David W. Fielding

Effects of making emergency contraception available without a physician's prescription: a population-based study

Background: Timely access to emergency contraception has the potential to reduce the number of unwanted pregnancies and subsequent abortions. A public health policy initiative in British Columbia beginning in December 2000 allowed pharmacists to provide emergency contraceptives (ECs) without a prescription. We sought to determine changes in EC use after the policy was introduced and to analyze EC use with data generated by the policy. Methods: All Ovral, Preven and Plan B EC prescriptions from Jan. 1, 1996, to Dec. 31, 2003, were identified through the BC PharmaNet and Medical Services Plan administrative databases and the data analyzed to determine changes between 1996 and 2002. Changes over time were determined in the frequency of EC provision, choice of EC agent, frequency of EC use by age group, repeat use and geographic distribution of EC prescription for the pre- and post-policy periods. Anonymized patient-specific data from treatment consent forms were used to describe the reason for EC use, interval between unprotected intercourse and EC prescription, proportion prescribed for immediate or future use, referrals for regular birth control and STD screening and concomitant antiemetic use. Consent data also provided the time in the menstrual cycle that the EC was requested. Results: The number of EC prescriptions increased from a pre-policy mean of 8805 (99% confidence interval 7823–9787) in the years 1996 to 2000 to a post-policy total in 2002 of 17 794. Physicians prescribed the levonorgestrel regimen (Plan B) less frequently than did pharmacists. The frequency of EC use was highest among women aged 20–24 years across all study years, and all age groups demonstrated a post-policy increase in use. On average, 2.1% of the women received an EC 3 or more times a year over the period of the study. More women in urban regions received ECs than women in more rural areas of the province. Analysis of pharmacist treatment consent forms used in 2001 and 2002 showed that 56.2% of women receiving an EC reported using a method of birth control that had failed, 55.7% of pharmacist-provided ECs were obtained within 24 hours after unprotected intercourse, 1.1% of ECs were obtained for future use, antiemetics were provided to 57.7% of women receiving the Yuzpe regimen (Ovral, Preven) and to 20.5% of women receiving levonorgestrel, and women tended to seek ECs when unprotected intercourse occurred at the time of highest risk of pregnancy in their menstrual cycle. Women in greatest financial need obtained ECs more frequently from physicians than from pharmacists. Interpretation: The policy change that granted pharmacists authority to provide ECs to women without a physicians prescription did not simply expand EC availability but was associated with an overall increase in EC use in the province.

Assessment of Communication Barriers in Community Pharmacies

This study identified previously reported facilitators and barriers to pharmacist-client communication and then evaluated their impact on the observed communication behaviors of pharmacists. Pharmacists (n = 100) completed a seven-page questionnaire collecting information on 11 variables that had been organized according to the Policy, Regulatory and Organizational Constructs in Educational and Ecological Development (PROCEDE) model as predisposing, enabling, or reinforcing of pharmacist communication with their clients. Demographic variables also were included. “Communication quality” served as the study’s dependent variable, whereas pharmacist responses served as the independent variables. Communication quality scores for each pharmacist were obtained from the analysis of 765 audio recordings of verbal exchanges occurring between the study pharmacists and their consenting clients during 4-hour, on-site observation periods. Four of the variables examined in the study were found to share a unique relationship with communication quality (pharmacists’ attitude, year of graduation, adherence expectations, and outcome expectations). Hierarchical multiple regression analysis revealed that the variables measured in the questionnaire accounted for 23% of the variance in communication quality scores. Plausible explanations for why the study was unable to capture more of the variance in its proposed relationships and future areas for research are provided.

Outcomes of Bupropion Therapy for Smoking Cessation during Routine Clinical Use

Background: Knowledge pertaining to the effectiveness of smoking cessation treatments and patient characteristics that may affect success may enable smokers and clinicians to select individualized treatment for each patient and ultimately increase the success rate of smoking cessation in general. Objective: To evaluate the effectiveness of bupropion as a smoking cessation agent when used in routine clinical practice. Methods: This was a prospective, observational study with a one year follow-up period. Adult smokers presenting to community pharmacies in British Columbia, Canada, with an index prescription for bupropion for smoking cessation (N = 205) were eligible. The primary outcome was the biochemically validated 12 month point abstinence (PA) rate from smoking. Secondary outcomes included the frequency of adverse events, patterns of bupropion use in routine clinical practice, and possible predictors of bupropion effectiveness. Results: The validated 12 month PA rate was 21.0%. Of subjects who reported taking at least one dose of bupropion, 70.4% (126/179) experienced at least one adverse event and 29.6% (53/179) reported stopping the drug due to adverse effects. Greater length of time on bupropion (OR 0.98) and a lower cigarette pack-year history (OR 1.05) were associated with an increase in the odds of smoking cessation. Conclusions: Subjects receiving bupropion in a real-life setting exhibited a similar abstinence rate at 12 months as has been observed in the active drug groups of placebo-controlled clinical trials. However, the patterns of use and discontinuation rate due to adverse events differed substantially from those observed in early efficacy studies.

The Developing Role of Pharmacists in Patient Access to Emergency Contraception

Unintended pregnancy and subsequent abortion remain major public health issues in many countries, despite evidence that post-coital emergency contraceptives have a good safety profile, are easy to use, and are effective in preventing unwanted pregnancies. Although emergency contraceptives have been prescribed in developed countries for more than 25 years, abortion rates have continued to rise steadily in many jurisdictions. Barriers to the use of emergency contraceptives reduce ready access of women to this birth control option. Because the effectiveness of emergency contraceptives is time dependent, establishing prescribing and dispensing mechanisms that are convenient to women is crucial to their ability to use the therapy in a timely manner.Emergency contraceptives in developed countries are traditionally prescribed by physicians in organized healthcare settings. In these countries, pharmacists are ideally situated to improve patient access to emergency contraceptives, since community pharmacies are widely available in both urban and rural settings and are open extended hours. Innovative initiatives using a variety of regulatory mechanisms now allow pharmacists a greater role in prescribing and distributing emergency contraceptives. In Washington State, USA, pharmacists entering into a collaborative drug therapy agreement with a physician or nurse practitioner can initiate emergency contraceptives based on a prescribing protocol. Several local programs in the United Kingdom have utilized accredited community pharmacists to supply emergency contraceptives using a patient group directive. In British Columbia, Canada, specially-certified pharmacists with independent prescriptive authority utilize an informed consent during the interactive consultation with the potential emergency contraceptive user. In yet other jurisdictions, emergency contraceptives have been transferred to over-the-counter (OTC) status.Relevant public health research questions can now be posed. Future studies will be able to compare the effectiveness of various regulatory mechanisms to expand access, to identify and address potential drawbacks of pharmacist-initiated1 emergency contraceptives, and to explore whether pharmacist-initiated prescriptions represent expanded access or simply a transfer of the prescribing of these agents from physicians to pharmacists. Countries with OTC emergency contraceptives will be able to explore the relationship between varying levels of pharmacist interaction with emergency contraceptive users and health outcomes, and to investigate whether the change in prescriptive status has resulted in unintentional barriers to access for populations such as teenagers and those with restricted discretionary income. These findings will provide valuable new information on the impact of initiatives designed to expand access to emergency contraceptives.

Provision of Emergency Contraceptives by Pharmacists British Columbia Experience a Template for other Provinces

CPJ/RPC • JULY/AUGUST 2004, VOL. 137, NO. 6 On December 1, 2000, specially trained pharmacists in British Columbia became the first in Canada to be formally granted independent prescriptive authority for emergency contraceptives (ECs). The provincial government implemented this precedent-setting health policy initiative to reduce barriers to access for this time-sensitive birth control option. Since legislation to enhance the scope of pharmacy practice was enacted three years ago, the provision of ECs to women at risk of an unwanted pregnancy has increased substantially. In the process, pharmacists have gained increasing recognition of their role as collaborative health care professionals. This article describes the change in BC health policy that granted pharmacists independent prescriptive authority, explains how pharmacist prescribing relates to Canadian federal and provincial drug schedules, and describes the impact of the expanded role of pharmacists on EC utilization. It also explores issues that remain to be considered should one or more of the EC agents be transferred to non-prescription status.