With Teen Pregnancies Skyrocketing, Ob/gyns Seek Support for Nonprescription “Morning-after Oill”

Barbara Sibbald

Support for a move to make emergency postcoital contraception available without a prescription appears to be mushrooming in Canada. The Society of Obstetricians and Gynaecologists of Canada (SOGC) and 23 other medical and pharmaceutical organizations have joined the groundswell of support since the SOGC launched a campaign to increase awareness and availability of the "morning-after pill" in November 1998.

But before tackling the issue of legislation needed to delegate prescribing authority, the SOGC is trying to ensure that it has broad support by asking 50 other organizations to endorse its motion. "We can't go it alone," explains Rosemary Killeen, the SOGC's director of communication and partnerships.

The 23 supporters who have signed on since March include the Canadian Pharmacists Association, the Royal College of Physicians and Surgeons of Canada, the Canadian Nurses Association, the Federation of Medical Women of Canada, the Canadian Paediatric Society, 6 provincial medical colleges and others. Recently, the SOGC received verbal approval of the motion from the National Association of Pharmacists Regulatory Authorities; the CMA is currently considering the motion.

The impetus for the motion came from the SOGC's June 1998 Contraception Consensus Document, which revealed that the number of teen pregnancies is increasing rapidly — by 18% between 1987 and 1994. The morning-after pill can also prevent unintended pregnancies for women in their 30s and 40s, many of whom use emergency postcoital contraception (EPC) due to contraceptive failure. The SOGC says EPC must be made more accessible because the sooner it's taken following intercourse — up to a maximum of 72 hours — the more effective it is. The SOGC says it makes sense to allow pharmacists to dispense the drug. "Pharmacists are the most accessible health care professionals," says Killeen.

For some health care groups, approval of the SOGC resolution has been somewhat controversial. Although the SOGC called for the drug to be available without prescription in pharmacies, family planning clinics, emergency rooms and walk-in clinics, and through school health programs, the Canadian Pharmacists Association (CPhA) motion restricts availability to pharmacists.

"Our board felt [the SOGC motion] was too broad," explains Janet Cooper, the CPhA's acting director of research and practice development. "We needed to have some controls. . . . We wanted health care professionals offering it."

In addition, some CPhA members feel emergency contraception "may interfere with implantation of the fertilized egg and they consider that more [like] abortion," said Cooper. Pharmacists for Life, a Canadian group with about 10 members, has already opposed the move, even though the World Health Organization (WHO) says taking the drug is not equivalent to performing an abortion because the woman is not pregnant.

Despite these concerns, says Cooper, the bottom line is that increased availability is a public-health issue. The CPhA and SOGC set up a 4-member joint working committee in July to look at the logistics of the project, though no completion date has been set. Two committee members, including Cooper, have studied a Washington state pilot project that allows certain pharmacists to receive prescribing authority. The state has a toll-free number that women can call to find these pharmacists. In that program's first year, 9000 prescriptions were dispensed. "It's not totally transferable [to Canada]," says Killeen, "but we can use their ideas."

Ideally, says Cooper, emergency contraception would become a schedule 2, behind-the-counter drug. Pharmacists would receive specific training in appropriate therapeutic protocols, patient counselling and referrals on contraception, sexually transmitted disease and related subjects. They would also be trained to identify victims of abuse or sexual assault.

The major stumbling block in Canada will be to change some provincial legislation to allow physicians to delegate prescribing authority under certain conditions. Cooper says the CPhA will also need to build in provisions for pharmacists who don't want to prescribe the drug for moral, ethical or religious reasons.

The SOGC's efforts come at an opportune time because Canada's first dedicated emergency-contraception drug, Preven, recently got the nod from Health Canada and should be available this fall. It is a combined oral contraceptive containing ethynyl estradiol and levonorgestrel (Yuzpe regimen). Currently, Canadian women typically take 4 norgestrelethinyl estradiol (Ovral) pills over a 12-hour period — 2 immediately and 2 more 12 hours later; usually they must buy a full cycle of the pills, although some doctors write 4-pill scripts. It is also common to recommend antinausea pills, since nausea is a common side effect. Another product — Plan B, the first progesterone-only pill — has been approved in the US and is being considered here.

"With teen pregnancies skyrocketing, ob/gyns seek support for nonprescription "morning-after pill"" * Reprinted from, by permission of the publisher, CMAJ, 1999; 161 (7), pp. 855. ©1999 Canadian Medical Association