Should oral contraception be accessible without a doctor’s prescription?

On January 1, Oregon became the first state to offer contraceptive patches and pills without a doctor’s prescription. A bill allowing California to do the same was signed into law in 2013 but has yet to be implemented, while Washington and Colorado are proposing similar legislation.

Could this work in Canada?

Phil Emberley, Director of Pharmacy Innovation at the Canadian Pharmacists Association, says while the option has been discussed off and on over the years, he knows of no plans to go forward. And, while he maintains the association holds no active position on the prospect, he says, “We strongly believe in accessibility, in the pharmacist being the drug expert, so if this was ever under consideration, we think it’s a logical step to take. But we do not and won’t be issuing a statement until we get more signals that this is being considered.”

Health Canada tells Yahoo! that it has yet to receive any signals either. The department explains that, in order to follow Oregon’s lead, oral contraceptives in this country would need to undergo a switch in status from prescription to non-prescription at the federal level. The request for such a status switch would need to come from the product’s manufacturer, and be accompanied by sufficient proof that the product is safe to use without the oversight of a health care professional. Such a process generally takes 12 months, followed by a six-month delayed implementation period to meet various trade obligations.

If Health Canada was satisfied, the manufacturer would then approach the National Association of Pharmacy Regulatory Authorities with similar data and a request to allow the contraceptives to be prescribed by the pharmacist. Since Canada’s health care system is managed by the individual provinces and territories, such a proposal would then fall within each of their jurisdictions.

In Oregon’s case, the proposal was signed, sealed and delivered in less than six months. “It was signed by our governor on July 8, our board wrote the rules around it, and developed the training program in 94 days, which is really fast under normal state processes,” says Marcus Watt, R.Ph., Executive Director for the Oregon Board of Pharmacy.

The quick turnaround, according to Watt, was thanks to nearly everyone, from pharmacists to physicians to other health care providers, being on board from the beginning. “You’d expect there to be some resistance from other health care professionals,” he says, noting the process was instigated by physicians, “there was none. Everybody looked at this with single-minded purpose that this was a good thing to do, that we needed to make it happen.”

Although it’s still too soon to provide hard data on how communities have responded to the new service, Watt says anecdotal evidence is positive. “In the first seven or eight days, we were told, there were about 100 pharmacist-patient interactions and about 90 of those resulted in a prescription being issued,” he says. “The remaining were referred back to a primary care provider [for further consultation].”

How Does It Work?

Both Watt and Emberley are quick to emphasize that this is not an over-the-counter service, nor are the drugs provided without a prescription. Women in Oregon still need a prescription to purchase birth control pills and the transdermal patch. The difference is that the authority to write those prescriptions has now been granted to the state’s pharmacists. That has resulted in a more streamlined and accelerated process.

According to Watt, a patient can now walk through the door of any participating pharmacy and, after screening, walk back out with their pills or patch — in as little as an hour. This is most beneficial, he says, for those rural residents who often wait up to 12 weeks just to see a physician.

Pharmacists who opt to provide the service must first complete five hours of specialized training, says Fiona Karbowicz, R. Ph, Pharmacist Consultant for the Board. She says the procedure starts with a questionnaire the patient fills out at the pharmacy, detailing such information as her health history, any chronic diseases, medications she’s currently taking, smoking habits, and other types of contraceptives she’s either using or has used. This is followed by a discussion with the pharmacist to rule out the possibility the woman is currently pregnant, as well as counselling on how to use the contraception, any possible side effects, and wrapped up with a blood pressure test administered by the pharmacist. If she passes the tests, is 18 or older (or under 18 with proof she’s previously been prescribed the contraception by a doctor), and not referred to a health care provider for further consultation, she walks out with up to 12 months of contraceptives.

Watt notes that, in the first week of the new legislation, 150-180 pharmacists were taking the training. By the end of February/first of March, he anticipates there will be up to 1,200. Not all pharmacists are on board, however. Some may refuse based on religious or moral grounds, just as they did in 2004 when Plan B, the morning-after pill, was introduced. “Our board at the time determined that, while a pharmacist had the right to refuse to engage in any therapy, that right could not be a barrier to the patient’s right to have that therapy,” says Watt. Pharmacists who decline are required to refer patients to their colleagues who will provide the service. “And we’ve had no issues with that approach,” he says.

Beyond personal ethics, the pharmacist can exercise discretion based on a patient’s health. “For example,” says Emberley, “if the patient had uncontrolled high blood pressure, the pharmacist would not prescribe the drug … because it’s a complicating matter that could adversely affect their health.”

Running the Risks

The birth control pill has been in use for over 50 years, and while it is not risk-free — a slight increase in stroke, blood clot or deep vein thrombosis has been associated on rare occasions — there is more of a risk for those conditions during pregnancy than with the pill.

“That was eye-opening to me as a woman, as a mom, to even think of pregnancy as a risk, since it’s so natural,” says Karbowicz. “However, the OB/GYN docs we worked with [said] the risks and problems of pregnancy do outweigh the risks associated with the patches and pills.”

Banking on the Benefits

“The majority of people in health care we’ve spoken to see it as a positive impact on women’s health and access,” says Watt.

Other benefits of the birth control pill include lighter, less painful periods, unintended pregnancies and a reduced risk for some cancers.

As for Oregon being the first to implement such a strategy, Watt says the state has a reputation for being maverick. “We were the first state to introduce death with dignity years ago, and this fits in with that spirit. But also the people in the legislature really saw the value and shared their vision. And it was the right vision.”

Meantime, all eyes — including Canadian eyes — will be on Oregon to see how the new procedure plays out, and possibly decide if it’s the right vision for us.