Should birth control be OTC?

New laws in California and Oregon now allow pharmacists to dispense birth control to pharmacy customers without a doctor’s prescription. But not many pharmacists are taking part-at least not yet.
Retail chains, pharmacy educators, and some pharmacists say the so-called pharmacist prescribing laws are a great opportunity for pharmacists to expand their services and to use their knowledge. The American College of Obstetricians and Gynecologists (ACOG) takes the position that requiring a pharmacist to dispense birth control-rather than offering it “truly” over-the-counter (OTC)-serves to place an unnecessary barrier between women and safe contraception.
Jim Graham, Walgreens’ senior manager of media relations, says that the drugstore chain is looking into incorporating the pharmacist prescribing law into its operations. He told Drug Topics magazine, a sister publication to Contemporary OB/GYN, “We appreciate the new law’s recognition of the valuable role that pharmacists can play as healthcare providers. We are currently assessing the [pharmacist prescribing] law’s procedural requirements.”
Walgreens plans to test the service in a small number of pharmacies, “which will also give us an indication of the demand for this service,” Graham said.

The Oregon law

Oregon House Bill 2879 became effective in January 2016. To develop a training program to assist pharmacists in dispensing birth control, the Oregon Board of Pharmacy convened a workgroup with representatives from the Oregon Medical Board, the Oregon State Board of Nursing, the Oregon Health Authority, and subject matter experts. It approved a 5-hour continuing education (CE) training program for pharmacists through the Accreditation Council for Pharmacy Education and Oregon State University, which can be completed online at a cost of $250.

California and Washington

Oregon State University offers a course to California and Washington state pharmacists as well. Lorinda Anderson, PharmD, BCPS, a professor at Oregon State University College of Pharmacy, says that about 1700 pharmacists practice in retail sites in Oregon. California and Washington do not require pharmacists to obtain CE before dispensing, whereas Oregon does. In Oregon, 936 pharmacists are contracted to take the course through their pharmacies, and Anderson says this number will soon rise to about 1600. In California, despite it not being required, about 1291 pharmacists are contracted to take the course, and in Washington, 922. Washington state does not have a specific law concerning the dispensing of contraception, says Anderson, but it could be covered under an older, separate law for collaborative practice agreements.

Opportunities, challenges

The ability to dispense birth control “is a great practice advancement opportunity for pharmacists and the first opening to truly practice at the top of our license/training,” said Cortney Mospan, PharmD, assistant professor of pharmacy at Wingate University School of Pharmacy in Wingate, North Carolina. “The provision of birth control is a greater opportunity for pharmacists as the medication experts on the healthcare team to really use our knowledge.”
“In the process [of dispensing] the pharmacist will review the patient’s other medications, conditions, and appropriateness of that prescription for a patient. Pharmacists fully recognize that we are not the diagnosis experts. However, I think our colleagues in medicine and nursing underestimate how much physical/patient assessment we do receive in our curriculum. We are fully trained on how to collect a patient history. We also know how to identify signs and symptoms of more severe [conditions] while assessing patients.”

Reasons for reluctance

Along with the ability to dispense birth control comes greater responsibilities for pharmacists and time away from dispensing prescriptions. “Pharmacists will need to be thorough in their patient assessment as well as their monitoring and knowledge of the differences in the types of birth control, such as the patch versus the NuvaRing versus injectables versus the multitude of oral contraception,” Mospan said.
Mospan said the lack of reimbursement for providing the service, fear of change, and the extra time required for counseling are among the barriers to more widespread adoption of birth control dispensing by pharmacists.
“Pharmacies are very busy, and to do this and do this well will take some reengineering of workflow, practice models, and [staffing],” she said.
“To see that happen, there has to be a way to pay the pharmacists. We need to be recognized by Medicare as providers and see changes in insurance code,” she added.

ACOG’s position

Mark S DeFrancesco, MD, MBA, former ACOG President, released a statement in January 2016 regarding pharmacist prescribing laws, which stated, “ACOG has long supported OTC access to oral contraceptives. Birth control is an essential part of women’s health care, and OTC status would help more women benefit from the ability to control their own reproductive health. Of course, decades of use have proven that oral contraceptives are safe for the vast majority of women, and that they are safer than many other medications that are already available OTC.
“However, pharmacist prescribing laws are not the same thing as OTC access. Requiring a pharmacist to prescribe and dispense oral contraceptives only replaces one barrier-a physician’s prescription-with another. This is not going to allow us to reach women who remained underserved by the current prescribing requirements.
“As ob-gyns, we respect our pharmacist colleagues, who share our commitment to quality patient care. But we know from evidence and experience that oral contraceptives are safe enough for OTC access, and do not require any prescription at all.““

OTC concerns

“It’s a little surprising to me that ob/gyns have so strongly advocated for OTC birth control and are not supportive of a pharmacist provision,” said Mospan. “I understand they don’t want to create a new barrier in place of an old barrier, but I don’t think it’s quite the same. [In] my experience with patients, I don’t think that oral contraceptives are ideally managed with OTC therapy. I don’t think a patient who was one of the few to experience some of the more severe side effects (ie, a blood clot or pulmonary embolism) would be able to recognize this quickly if there were no healthcare provider associated with accessing this medication and providing counseling on severe side effects.
“I also am not in support of OTC birth control because I believe this will likely cause another barrier in access: lack of insurance coverage. Prescription insurance does not require coverage of OTC medications, and in my experience, maybe 5% of the time are these covered by insurance companies. So the work that was done by the ACA to increase access through a lack of copays would be negated.”