Accessible Birth Control Rules Erode Risks

Despite the relative firestorm of anti-women’s health rhetoric that went on last year, a bill in Oregon that allows pharmacists to prescribe contraception “over-the-counter” made it through the legislative process and took effect on the first day of the 2016.

The law now allows pharmacists in Oregon to prescribe and dispense two types of hormonal contraception, the pill and the patch, to women at least 18 years of age with no prior history of prescription.

A similar law that allows pharmacists to prescribe an additional form of self-administered hormonal contraception, the vaginal ring, passed in California in 2013 and will take effect this March. While these are huge steps toward increased contraceptive access for women, it’s important to question the safety and costs of over-the-counter contraception, especially if other states continue to pass similar laws.

Though oral contraceptives and contraceptive patches are considered fairly safe medications, they are not without risks. According to a publication from the non-profit organization PRB, Contraceptive Safety: Rumors and Realities, the main risks of both medications stem from the estrogen-type hormones integral to their contraceptive properties.

These hormones can cause increases in blood pressure, slight increases in the risk of blood clots, and, in current or recent users, a small increase in breast cancer risk.

As scary as all that sounds, these increased risks are minor in most young, healthy women. It is patients with certain risk factors, such as being a smoker (especially over the age of 35) or a prior history of or predisposition to high blood pressure, strokes, migraines, blood clots, and breast cancer, that the safety of the pill and patch becomes concerning.

However, the California and Oregon bills appear quite comprehensive in regards to covering the safety problems that could arise when primary care providers (PCPs) are cut out of the medication access chain.

Notably, these medications are not truly over-the-counter. Patients cannot just walk into the pharmacy, pick the pill or patch up in an aisle, and pay for it at the front cashier as though it were Tylenol or NyQuil.

These laws give pharmacists the power to prescribe, as well as dispense, the medications; a power previously restricted to PCPs.

In Oregon, pharmacists who want to prescribe these contraceptives must complete a State Board of Pharmacy-approved training program. California’s law has taken so long to go into effect because the State Board of Pharmacy has been developing their own protocols for hormonal contraception prescription. In both states, pharmacists who prescribe contraceptives must refer the patient to their PCP so that the patient can receive adequate follow-up.

Patients must also complete a self-screening risk assessment tool, which the pharmacist can use to decide whether or not hormonal contraceptive are safe to prescribe without further evaluation of the patient. Furthermore, in Oregon, pharmacists must also refuse to continue prescribing contraceptive prescriptions to any patient who fails to see her PCP within three years of her first pharmacist-provided prescription.

Hopefully these measures will prevent women at higher risk of complications from accessing hormonal contraceptives over the counter.

There are also some indirect risks to consider that are not addressed in the new law. Pharmacists may not have the time to adequately counsel patients about the lack of protection against sexually transmitted infection (STI) when exclusively using hormonal contraceptives and their pesky, but non-life threatening, side effects.

Patients may not realize that the pill and patch do not inherently protect against STIs and, in certain places, as many as 50% of women stop taking oral contraceptives within one year due to irksome side effects such as menstrual spotting, nausea, mild headaches, slight weight gain, and mood changes, according to Contraceptive Safety: Rumors and Realities.

Without proper counseling, patients may discontinue using condoms and be vulnerable to infection, or stop using their pharmacist-prescribed method of birth control and be at risk for an unintended pregnancy.

Both bills prohibit pharmacists from requiring patients to schedule an appointment for either prescription or dispensation, so any counseling on STI risk and non-lethal side effects will depend on how much time the pharmacist has on a given day.

The Oregon bill also addresses the cost of these medications to a certain extent, as all laws regarding insurance coverage of contraceptive drugs will extend to hormonal contraceptives prescribed by a pharmacist.

The Oregon Health Plan (OHP), Oregon’s version of Medicaid, covers all medical prescriptions (though a copay may still be required). Low-income women will be able to take advantage of the expanded access to contraceptives if they are enrolled in OHP.

Although the California law makes no such specific stipulations, it appears that pharmacist-prescribed hormonal contraceptive will be similarly covered by insurance.

As such, one could argue that these laws do not go far enough to increase access to self-administered contraception. In both Oregon and California, lack of financial coverage for uninsured women could still be a huge barrier depending on the out-of-pocket costs of hormonal contraception.

In Oregon, women under 18 years of age are required to have a history of a prior prescription for hormonal contraception for a pharmacist to prescribe the pill or patch. In addition, Oregon’s law covers one less option of self-administered birth control (the vaginal ring) than California’s law.

Overall, the benefits of over-the-counter birth control appear to outweigh the risks. If more states follow suit, these laws will increase women’s access to a broad range of self-administered contraceptives and appropriate safety mechanisms will still be in place to protect women who may be at risk for serious side effects of hormonal medications.