Johnathan Laird
AS a practising community pharmacist there is no way I can agree to making either levonorgestrel or ulipristal acetate general sales medicines (GSLs). In other words, they should never be available to buy straight off the shelves down the local newsagent or at the local supermarket.
There is little doubt that the availability of emergency hormonal contraception (EHC) is a useful thing. Many thousands of folk over the years have made use of the availability of levonorgestrel or more recently ulipristal acetate. In my view rightly so. We are fortunate that our culture allows us to have the choice of EHC.
How it is supplied, from where and how much it should cost are all up for debate.
How much should it cost?
EHC should be free for all to access when they need it. Quite simply, it is a question of fairness. If a charge were to be levied it would of course fall to the female to pay. This is not fair in my opinion, especially given that the reasons for accessing EHC are not always through consensual sex.
In Scotland community pharmacists can write a prescription for either type of EHC medicine. Both levonorgestrel and ulipristal acetate are available via this patient group direction (PGD) from community pharmacies across Scotland. I think this is not far off the ideal situation in terms of an arrangement to supply EHC. There is no fee to the patient and most importantantly there is no ambiguity around what groups of patients should pay or not pay. It is free for everyone.
Who should supply it?
I think EHC should be supplied by an appropriately trained healthcare professional within the correct environment for a number of reasons. My preference is supply by a community pharmacist in a community pharmacy. The accessibility of community pharmacy makes it a good location to deliver this service.
I should declare that I write from the perspective of a community pharmacist who regularly supplies EHC to patients from the community pharmacy setting. I know that no system is perfect, but it is up to pharmacists to make the patient feel comfortable, and keep the consultation private. Most pharmacies now have a private consultation area to deliver discrete services like EHC. Staff should be trained to support pharmacists in the process of delivering the service in a non-judgemental and understanding way.
The massive advantage of using pharmacists to deliver the service is to pick up the minority of cases that are not so routine. Perhaps a young girl presents for EHC. There could be child protection issues here that a pharmacist may pick up through a clever consultation. Cases of rape or sex with vulnerable adults are other situations that may be picked up by contact with a pharmacist. I do feel that a service for the masses should also take into account the more vulnerable in society. By supplying EHC in a community pharmacy we open the door to the opportunity to support these vulnerable people.
Sometimes patient education, or lack thereof, is the reason that EHC is used. The consultation in the pharmacy should be a really good chance to support and inform the patient of some of the types of long term contraception available, their efficacy, advantages, disadvantages and risks. Perhaps in this way patients may feel much more in control and have time to make really informed decisions about future contraceptive methods.
Clinical considerations
Clinically there are quite a number of important points to cover with patients when supplying EHC. For example, ulipristal Acetate is not recommended in severe asthma. There are situations where both drugs become less efficacious due to interactions with other medicines. Certain conditions can reduce efficacy, such as severe malabsorption syndrome, which can reduce the efficacy of levonorgestrel.
The issue of existing or future contraception and the effect of EHC also need to be covered. Patients will, in my experience, seek reassurance on where they stand in terms of current contraception, for example if they are using EHC because of a missed contraceptive pill. Pharmacists needs to satisfy themselves that the patient is not currently pregnant before supply is made. Previous allergy to the drugs is also consideration. The list goes on.
The final reason that I am an advocate of the face-to-face consultation is because the encounter presents an opportunity to reassure or give advice on sexually transmitted infections (STIs).
I do understand the perceived ‘shame’ or loss of dignity by having to walk in to a pharmacy and ask for EHC. However, my experience of supplying EHC has taught me first hand that there is a clear range of benefits when pharmacists make that supply. I absolutely accept that pharmacists perhaps need to reflect on their own practice and the environment within which they practise. Listening to patients and meeting the needs of as many as possible is something we should strive for.
For any pharmacist that has ever supplied emergency hormonal contraception, this blog: The politics of the morning after pill, on the Fashion Slave website is a cracking read. It is so honest and articulates beautifully how important discretion, empathy, rapport and just common decency is when embarking on this type of consultation.
Johnathan Laird is a community pharmacist independent prescriber with a special interest in asthma. He is a member of the RPS Scottish Pharmacy Board and is based in Aberdeen
Follow Johnathan @JohnathanLaird