Pharmacists called a barrier to emergency contraception

Pharmacists, along with physicians and politicians, top the list of barriers keeping emergency contraception out of easy reach. That's the news from the annual meeting of the American College of Obstetricians and Gynecologists (ACOG). "Emergency contraception [EC] is almost trivial in medical terms," said Eve Espy, M.D., MPH, associate professor of obstetrics and gynecology at the University of New Mexico. "It is relatively simple, safe, and highly effective."

EC faces six problems, Espy told meeting attendees in San Francisco: Many women don't know about EC; many prescribers don't write for EC; women can't get a script on short notice; many pharmacies don't carry EC; some pharmacists may refuse to dispense it; and the Food & Drug Administration puts politics ahead of science in refusing to make EC an over-the-counter product.

"This medicine should be OTC," Espy said. "Every woman should have it in her medicine cabinet. I tell my patients that even if they don't need it, they can always give it to a girlfriend at her need."

A growing number of pharmacists are refusing to dispense EC. Wisconsin pharmacist Neil Noesen made headlines when he would not fill a contraceptive script in 2002. He also refused to transfer the script to another pharmacy and refused to return the script to the patient. In the past six months, there have been about 180 similar cases, Espy said. "Is it really the role of the pharmacist to dispense morality? Does the pharmacist next get to ask men if they are using Viagra within the confines of marriage and, if not, refuse to dispense?"

Women have three choices: high-dose oral contraceptives-at least 1 mg of levonorgestrel and 200 mcg ethinyl estradiol; progestin-only OCs or Plan B; and a copper IUD.

"The earlier you take EC, the better, but some studies show it is effective up to five days after intercourse," said Tony Ogburn, M.D., assistant professor of obstetrics and gynecology, University of New Mexico.

Conventional EC dosing calls for one Plan B tablet within 72 hours of intercourse and the second tablet 12 hours later. More recent data indicate that taking both tabs at once is equally effective. The increased nausea and vomiting can be treated with a conventional anti-emetic such as meclizine. "If your patients are feeling nauseous or vomiting, the EC is working," Ogburn said. "If women ask if vomiting means they need a second dose-they don't."

The efficacy of EC varies. Combination products reduce the incidence of pregnancy by about 75%, Ogburn said. Progestin-only products are about 88% effective, and the IUD is 99% effective.

ACOG, the American Medical Association, the American Public Health Association, and other healthcare groups advocate OTC status for Plan B, Espy noted. The FDA Reproductive Health Drugs Advisory Committee and Nonprescription Drugs Advisory Committees voted 22 to 5, with one abstention, in favor of OTC status for Plan B. FDA rejected the scientific panel's recommendation and left Plan B as an Rx-only product. Steven Galson, acting director of the FDA's Center for Drug Evaluation and Research, cited concerns about use by women under the age of 16. Advisory committee members called it a political decision.

Canada's counterpart to the FDA, Health Canada, considered the same science and approved Plan B for OTC sale. A Health Canada spokeswoman said there were no outstanding concerns on the safety of Plan B in younger teens and no reason to delay timely access of EC to other women.