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Update on Emergency Contraception

(Published March 2011)

Pharmacist Consultation

Because of their dual-label status, over-the-counter (OTC) progestin-only emergency contraception pills (ECPs) are kept behind pharmacy counters. This placement provides pharmacists with an opportunity to play a crucial role in providing advice and information to patients about emergency contraception (EC). OTC sale to patients 17 years of age or older improves access to progestin-only EC by removing the delay associated with obtaining a prescription for this time-sensitive medication, thereby increasing use of this safe and reliable method for preventing an unplanned pregnancy. Pharmacists have become a critical link between EC and women who need it.

Dispensing and selling EC

Table 2. Action items for pharmacists regarding EC
  • Stock and dispense ECPs.
  • Make sure all of your pharmacy's employees, particularly those who answer the telephones, know that you provide ECPs.
  • Routinely discuss EC with appropriate patients (e.g., new users of oral contraceptives, condom users).
  • Provide ECPs in advance to patients when possible.
  • Determine your state's requirements for prescribing progestin-only ECPs to patients 16 years of age or younger.
    • In pharmacy access states, prescribe progestin-only ECPs for women younger than 17 years.
    • In other states, suggest that patients younger than 17 years obtain a prescription from their primary health care provider for use if ECPs are needed.
  • In pharmacy access states, determine your state's requirements for pharmacist prescribing of UPA and contact your state's board of pharmacy regarding any related changes required.
  • Advertise the availability of ECPs in your pharmacy.
  • List your pharmacy in directories of pharmacies carrying ECPs.
  • Have an area available where you can discuss EC with patients confidentially.
EC, emergency contraception; ECP, emergency contraception pill; UPA, ulipristal acetate

Practices may vary by pharmacy and state; however, pharmacists are only required to verify the age of the OTC progestin-only EC purchaser. If the individual is age 17 years or older, progestin-only ECPs can be sold, and no other screening or counseling is required. If a woman has public or private insurance coverage of prescription ECPs, then pharmacists in pharmacy-access states can prescribe progestin-only ECPs to ensure insurance coverage even though the woman is eligible for OTC progestin-only EC based on her age. In some instances, counseling may be viewed as intrusive or an additional barrier to access to OTC EC. The pharmacist must determine whether such services are desired by the purchaser. Prescription EC counseling is mandated by federal and state laws.

In contrast with progestin-only EC, ulipristol acetate (UPA) requires a prescription for all women, regardless of age. In direct access states, pharmacists should review their state laws to determine whether UPA falls under the definition of EC within the current legislation. If the pharmacist cannot prescribe UPA, he or she should refer the patient to a practice site at which she can access UPA.

If the patient is interested, has the time, and the pharmacist has a private area in which to counsel, the pharmacist may provide the patient with a short summary of key issues, including ongoing contraceptive options, and offer further counseling. Pharmacists should be aware that some patients may feel stressed or embarrassed when inquiring about EC.

Additional considerations for pharmacists

In pharmacy-access states, pharmacists provide patient assessment, consultation, and EC prescribing.1 Policies about paying pharmacists for this type of service vary among states and insurance companies. As EC has evolved, pharmacists in many states have been actively engaged in making it available to more women (Table 2). In pharmacy-access states, this often has been achieved through the development of collaborative practice agreements permitting pharmacists to prescribe ECPs.2 Experts in pharmacy provision of EC urge all pharmacists to join their colleagues in providing this important component of women's health care.

Case study:  Bethany

A woman comes to the pharmacy counter and tells you that she has missed the first three doses of her birth control medication and wonders if she needs emergency contraception (EC).

  • Ask the woman if she has a few moments to talk privately.
  • Ask her whether she has had unprotected sex within the previous 120 hours. If she has, offer to provide her with emergency contraception pills (ECPs). If she has had sex without using a condom, you might inform her to consider a follow-up visit with her primary provider for an examination for sexually transmitted diseases/infections.
  • If she has insurance coverage and you practice in one of nine states that allow pharmacist-initiated prescription of ECPs, you can prescribe progestin-only EC and generate an insurance claim. Pharmacists in all direct access states should review their state laws with regard to restriction of EC prescribing to determine whether they can prescribe ulipristal acetate (UPA).
  • If the woman has time, ask her if she’s satisfied with her current form of ongoing contraception and if she commonly misses doses. Suggest other forms of ongoing contraception, provide her with information about other methods, and make a referral if needed.

Case study: Dave

A man comes to the pharmacy counter and wants to know if you will sell him ECPs for his girlfriend.

  • Tell him that you would be happy to provide him with EC if he is eligible.
  • Ask for his identification to verify that he is old enough to buy OTC EC.
  • If he is old enough, sell him the EC.
  • If he is not old enough but his girlfriend is, let him know that she can purchase the EC herself. Alternatively, someone else who is old enough to purchase EC without a prescription may purchase the products.

Case study: Marie

A young-looking female tells you that she needs EC. In talking with her, she tells you that she’s been raped and that she is 15 years of age.

  • You can prescribe EC if you practice in one of nine states that allow pharmacist-initiated prescription of EC. If she doesn’t have money to purchase EC, check your pharmacy’s policy about “charity care” for these kinds of situations.
  • If you can provide her with EC, then talk with her and coordinate a referral to a local Title X clinic/Planned Parenthood clinic or emergency department to provide her with postrape care. Consider having a pharmacy staff person escort the girl to the referral site.
  • If not able to directly provide her with EC, you should consider contacting a local Title X clinic/Planned Parenthood clinic or emergency department for EC and postrape care.
  • In most states, this situation would mandate a report to a child protection service.

References:

  1. Boggess JE. How can pharmacies improve access to emergency contraception. Perspect Sex Reprod Health. 2002;34(3):162–5.
  2. Monastersky N, Landau SC. Future of emergency contraception lies in pharmacists' hands. J Am Pharm Assoc. 2006;46:84–8.