In Washington, California and Alaska, women can obtain "morning-after pills" directly from their pharmacists. Can easier access to emergency birth control be a key to better reproductive health?

By Leslie Laurence

Pharmacist Ed Wong was manning the drug store section at a Los Angeles Costco when a young woman asked for his help with a private matter. The druggist took her to a consultation area where she explained that her partner's condom had broken during sex two nights earlier. Could Wong provide her with the "morning-after pill" so she wouldn't become pregnant? He asked the 29-year-old woman about her health history and explained that if she were already pregnant, the medication would not harm her fetus or cause an abortion. Emergency contraception, he told her, could only prevent a pregnancy from occurring. Then, without needing to contact the woman's doctor, Wong provided her with Plan B, a two-pill EC regimen that can reduce the risk of pregnancy by as much as 95%. Time elapsed: 15 minutes. Cost: $38; $23 for the medication, partly covered by insurance; $15 for the consultation.

Wong's client was able to obtain emergency contraception directly from his store because she lives in one of three states -- Washington and Alaska with California -- in which pharmacists dispense emergency contraception (EC) under general standing orders from a physician. Elsewhere, a woman seeking EC must get an individual prescription from a doctor.

Pharmacy access does not make EC a non-prescription drug, although many reproductive-health experts believe it should be one. "It meets all the criteria for a drug going over the counter," says James Trussell, Ph.D., professor of economics and public affairs at Princeton University's Office of Population Research. "It is extremely safe and effective. It's not addictive and it's the same dose for all people." The American College of Obstetricians and Gynecologists and other mainstream medical groups support the switch to non-prescription status. One reason: "The sooner you take the pills, the better they work," notes Kirsten Moore, director of the Reproductive Health Technologies Project, a not-for-profit research group. For instance, Plan B can prevent nearly all expected pregnancies when taken within 24 hours after unprotected intercourse. At 72 hours, effectiveness drops to 75%, on average. While both Plan B and Preven, the two FDA-approved brands of EC, still offer some protection after three days, studies have not yet determined how much. In addition to the time-sensitivity, EC has been suggested for over-the-counter availability because it meets several important criteria for non-prescription status, including a condition that is easy to self-diagnose (unprotected sex), a treatment regimen that is easy to follow, and relatively few side effects.

Avoiding unwanted pregnancy has several benefits, notes Jane Hutchings of the Program for Appropriate Technology in Health (PATH), a not-for-profit organization that developed the program in Washington, where researchers estimate that easier access to EC has helped prevent at least 2,000 unintended pregnancies since the program began in 1998. "Some would have resulted in miscarriage and ectopic (tubal) pregnancy and about 50% would have been abortions," Hutchings says. She views this as a reliable barometer of the program's potential value.

Pharmacist-physician collaborations like the ones in Washington and California are not new. Thirty-one states allow druggists to provide services such as routine immunizations and smoking cessation programs and to treat conditions such as asthma, diabetes and hypertension in partnership with doctors. In Washington, state regulators, with input from women's health advocates, agreed that EC fits existing criteria for collaborative dispensing. In California, advocates worked with legislators to amend the law to insure that EC specifically would be covered under the collaborative practice statute. Some state laws, however, are too rigid to cover the dispensing of EC requiring, for instance, that the physician, pharmacist and patient sign off on a treatment plan in advance. "That doesn't work when you're talking about an emergency," says Don Downing, R.Ph., a clinical associate professor in the department of pharmacy at the University of Washington-Seattle, who helped launch his state's program.

Even with loosened rules, however, getting pharmacists and pharmacies to sign up as arbiters of contraception presents some hurdles. Qualifications are simple in all three states -- druggists who wish to participate in the voluntary programs undergo training and team up with doctors willing to write standing prescriptions - but not everyone has jumped on board. In the four years since Washington began its program, 250 pharmacies -- 20% of the state's total -- have participated. And while the numbers may not sound particularly high, organizers say the program has made an impact. In the first three years, through July 2001, 45,000 women received EC from a pharmacist, and numbers are growing by about 1,200 a month. "This means a whole lot of women are getting access," says Jacqueline Gardner, associate professor of pharmacy at the University of Washington. In California, where the law went into effect in January, 1,535 pharmacists in 365 pharmacies have qualified. That's roughly 7% of the state's total but represents every county in California, according to Lili Sims of the Pharmacy Access Partnership at the not-for-profit Public Health Institute, which wrote California's legislation. (Launched in April, Alaska's program has not yet produced data.)

It's possible some pharmacists are wary of community reaction. Even Ed Wong of Costco has not posted any signs advertising the availability of EC. "I want to get the word out but we're having trouble figuring out the best way to do that. Access for teenage girls can be a politically sensitive topic. "Logically, you know that the folks who disproportionately suffer from unintended pregnancy are adolescents and you know the public health benefits a program like this can have," says Jane Boggess, Ph.D., Director of the Pharmacy Access Partnership. "But in our society, where there is so much divisiveness around sexuality and contraception, if you want to be successful in passing legislation you're best to stay away from hot button issues. And hot button issues are abortion, teen sexuality and, in some quarters, non-marital sex."

Offering emergency contraception outside a doctor's office may have broader implications than solely preventing unplanned pregnancies. In Seattle, pharmacists are using EC counseling to draw underserved women into the health care system by broaching such topics as sexually transmitted diseases (STDs), ongoing contraception and abstinence during the EC consultation. "We don't just throw pills at somebody," says Don Downing. "We have made thousands of referrals into the health care system - to Planned Parenthood clinics, private doctors and rape crisis centers -- for women whose first contact with a provider was through a pharmacist. This is a new approach to public health."

Downing's outreach has attracted the attention of the National Institutes of Health, which has awarded the University of Washington schools of Pharmacy and Medicine a four-year grant to expand pharmacy access to other contraceptives, a progression that some critics may view as a slippery slope. In addition to EC, by early next year five Fred Meyer pharmacies in the metropolitan Seattle area, in collaboration with physicians, will provide women who meet specific health requirements up to three-month supplies of oral contraceptives, the patch or the contraceptive ring. Pharmacists will monitor women for side effects, check their blood pressure and refer them to a doctor for follow-up Pap smears, pelvic exams and, where appropriate, mammograms. Downing, who is one of the principal investigators working under study head Jacqueline Gardner, hopes to expand to 15 pharmacies in the second year and eventually to offer STD screening using self-administered tests. One selling point, he says, is confidentiality. "We believe young women at risk (for STDs) will find pharmacies very acceptable. You can come in after school before your parents get home and you don't have to fear your doctor telling your parents." Unlike clinics, however, most of which are free, the $50 to $60 cost for initial visits (subsequent visits will be less) may prove too costly for young women.

To get the word out, organizers plan in-store, radio and newspaper advertising. "This will be a novel experiment," Downing admits. "We do anticipate some resistance. It might come from physicians fearful we're going to take patients away from them, as it originally did with emergency contraception. But we anticipate referring thousands and thousands of new patients throughout the state."

Surprisingly, antiabortion activists have not voiced unified, strong opposition to EC access. The National Right to Life Committee has not taken a public stand against EC, though some local chapters have. Members of the group Pharmacists For Life International (PFLI) in Bellingham, Wash., who consider EC an abortifacient, (see Part 1 of this report) organized a letter-writing campaign denouncing the program and succeeded in convincing a few druggists in one community not to sign up. "Our organization promotes the use of medication to save life and restore and maintain health, not to kill humans," says PFL executive director Bogomir M. Kuhar, PharmD., who calls the method EA, or "emergency abortion."

One charge made by opponents -- that easy access to EC will promote unprotected sex -- was not borne out in a recent study. Researchers at the University of Pittsburgh School of Medicine compared the sexual and contraceptive behaviors of adolescent girls who were given EC education and an advance provision of pills with a control group who received EC education only. At six months, 77% of the advance EC group reported using condoms, versus 62% of the control group. Overall, the advance EC group used the method more often if it was needed, began taking the medicine more quickly and reported fewer new pregnancies and STDs.

It's difficult to gauge whether easy access to EC will spread quickly -- or even slowly -- across the country. Hawaii, New York, New Hampshire and Virginia have all expressed interest in passing legislation similar to California's but many other states appear unlikely to do so. Virginia lawmakers have already struck down two attempts to make EC more accessible and a recent attempt in Hawaii was defeated. With that in mind, later this year Women's Capitol Corp., which sells Plan B, expects to file a formal request with the Food and Drug Administration for over-the-counter status for its product and Gynetics, the maker of Preven, is considering such a move.

Even if the FDA agrees, proponents will still have to grapple with consumers' lack of awareness. To help remedy the problem, in March 2002 Senator Patty Murray (D-Wash.) and Representative Louise Slaughter (D-N.Y.) introduced the Emergency Contraception Act, which authorizes $10 million a year for five years to the Centers for Disease Control and Prevention and the Health Resources and Services Administration to develop and distribute information on EC to the public and to health care providers. Support for the measure appears to be strong. A survey of 503 male and female likely voters conducted in July 2002 for the Reproductive Health Technologies Project found that, overall, 72% of respondents were in favor of government involvement in informing the public about EC. (The margin of error is +/- 4.5%.)

Until that occurs, proponents of pharmacy access face a daunting Catch-22. "If women don't know about emergency contraception, they won't come in asking for it," says Jane Boggess. "And if they don't come in, pharmacies will decide it's not something women want."

For information and a list of participating pharmacies in California, go to http://www.ec-help.org. For general information on EC, go to http://www.not-2-late.com.

Leslie Laurence is a National Magazine Award-winning journalist specializing in women's health and health policy. Her work has appeared in Glamour, Ladies' Home Journal, New York, Redbook and many other magazines.

Part 1 of this report appeared on Jan. 14, 2002. This report is the 12th in kaisernetwork.org's series on emerging and underreported issues in HIV and Reproductive Health, which is available online.