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Quebec pharmacists should not act as gate-keepers for emergency contraception

Commentary/Opinion by

The condom broke, you skipped a pill, or your memories are foggy from the night before. Accidents happen: Thankfully, emergency contraceptive pills are available. Since 2005, pharmacies have provided levonorgestrel pills (Plan B) without a prescription in Canada. In 11 provinces and territories, you can now find Plan B beside the condoms on drugstore shelves, while Quebec and Saskatchewan both keep it behind the counter. But in Quebec, it is only administered after a mandatory consultation with the pharmacist. This barrier impedes the autonomy of women seeking emergency contraception. It is unreasonable and unethical for Quebec to continue to uphold this standard when most of Canada has removed it.

When I went to get Plan B in Montreal, my consultation was with a pharmacist who seemed to be close to my age. He asked whether I had taken emergency contraception before, the date of my last menstrual cycle, the length of my typical cycle, why I thought I needed emergency contraception, when the "event" had occurred, and whether I used other methods of birth control. At the end of our consultation, he agreed that he would dispense the pill.

My bill came to $44.50. The consultation and the pill both cost $22, which is on the low-end of pricing in Montreal. If you have a valid Quebec health card, the consultation is free of charge. The pill can be partially or completely covered by insurance, depending on your plan. And, if you're under 18, it's always free. But, because I'm a student and it's not a prescription medication, I have no coverage.

 

Given the right information, women should be able to decide on their own if they need emergency contraception.

At the end of my consultation, I asked whether he would ever refuse to dispense it. He confirmed that he would if there was little chance of the woman being pregnant, or if she were outside the window of effectiveness.

While the latter condition may be reasonable, the period of efficacy is not widely agreed upon and depends on the pill. There is some evidence that the pill is still effective within five days, but other studies suggest that it decreases significantly after 3 days.

Refusal to prescribe the pill based on the likelihood of pregnancy, however, is unreasonable and unethical. While the chance of pregnancy immediately after or before a period is extremely low, the women who seek out emergency contraception are typically in their early 20s, and in the reproductive prime of their life. Furthermore, regardless of the likelihood of a pregnancy, emergency contraception empowers women with autonomy over their bodies. Even if a woman forgot to take her pill, or the condom broke, or there was a sexual assault, she can still be in control of her reproductive system. Barring situations where use of Plan B would be unsafe, it is unethical for a pharmacist to send a woman who was attempting to exercise this autonomy home.

The Canadian Women's Health Network and the World Health Organization have declared that there is no medical argument to justify a consultation or examination to obtain the pill. While they should certainly ensure that patrons are educated on the proper use of any drug, pharmacists are not medical practitioners. They are not a sexual health consultants or necessarily experts in women's health, either. The paternalistic idea that a pharmacist knows best what every woman needs is therefore rattling. Given the right information, women should be able to decide on their own if they need emergency contraception.

I work in sexual health, so my level of comfort with this consultation may not reflect the comfort of all women. These conversations can cause shame and embarrassment, especially in the case of assault. This consultation also makes it impossible for women to buy emergency contraception in advance—just in case.

When taken safely, Plan B is a fast and non-invasive way for women to take control of their sexuality. Mandating a consultation detracts from this, and there is no excuse for the fact that Quebec has yet to abolish this standard.

 

 

Emily Heer is a M.Sc Public Health Candidate at McGill.

 

 

 
  • Pharmer

    Hi Emily, I know that this article is a little old at this point but I do believe that I offer a valuable perspective (Saskatchewan pharmacy student). While I can’t speak to your specific situation as I do not know what was discussed between yourself and the pharmacist, in my education we are taught that we have to use our clinical judgement in certain scenarios such as this one (which can be where the grey area appears). For example, current guidelines for pharmacists in Canada do not recommend the use of levonorgestrel after 3 days due to decreasing efficacy at that point (which is what the current collective body of evidence indicates when looking at well-designed randomized controlled trials). With the decreased efficacy, not only is there an increased risk of emergency contraception failure (pregnancy), it would also result in an unnecessary drug cost to the patient.

    Where this story seems to go wrong though is that it should have been discussed that there are still options at this point. Ella (ulipristol acetate) is another form of emergency contraception that exhibits constant success rates for 5 days after contraceptive failure (please note that I do not know your medical history and that any drug has contraindications). Another emergency contraceptive (and is often the last resort) is the copper IUD, which can be administered up to 7 days after contraception failure (however, patient preferences and cost can be barriers). Regardless, pharmacists have a duty to to share your full options with you and I hope you can understand that the guidelines state that this is the approach that must be followed.

    While I can’t speak on behalf of Quebec, as I know you mention Saskatchewan I want to clarify that within our consultation procedures and guidelines allows for dispensing prior to sexual intercourse (“just in case”) so I hope you can see why this service is beneficial (discuss all appropriate options, ensure proper and safe medication use and storage, avoid side effects, ensure no contraindications to different medical diagnoses/prescription drugs/herbals/OTCs, and when to seek further pharmacist or physician help).

    Finally I’m going to disagree that we are not medical practitioners–our legislature specifically clarifies that we are; pharmacists are trained not only in the mechanism of the drugs (which physicians receive), but also receive education in the therapeutic treatment of disease states and the specific prescribing of medications for these pathological and physiological conditions, in addition to evidence-based prescribing that improves patient health outcomes (in addition to all the lovely topics of pharmacokinetics, medicinal chemistry, pharmaceutics and formulation, among many others). In fact, we have numerous course hours dedicated specifically to female development and women’s therapeutic health (which is an area pharmacists can further specialize their educational training in after heir degree). A pharmacist receives at minimum 5 years of education, with many ending up with 8 upon graduation. Upon graduation, pharmacists have the option of completing residencies, clinical masters and doctorate degrees, or post-baccalaureate pharmDs depending on where they wish to practice. If pharmacists were trained to be dispensing and distribution only, they would be called pharmacy technicians and would be in an 18 month program (not knocking technicians, y’all run the pharmacy world by understanding inventory, ordering, and insurance policies more than I can ever dream to)

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