Emergency contraception simplified?

Ombudsman’s office attempts to reconcile privacy and pharmacist’s privilege

Tessa Vanderhart Staff

New recommendations were announced on Feb. 3 to clarify the role of the pharmacist in distributing emergency contraceptives to women in Manitoba.

Since the most popular emergency contraceptive (EC), Levo-Norgestrel, was made an over-the-counter drug in Canada this April, the pharmaceutical community in Canada has struggled to deal with its distribution in a way that reconciles accessibility with patient safety and privacy.

Classified as a schedule 2 product, the drug has to be kept behind the pharmacist’s counter, which requires interaction between the patient and pharmacist. However, the precise content of this interaction is unclear: no formal provisions were made to balance the duty of the pharmacist to counsel the patient with Health Canada’s intentions to improve access to the drug.

“Pharmacists should request only the minimum amount of information necessary,” emphasized Irene Hamilton, Manitoba’s Ombudsman. “Personal info isn’t needed unless a person wants to make an insurance claim.”

Hamilton said that the new recommendations released by her office last week were intended to clarify, not change, the existing rules for distributing EC.

The original guidelines of the Canadian Pharmaceutical Agency (CPhA) for dealing with EC called for Plan B requests to be recorded on the health records of patients in order to track the number of times it is purchased — something not normally done for schedule 2 products.

It will remain up to individual pharmacists to ask patients to attach a record of the drug to their medical records. Also, it is left to the discretion of the patient to fill out the questionnaire recommended by the CPhA, which asks basic medical questions. In addition to information on menstrual cycles and medical history, the question sheet included the patient’s name and date of birth.

Hamilton said she hopes the commentary makes it clear that a request for this information does not constitute grounds for filing a complaint that a patient’s privacy has been violated.

Patients who do not feel comfortable providing any or all of this information are not to be denied access to the drug, according to the existing rules.

The CPhA continues to strongly recommend training for pharmacists who distribute emergency contraception, although it is only required in BC, Saskatchewan and Ontario.

No pharmacy has to stock EC, but pharmacists are required to make patients feel comfortable, to refrain from asking for more personal information than is necessary, and to direct patients to a pharmacy where the drug is carried.

In Ontario, however, complaints to the privacy commissioner spurred an overhaul of the entire process. The resulting media attention led Hamilton’s office to release their own commentary.

In response to public reaction, “Ontario sent out guidelines that were quite a bit different, and reinforced the individual’s right to remain anonymous . . . it seemed like a good approach,” said Hamilton.

Louise Crandall, the manager of public affairs for the Canadian Pharmaceutical Association, pointed out that the drug is often misused: “20-35 per cent of the women that walk in don’t need it,” she said.

Crandall said that most complaints have come from outside women’s interest groups, and very few from women themselves. When women do have questions, she added, it is often because “they don’t understand why the pharmacists are asking the questions — the questions are quite personal.”

Still, she said, Plan B is available over the counter to increase women’s access to it, while maintaining the “best standard of care” and making sure that it is used effectively by women.

“I don’t think there’s going to be a change, nor should there be a change,” she said. “All the provinces require pharmacist intervention — it’s just the questions, and whether the woman’s name is recorded that may vary by province.”

Dr. Philip Hall, a gynecology professor, said that he thinks the drug is so safe it could be “on the shelf with condoms.” He said that the unrestricted choice has been available for women in Europe for well over a decade.

“The point is if . . . a woman has had unprotected sex over the last three days, this works.

“I think that any approach that doesn’t allow the woman to make her own decision implies, for some reason, that women don’t have the brains to figure that out on their own. It’s patronizing,” said Hall. “It’s on the box!”

He emphasized that the product is a contraceptive, not an abortion pill: it works by preventing the release of the egg from the ovary, and also by interfering with the meeting of the egg and sperm.