraception program in Washington state, made possible by a law passed previously in 1979 that granted pharmacists in the state the ability to prescribe medicine to patients on their own authority. Before the program, women were able to access emergency contraception only by scheduling an appointment and meeting in person with a doctor. After its implementation, the program helped close to 12,000 patients receive the necessary medication.⁹

“We’ve probably prescribed somewhere around 20 million prescriptions since 1979, maybe more,” said Downing. “When we started prescribing prescription emergency contraception in 1998, we were prescribing more in a month than all the doctors in the state were prescribing in a year. We don’t know what’s going to happen with medication abortion, but we might expect that for whatever reason, patients who are seeking this treatment might find a pharmacist more readily available than other providers.”

Although Downing believes that pharmacists “represent a new professional workforce, in addition to physicians and nurse practitioners, that women can call on at their own choosing for reproductive care,” he acknowledges they are afforded legislative luxuries in the state of Washington that are unavailable to others located elsewhere. In the Evergreen State, pharmacists can prescribe outside of a pharmacy, such as in an at-home office. They don’t have to prescribe as an employee of a pharmacy, either—meaning that unlike physicians’ offices, they are not restricted by a typical 9-to-5 schedule. What’s more, pharmacists are included in telemedicine language used in state law that allows them to expand patient service beyond brick-and-mortar pharmacies to virtual services. When it comes to accessing time-sensitive reproductive health services, these allowances help optimize patient outcomes.

“For women who cannot access services like medication abortion and emergency contraception, there’s the time clock ticking,” said Downing. “We looked at how quickly women could access emergency contraception from a pharmacy— it was less than 18 hours between the time they realize that they need it and [when they] are able to access emergency contraception, whereas it was over 48 hours for physicians.”

Late last year, GenBioPro, a manufacturer of generic mifepristone, released a list of pharmacies that had publicly declared to have finished the certification process for dispensing the drug.⁶ Haller’s Pharmacy group, based in California, is one of the pharmacies that appears on the list. According to Sanjay Patel, RPh, pharmacy director at Haller’s, making the decision to enroll in the program was simple.

“We decided that medication abortion works, and we should offer it,” Patel said. “Even if 1 person needs it and 1 person can use our service, it’s beneficial to the community and beneficial to the patient’s needs.”

To obtain certification, Patel first had to attend a 2-hour educational program that taught attendees about the process of dispensing mifepristone, how to monitor patients, and how to comply with the Risk Evaluation and Mitigation Strategy program requirements. After filling out applications specific to 2 dispensing programs, he waited for approval. Ultimately, he selected GenBioPro’s program because it had gotten back to him sooner. After all was said and done, Patel said the process only took 3 months.

“We’re in the health care industry, so we decided whatever service we could provide in the community would be welcome. Even though we’re an urban pharmacy, we have that homely feel,” Patel said. “Although physicians in the area provide abortion services, we wanted to be there in case somebody falls through the cracks and needs it.”

Despite Patel’s sanguinity about his decision to dispense mifepristone, it is no secret that electing to offer abortion services comes at a cost. Although Walgreens had initially pledged to dispense abortion pills at the turn of the FDA decision in 2023, months later the pharmacy giant said it would not dispense in some states where abortion is legal after receiving threats from state officials and antiabortion activists—those like the self-described peaceful and progressive members of Progressive Anti-Abortion Uprising, an antiabortion group.¹⁰ Last year, activists from the group hid in a closet at a nearby location for 9 hours before breaking into the room where a Walgreen’s shareholder meeting was being held to discuss the company’s decision to start selling abortion pills.¹¹

Patel explained that he has opted out of marketing mifepristone on his pharmacy’s website to ensure a safe experience for patients.

Voices like Patel’s, Downing thinks, are what are needed to support patients as they navigate the tangle of state-imposed abortion restrictions to access necessary treatment. While the legal landscape of abortion remains uncertain, pharmacists, with their unique connection to patients, have the potential to be powerful advocates for reproductive health care.

“If our profession of pharmacy is going to remain relevant in the United States, we have to be willing to take these risks and mitigate those risks with quality care, and have pharmacists step up and decide they want to be engaged in something very important in people’s lives,” Downing said.

READ MORE: Women's Health Resource Center

References

1. Jones RK, Nash E, Cross L, Philbin J, Kirstein M. Medication abortion now accounts for more than half of all US abortions. Guttmacher Institute. February 24, 2022. Accessed Feb 7, 2024. https:// www.guttmacher.org/article/2022/02/medication-abortion-now-accounts-more-half-all-usabortions

2. Quinn M. Supreme Court lets Idaho enforce abortion ban for now and agrees to hear case. CBS News. January 5, 2024. Accessed February 7, 2024. https://www.cbsnews.com/news/supremecourt-idaho-abortion-ban/

3. Edelman A. ‘Insidious,’ ‘draconian,’ ‘cruel’: new Texas abortion law empowers vigilantism, experts say. NBC News. July 24, 2021. Accessed February 7, 2024. https://www.nbcnews.com/ politics/politics-news/insidious-draconian-cruel-new-texas-abortion-law-empowers-vigilantismexperts-n1274642

4. Planned Parenthood stands for care. Planned Parenthood Gulf Coast Inc. Accessed February 7, 2024. https://www.plannedparenthood.org/planned-parenthood-gulf-coast/patients/abortion

5. Gottlieb S. Abortion pill is approved for sale in United States. BMJ. 2000;321(7265):854. doi:10.1136/sbmj.0011402a

6. Ollstein AM, Gardner L. Pharmacies begin dispensing abortion pills. Politico. October 6, 2023. Accessed February 7, 2024. https://www.politico.com/news/2023/10/06/pharmacies-begindispensing-abortion-pills-00120397

7. 9 out of 10 Americans live close to community pharmacy. News release. EurekAlert. July 28, 2022. Accessed February 7, 2024. https://www.eurekalert.org/news-releases/960126

8. Health care and insurance: therapeutic drug use. CDC. Accessed February 7, 2024. https://www. cdc.gov/nchs/fastats/drug-use-therapeutic.htm

9. Gardner JS, Hutchings J, Fuller TS, Downing D. Increasing access to emergency contraception through community pharmacies: lessons from Washington state. Guttmacher Institute. July 1, 2001. Accessed February 7, 2024. https://www.guttmacher.org/journals/psrh/2001/07/increasing-accessemergency-contraception-through-community-pharmacies-lessons

10. Ollstein AM. Walgreens won’t distribute abortion pills in states where GOP AGs object. Politico. March 2, 2023. Accessed February 7, 2024. https://www.politico.com/news/2023/03/02/ walgreens-abortion-pills-00085325

11. Cheung K. Anti-abortion protesters hid in closet for 9 hours before storming Walgreens shareholder meeting. Jezebel. January 27, 2023. Accessed February 7, 2024. https://jezebel.com/ anti-abortion-protesters-hid-in-closet-for-9-hours-befo-1850040341