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Volume 4, No. 7, July 2006
Abstract of the Month
Point / Counterpoint:
Refusals by pharmacists to dispense emergency contraception
I wanted to take the opportunity to respond to one of the articles in the June 2006 issue of CCC Corner. The article “Refusals by pharmacists to dispense emergency contraception: a critique” addresses an issue that has been in the news off and on for the last couple of years. Many of the leading pharmacy organization issued a response to the Obstetrics and Gynecology article. (see References)
Over the last 30 years, the IHS Pharmacy Program has worked with physicians and other providers to assure that our patients receive the medications they need.
On April 8, 2005, an e-mail was sent out on the Pharmacist and Physician listserv(s) discussing this issue. The e-mail is provided below.
Subject: Dispensing Birth Control and Emergency Contraception
Many of you may have read the articles this week (see below) about the Governor of Illinois directing pharmacists to fill prescriptions for birth control and emergency contraception. This issue was also discussed this week at the American Pharmacists Association Annual
Meeting in Orlando, FL.
Over the years, IHS has tried whenever possible to accommodate pharmacists who do not feel they can ethically dispensing birth control or emergency contraception while still meeting our mission of providing needed pharmaceutical services to our patients.
At most sites, this issue is resolved by having another pharmacist who is willing to dispense the medication fill the prescription and counsel the patient. This solution is acceptable if the workload volume does not place an undue burden on the dispensing pharmacist. In clinics with only one pharmacist, the pharmacist can discuss this issue with the Clinical Director and see if there is a physician or other prescriber who would be available to dispense these medications. Policies and procedures need to be in place for when the pharmacist or prescriber is on vacation or unavailable so that the patients can receive medications without delay.
Other sites have looked at how they can assure that these medications are available 24/7 without violating any employee's ethical concerns nor causing any embarrassment for the patient (especially at sites that do not have 24 hour pharmacy coverage). Some sites provide pre-packed, pre-labeled Emergency Contraception in a controlled (for example Omnicell) location for providers that might be prescribing this medication. This allows the 24/7 option, allows first dose administration by the provider in the clinic or ER if desired, and automatically provides a work around for any pharmacist with ethical concerns. Most providers were very willing to work with us on this issue and patients are getting the care they are seeking.
Please discuss this issue at your site and if needed come up with a workable solution. If you have any questions, please contact me at the address below.
RADM Robert E. Pittman
PHS Chief Pharmacist Officer
robert.pittman@ihs.gov
OB/GYN CCC Editorial comment:
This is another in our series of Point / Counterpoint topics that allows our readers to fully explore various sides of complex issues. I want to thank James Bresette, HQE, for helping facilitate this Point / Counterpoint.
The June 2006 CCC Corner noted increasingly numerous instances have been reported in the United States media of pharmacists refusing to fill prescriptions written for emergency postcoital contraceptives. These pharmacists have asserted a "professional right of conscience" not to participate in what they interpret as an immoral act.
Above, the PHS Chief Pharmacist Officer in a simple, but elegantly worded response makes it clear that policies and procedures need to be in place for when the pharmacist or prescriber is on vacation or unavailable so that the patients can receive medications without delay.
The PHS Chief Pharmacist Officer’s comments are especially important because some of our AI/AN patients may be a thousand miles by airplane away from the nearest alternative pharmacy provider.
The American Pharmacists Association (APhA), the national professional society of pharmacists, has actually been a strong advocate for women. The APhA has been active in facilitating pharmacists to prescribe emergency contraception directly to women in need in a number of states. Please see the APhA Special Report below.
It may not only be the individual provider or pharmacist’s approach that creates barriers to our patients. In some cases there can be systematic issues that can also lead to impaired access. Another article posted in the CCC Corner on this topic was co-authored by 2 former Indian Health staff who are now on the faculty of the University of New Mexico. Espey et al reported that Plan B and Preven were not in stock at the majority of pharmacies in a moderately sized metropolitan area. Lack of availability at the pharmacy constitutes a major barrier to emergency contraception access.
Lastly, it is my experience that pharmacists tend to be much more organized than most providers, hence are much more likely to have an effective policy or procedure for something like this. I think an individual patient is much more likely to have her choices limited by a provider. The Indian Health Primary Care Discussion Forum referenced below provides a variety of views on this topic. If a provider does not feel she/he can offer the full range of services to a patient, then they should make similar arrangements to those described by our pharmacy colleagues. Just like our pharmacy colleagues, we should honor that provider’s opinion while we continue to provide the highest level of care to our patients.
I encourage continued dialogue on this and other topics. I find we can learn best if we can truly listen to those we think we disagree the most. Please consider the ‘walk a mile in my shoes’ concept before you begin to you make any final decision. Once we completely understand all the variables, then we can better serve our patients.
References:
Pharmacist Critique Woefully Outdated and Uninformed
American Pharmacist Association
http://www.aphanet.org/AM/Template.cfm?Template=
/CM/ContentDisplay.cfm&ContentID=5735
Wall LL, Brown D. Refusals by pharmacists to dispense emergency contraception: a critique. Obstet Gynecol. 2006 May;107(5):1148-51.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db
=pubmed&list_uids=16648422
APhA Releases the Special Report: Emergency Contraception: The Pharmacist’s Role
http://www.aphanet.org/AM/Template.cfm?Section
=Search&template=/CM/HTMLDisplay.cfm&ContentID=1913
Espey E, et al Emergency contraception: pharmacy access in Albuquerque, New Mexico. Obstet Gynecol. 2003 Nov;102(5 Pt 1):918-21
Emergency Contraception: Primary Care Forum Discussion
http://www.ihs.gov/MedicalPrograms/MCH/F/PCForum_docs/ECDiscussion1604.doc
Contents Summary ‹ Previous | Next › From Your Colleagues
OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
