Here’s how pharmacists could have better handled Christie Hayes’ requests for emergency contraception, writes Jarrod McMaugh
A few days ago, MamaMia published an article written by Christie Hayes describing her experiences after attempting to purchase Emergency Contraceptive (often called “The Morning After Pill”).
I came across the article on a forum for early career pharmacists. I’m a little disappointed to say that the comments to this article were generally defensive in nature, and tended to blame Christie for the experience she had, despite it being quite clear that the situation was driven by the failure of the pharmacists in question to apply their knowledge for the correct supply of this medication.
About “Over The Counter” Medications
The term “Over The Counter” is used to refer to medications that can be purchased without a prescription. What is important to remember is that many medications still require significant clinical input from a pharmacist – this is referred to as “Schedule 3”.
Medications are often put in to schedule 3 for one of three broad reasons – There is a potential for abuse, the medication has a high potential for side effects, or the condition being treated requires clinical skills to determine the correct course of treatment (emergency contraception falls into this point).
In all of these cases, there is a requirement for the pharmacist to communicate directly with the patient in order to determine the best course of action.
How the situation for Christie was handled at the first request
The last point above has been used by many commentators (pharmacists and non-pharmacists alike) to justify how the pharmacist handled Christie’s husband when he presented to the pharmacy. Quite a few of these comments have been pretty smug, and have even been aimed at Christie as if she should have known better, or that not presenting to the pharmacy herself was a grievous error that deserved ridicule.
Each of these people are wrong, and here is the reason why.
A pharmacist has the capacity to supply medication to a third party, including Schedule 3 medications. There is no law that says this medication cannot be supplied in this situation, and despite some commenters asserting that this is a breach of the law, it isn’t.
So what went wrong? The problem here is that the pharmacist should have requested to speak to the patient. This is easily achieved with a phone call, wherein the pharmacist can seek the information they need to make a clinical decision, and can provide the advice that is necessary to ensure that this medication is used effectively.
The pharmacist absolutely has an obligation to ensure that the medication is used correctly, and despite the fact that people have a right to access over-the-counter medication, pharmacists also have an obligation to restrict this access if the use is either inappropriate, unsafe, or likely to be ineffective. That was not the case here.
There has been some discussion about safety for any woman who has this medication purchased on their behalf. If they don’t receive the correct information, they may not use it correctly.
The third party may be intending to prevent a pregnancy they do not want, even if the woman DOES want to become pregnant. More nefariously, the third party may be using this medication to prevent a pregnancy in someone they have sexually assaulted. If this kind of situation were to occur, the outcome would certainly be poor, and the public outcry would be (rightly so) deafening.
In my career, I have refused the supply of an emergency contraceptive only once, and it was in the situation where the intended patient was unable to be contacted, despite the person requesting the medication having their contact details.
I have also supported one of my staff in making the same decision, as the person requesting the medication was very agitated and aggressive, and even refused to provide the name of the patient (not a legal requirement, but a policy of our pharmacy is that all Schedule 3 medications are adequately recorded as a medical intervention).
The point is – refusing supply of this medication to a third party should be a rarity, unless some clinical point makes the supply inappropriate. We live in a world of technology where you can talk to anyone anywhere, while they are doing anything. Not attempting to contact Christie to discuss the clinical appropriateness and correct use of this medication was a mistake.
How the situation for Christie was handled at the second request
From Christie’s description, the second request was also handled poorly. It’s possible that the first person she spoke to wasn’t a pharmacist, and that the discussion with a colleague was required – a pharmacist must be part of the interaction. If this is the case, the second person (assuming they were the pharmacist) should have taken over the interaction.
In addition, as Christie pointed out, there was no discussion about the timing – this information was clearly provided, and yet the advice was still a rehearsed response that didn’t fit the situation. There should have been advice on how to confirm the effectiveness of the medication, what to do next, and the time frame for these things to occur.
No other relevant information was discussed – a breach of the pharmacist’s obligations
Another issue is discretion. Christie described the whispered conversation. Ensuring that the conversation is not overheard is absolutely critical, as privacy is a key factor…. But is a whispered discussion in front of anyone discreet?
How could this have been done correctly?
In the first instance, the pharmacist should have contacted Christie by phone, discussed with her the options, and discussed the issues that can make levonorgestrel less effective:
- Vomiting or diarrhoea within a short time of taking the dose.
- Weight (there is some controversy as to whether this medication is effective in women over 85kg – a discussion with a doctor in this case is recommended).
- Whether Christie may have already been pregnant before this instance.
- If Christie has a history of Deep Vein Thrombosis (most data show that this is no longer a risk with levonorgestrel, but a history of DVT may be relevant).
After satisfying themselves of the appropriateness of the use of this medication, it should then have been sold to her husband, and no further delay or inconvenience would have been caused.
In the second instance, the pharmacist should have tailored their advice to the situation in hand. I would recommend a pregnancy test to ensure that the medication had worked, and a referral to a doctor for other medication that can be prescribed if a pregnancy occurs but is still not desired.
What should pharmacists take away from this?
Pharmacists sometimes get caught up in the semantics of medication supply… we tend to be very fact-based, and sometimes when presented with a situation that isn’t explicitly included in guidelines, we start to look around for a black-and-white answer, instead of applying our considerable clinical and forensic knowledge.
Pharmacists are also risk-averse. Many of the medications that we are responsible will kill people very quickly if supplied inappropriately (including non-prescription medications). In this case, these two factors overlapped, and the first pharmacist wasn’t sure what to do.
The primary thought every pharmacist should keep in their mind is always to ensure that any person leaving their pharmacy should know what they are doing next. The pharmacist needs to be flexible in their thinking, and how they would tackle a situation that isn’t expressly covered in law or in guidelines.
If the person presenting is not the patient, then we should do what we can to contact them. If this contact cannot occur, and the supply is rendered inappropriate, then this person should be given all the advice necessary to ensure that the supply is not further delayed.
It’s not acceptable to refuse supply for ANY medication without having a further discussion about why, and what the person should do next.
Lastly, I’d like to extend my apologies for Christie for her experience. There really shouldn’t have been any need to go through the experience she did.
I believe that the majority of pharmacists would feel the same way, and I hope that any pharmacist who sees themselves in Christie’s story learns from her experience and puts some thought into how to proceed next time they are presented with a situation they aren’t sure how to handle.
Jarrod McMaugh is a community pharmacy practitioner in the northern suburbs of Melbourne. He has extensive experience in developing and delivering professional services in the community pharmacy setting.