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Update on emergency contraception: Has status change increased access?
Client Confidentiality Card may help women overcome barriers
A year after the Food and Drug Administration (FDA) approved behind-the-counter status for the emergency contraceptive (EC) pill Plan B (Barr Pharmaceuticals; Pomona, NY) is the drug more available to women? While the company says sales have increased from about $40 million annually to an expected $80 million for 2007, availability is mixed, according to reports around the country.1
For example, in New York City, results of a recent survey indicate that 94% of contacted pharmacies carry the drug since shipments of the dual-status drug began in November 2006.2 The figure represents an increase from just more than 50% in the last five years, say city officials.
Krista Anders, MD, obstetrics and gynecology resident at the University of Florida (UF) College of Medicine — Jacksonville, performed a telephone survey of Northeast Florida pharmacies in the Duval County/Jacksonville area. Her survey revealed that prior to behind-the-counter status, approximately one-half of pharmacies carried Plan B, says Andrew Kaunitz, MD, professor and assistant chair in the Obstetrics and Gynecology Department at UF College of Medicine — Jacksonville. Following the FDA approval of dual status, about three-quarters of pharmacies now stock Plan B, says Kaunitz. However, pharmacies in low-income areas were less likely to stock Plan B, he reports.
Contrast these overall gains in access against the numbers amassed through a recent survey of North Carolina pharmacies conducted by NARAL Pro-Choice North Carolina. The survey, conducted among some 600 pharmacies across the state, shows about 40% do not stock the drug, with more than 30% of that figure refusing to order it.3 The numbers are especially troubling for victims of sexual assault, given that a 2004 survey conducted by NC Women United, Planned Parenthood, NC Coalition Against Sexual Assault, and NARAL found that about 25% of hospitals do not provide EC. Many of those hospitals who did not provide EC onsite said they offered a prescription for the drug, says Melissa Reed, executive director of the state NARAL organization. The new survey shows that many of the pharmacies that don't stock EC are located in rural areas, similar to hospitals that do not provide EC on site, she notes.
"It is really a double jeopardy for women in rural communities," says Reed.
Impact of state laws?
Availability of EC in the United States may vary with differences in state laws, according to a survey presented at the recent American College of Obstetricians and Gynecologists (ACOG) annual clinical meeting.4 The survey, performed in 2005 prior to the FDA approval of dual-label status, looked at more than a thousand pharmacies in Atlanta, Philadelphia, and Boston. Overall, 23% were unable to fill a prescription for EC within 24 hours. About one-third of Atlanta pharmacies (35%), 23% of Philadelphia sites, and 4% of Boston facilities were unable to meet the 24-hour deadline. Researchers also report that 9% of the pharmacists in Atlanta and 5% of pharmacists in Philadelphia said they would refuse to dispense the drug.
Subtle differences in state law may affect EC availability. In Georgia, pharmacists can elect not to carry Plan B, while in Massachusetts, state laws require that pharmacies stock the drug if there is a demand for it. In Pennsylvania, no laws have been enacted regarding whether the drug should be stocked.5
The FDA's approval of dual status for Plan B may well change the numbers, says Rebekah Gee, MD, MPH, Robert Wood Johnson clinical scholar at the University of Pennsylvania, who presented the survey results at the ACOG meeting. She is performing a similar study of pharmacies and says refusals to carry the drug are "much lower" now.
"I think that the FDA decision raised awareness about Plan B and helped to define the drug more as a mainstream medication," states Gee.
Up access with 'C-Cards'
Plan B's dual status means that the drug is available "behind the counter," but without a prescription, to consumers 18 years of age and older. It remains prescription-only for women 17 and younger. Nine states — Alaska, California, Hawaii, New Mexico, Maine, Massachusetts, New Hampshire, Vermont, and Washington — have pharmacy access programs that enable women to get Plan B directly from specially trained pharmacists without going to a prescriber first for a prescription. Women younger than 18 in those states are able to access Plan B directly from a certified pharmacist; those younger than 14 in Hawaii need parental consent to get Plan B through a pharmacist.
Some women, especially those of younger age, may feel inhibited to ask for EC in the pharmacy setting, where there often is little privacy to discuss personal health care issues with the pharmacist. Research conducted by the Pharmacy Access Partnership and the Pacific Institute for Women's Health shows that young women would be more likely to seek such services if there were a way to have a private conversation with a pharmacist in a crowded pharmacy, says Belle Taylor-McGhee, the partnership's executive director. The two groups have developed the Client Confidentiality Card, or the "C-Card," to help women of all ages access EC in a discreet, confidential manner.
The top half of the C Card contains basic information about EC and how it works. The bottom half has a message for pharmacists that can be torn off and used to request EC nonverbally in a discreet manner in a crowded pharmacy. The bottom half of the C-Card states: "Dear Pharmacist, I would like to obtain emergency contraception. Please help me learn about this important backup birth control method in a confidential way. Thank you." The idea is that the pharmacist will then find a private way to discuss with and provide EC to the woman, out of earshot of other pharmacy patrons.
The Pharmacy Access Partnership has been contacting pharmacy associations and organizations around the country to spread the word about the card's availability, says Taylor-McGhee. Public health departments, as well as pharmacists, are interested in distributing the cards, she says.
Women need to know
More effort will be needed to increase access to emergency contraception. The American Medical Association has just adopted a new policy requesting that pharmacies use their web site or other means to let patients know whether they stock and dispense EC and if a prescription is required. If a pharmacy doesn't dispense EC, pharmacies should indicate where it can be obtained in their region, the policy states.6
NARAL Pro-Choice North Carolina says it will continue to work with pharmacists to increase their knowledge of EC, as well as with the state hospital association to boost the number of facilities that stock EC. The group lobbied for legislation this year to require hospitals and urgent care facilities to stock the drug, says Reed. While the bill did not pass, women's health advocates will push for approval in the following session, she reports. The NC organization also will work to boost community awareness of EC availability to increase access to the drug, she adds.
The Pharmacy Access Partnership is working with several pharmacy associations around the country to survey pharmacists about their experience with EC in the dual-status environment, reports Taylor-McGhee. While the analysis is ongoing, preliminary results appear "mixed," she states. In states such as California, which offered pharmacist access prior to the label change, access to EC appears less cumbersome, she notes. Education is a key part of EC access, Taylor-McGhee notes.
"I think the challenge will continue to be to educate women about emergency contraception availability and emergency contraception use, and also to encourage pharmacists to provide the kind of environment that is conducive to women accessing it without intimidation, without barriers," she states.
Telling women about EC is a key piece in the access puzzle, says Gee. "I tell all my patients of reproductive age about Plan B, especially if they are on a birth control method that has higher failure rates or lower compliance like withdrawal, the rhythm method, the condom, or the pill," she states.
To obtain Client Confidentiality Cards, visit the Pharmacy Access Partnership's web site, www.PharmacyAccess.org. Click on the link under "Client Confidentiality Card" for ordering information. Cards are $10 per 100 (including shipping and handling) and may be ordered online, by telephone at (510) 272-0150, or e-mail to firstname.lastname@example.org.