Doi:10.1016/j.annemergmed.2005.07.00

Nonprescription Availability of Emergency Contraception in the United States: Current Status, Controversies, and From the Department of Emergency Medicine, Brown Medical School, Providence, RI.
In October 2004, the American College of Emergency Physicians Council joined more than 60 otherhealth professional organizations in supporting the nonprescription availability of emergencycontraception. This article reviews the history, efficacy, and safety of emergency contraception; theefforts toward making emergency contraception available without a prescription in the United States;the arguments for and against nonprescription availability of emergency contraception; and thepotential impact nonprescription availability could have on the practice of emergency medicine in theUnited States. [Ann Emerg Med. 2006;47:461-471.] 0196-0644/$-see front matterCopyright ª 2006 by the American College of Emergency Physicians.
doi:10.1016/j.annemergmed.2005.07.001 efficacy of emergency contraception using a lower-dose At the 2004 American College of Emergency Physicians combination of estrogen and progestin. Thereafter, the ‘‘Yuzpe (ACEP) Scientific Assembly in San Francisco, CA, the ACEP method’’ became the standard for emergency contracep Council passed a member-sponsored resolution stating that The Yuzpe emergency contraception method includes 200 mg of ACEP ‘‘supports the availability of nonprescription emergency ethinyl estradiol and either 1.0 mg of levonorgestrel or 2.0 mg contracepBy passing this resolution, ACEP joins other of norgestrel in 2 divided doses 12 hours apart. The first dose is health professional organizations, including the American taken within 72 hours of unprotected intercourse. The Yuzpe Medical Association, the American Public Health Association, method can be used with most commonly available oral the American College of Obstetricians and Gynecologists, the contraceptive pills (eg, Ovral [ethinyl estradiol/norgestrel], Alesse American Academy of Pediatrics, and at least 60 other [ethinyl estradiol/levonorgestrel]).
organizations in advocating for the release of restrictions on The Yuzpe method has been shown in several studies to be selling birth control pills for emergency contraception over-the- effective. For example, in 1977 Yuzpe and Lancee observed the counter in the United States.The resolution primarily serves occurrence of only 1 pregnancy among 608 women taking to clarify ACEP’s position on this matter. To elucidate the 200 mg of ethinyl estradiol and 2.0 mg of norgestrel after reasons behind this resolution, this article will review the unprotected intercourse.In a 1982 study, Yuzpe et al history, efficacy, and safety of emergency contraception; the observed an 84% reduction in the estimated risk of pregnancy efforts toward making emergency contraception over-the- among women using emergency contraception. Other counter in the United States; the arguments for and against researchers have found even greater reductions of pregnancy risk over-the-counter emergency contraception; and the potential impact over-the-counter emergency contraception could have Many alternatives to the Yuzpe method for emergency on the practice of emergency medicine in the United States.
contraception exist and have been evaluated for effectiveness inpreventing pregnancy. Levonorgestrel alone, a progestin-only version of emergency contraception, has been extensively researched and is a widely used alternative to the Yuzpe Apart from intrauterine devices that are infrequently inserted method.In a double-blind, multicenter, randomized, as a postcoital preventive measure, emergency contraception controlled trial of 1955 women, the World Health Organization primarily consists of the use of oral contraceptive pills after sexual (WHO) found a levonorgestrel-only emergency contraception intercourse to prevent pregnancy. Emergency contraception regimen to be more effective in preventing pregnancy than the using high-dose estrogens was first reported in 1964 in the Yuzpe method.According to a Cochrane review, the relative risk NetherlanIn 1974, Yuzpe et aldemonstrated the safety and of pregnancy with a levonorgestrel-only regimen versus the Yuzpe Nonprescription Availability of Emergency Contraception in the United States method is 0.51 (95% confidence interval 0.31 to 0.83).The effectiveness of the Yuzpe method if taken between 72 and same review concluded that taking both levonorgestrel pills as a 120 hours after unprotected intercourse; they reported a single dose is clinically equivalent to the 2-dose regimen. In reduction in pregnancy risk of 87% to 90% if taken fewer addition, in a double-blind, multicenter, randomized, controlled than 72 hours versus 72% to 87% if taken between 72 and trial, a norethindrone-based emergency contraception regimen 120 hours. Ellertson et similarly observed that the estimated was as effective in preventing pregnancy as a standard 2-dose reduction in pregnancy for the Yuzpe method 96 to 120 hours after unprotected sexual intercourse was 77.2% with perfect Non–estrogen-based emergency contraception options exist compliance and was 54.6% with typical compliance.
that might be more effective and perhaps work as emergency The commonly reported adverse effects of the Yuzpe regimen contraception and perhaps work by different mechanisms. The include nausea (50.5%), vomiting (18.8%), dizziness (16.7%), antiprogestin mifepristone (RU-486) can be used for emergency fatigue (28.5%), headache (20.2%), and lower abdominal pain contraception in much smaller doses than are necessary to induce (20.9%Adverse effects reported with levonorgestrel-only abortion. A Cochrane summary of 7 trials comparing low-dose regimens are significantly less frequent: nausea (23.1%), (\10 mg) mifepristone to levonorgestrel and 3 trials comparing vomiting (5.6%), dizziness (11.2%), fatigue (16.9%), headache low-dose mifepristone to the Yuzpe regimen reported that the (16.8%), and lower abdominal pain (17.6%). Nausea and effectiveness of mifepristone is at least as good as, and may be vomiting can be mitigated by administering antiemetics 1 hour better than, either of these methods.Unlike other hormonal before or by taking emergency contraception with food.
methods (discussed below), the increased efficacy of mifepristone However, a recent study disputed the nausea-mitigating effect of is attributed to its ability to inhibit implantation, as well as food.Menstrual spotting is observed occasionally, and early ovulatiDanazol (an antigonadotropin) has also been compared to the Yuzpe method, but data are insufficient to Two major adverse effects, ectopic pregnancy and conclude differences in effectiveness.
thromboembolism, have been hypothesized to be associated with Emergency contraception’s mechanism of action is not emergency contraception usage. Ectopic pregnancy has been known definitively. The Yuzpe method most likely prevents noted in 4 patients who used the Yuzpe regimenand in 19 pregnancy by inhibiting or delaying ovulation.It may also patients who used the levonorgestrel-only regimenAccording interfere with corpus luteum formation or implantation, to a Cochrane review, however, only 5 ectopic pregnancies have modulate luteinizing hormone levels, and perhaps inhibit been reported among a group of 33,110 women using emergency transport of sperm, egg, or embryo in the fallopian tubes. There contraception.In postmarketing surveillance studies of is no evidence that the Yuzpe method directly interferes with levonorgestrel, among 4.4 million units of levonorgestrel sold, fertilization. Levonorgestrel probably prevents pregnancy by only 8 cases of ectopic pregnancies were reported.The incidence blocking or delaying ovulation.The precise mechanism of ectopic pregnancies is lower than that expected based on the of emergency contraception likely depends on when in the observed failure rate for emergency contraception. In other words, menstrual cycle emergency contraception is taken.Some given the number of pregnancies expected to occur because of studies suggest that emergency contraception is not effective emergency contraception failure, 700 ectopic pregnancies would once fertilization has occurred,whereas others dispute this be predicted among the group studied. Thromboembolic events, assertion.With the possible exception of mifepristone, including retinal vein thrombosisand cerebrovascular given that emergency contraception’s mechanism of action is infahave been described in 3 case reports in patients certainly before implantation and is likely before fertilization, using the Yuzpe method. However, Vasilakis et reviewed the most authorities, including the United States Food and Drug cases in the General Practice Research Database of the United Administration (FDA) and the WHO, do not consider Kingdom of 73,302 women who were younger than 50 years and emergency contraception an abortifacienEmergency received emergency contraception between 1989 and 1996 and contraception has no effect on established pregnancies (ie, those found no cases with idiopathic deep venous thrombosis or already implanted in the endometrium), because administration pulmonary embolism. The current standard of care in the United of hormones alone will neither interrupt nor adversely affect States, nonetheless, is use of a progestin-only emergency contraception formulation for women at risk of venous Because emergency contraception probably exerts its effect thromboembolism under the reasoning that if thromboembolism before fertilization, pregnancy is prevented more effectively the were a true adverse effect of emergency contraception, it would earlier emergency contraception is administered. Effectiveness presumably be due to the estrogen in some emergency varies, depending on the regimen used, compliance with dosing schedules, and time elapsed since sexual intercourse, as well as In recognition of the possible adverse effects associated with individual variations in menstrual cycles.The WHO found emergency contraception, the WHO concludes that there are no that the greatest effectiveness of both the levonorgestrel and absolute medical contraindications for emergency contraception Yuzpe regimens occurred when emergency contraception was with Yuzpe or levonorgestrel-only regimens.They do taken fewer than 24 hours after unprotected intercourse.
advise that patients with a history of severe cardiovascular Rodrigues et observed continued, albeit decreased, complications, angina pectoris, migraines, or severe liver disease Nonprescription Availability of Emergency Contraception in the United States require careful follow-up when taking emergency contraception.
distribute emergency contraception as part of a collaborative Pregnancy is considered a contraindication only because emergency practice agreement with an authorized prescriber. The contraception is not effective once a woman is already pregnant.
obligation to find a willing collaborator (a physician or midlevel The WHO does not consider emergency contraception usage practitioner, depending on the state) falls on the pharmacist.
during pregnancy harmful to a woman or her fetus.
California and New Mexico permit pharmacists to dispenseemergency contraception under a statewide protocol; California also permits collaborative practice agreements with authorized prescribers. The number of pharmacists participating in In 1994, the Center for Reproductive Law and Policy these states’ programs differs widely, from approximately petitioned the FDA to require manufacturers of combined oral 15 pharmacists in Alaska to greater than 2500 in California.
contraceptive pills to amend their labeling and patient State population notwithstanding, this variability is thought to packaging to include information on the use of these products reflect differences in ease of certification for emergency for emergency contraception.The FDA declined the petition contraception dispensation, as well as differences in degree of and referred the matter to their advisory committee. In 1996, pharmacist and public interest in pharmacist-dispensed the advisory committee unanimously concluded, and the FDA concurred, that 4 brands of estrogen/progestin combination oral The history of attempts to make emergency contraception contraceptive pills are safe and effective as emergency available over-the-counter in the United States begins in 2001, contraception. The FDA also stated that it would accept when the Center for Reproductive Rights submitted a ‘‘citizens’ applications for dedicated emergency contraception products petition’’ to the FDA requesting that emergency contraception without requiring further trials to prove safety and efficacy.
be made available over-the-counter throughout the United Pharmaceutical companies were, however, hesitant to create StatesThe FDA did not amend its policies based on this dedicated emergency contraception products, citing concerns petition. In April 2003, Women’s Capital Corporation about liability, limited profit potential, and abortion politic petitioned the FDA to distribute Plan B as an over-the-counter In September 1998, the FDA approved marketing of the first medication. In response, 2 FDA advisory groups, the dedicated emergency contraception product, Preven (ethinyl Nonprescription Drugs Advisory Committee and the Advisory estradiol/levonorgestrel combination, originally produced by Committee for Reproductive Health, held a joint meeting to Gyne´tics, Inc, Somerville, NJ), a prepackaged version of the consider the appropriateness of over-the-counter Plan B. In Yuzpe regimen.In July 1999, the FDA approved marketing of December 2003, these expert committees voted 24 to 3 to Plan B (levonorgestrel only, originally produced by Women’s recommend that the FDA permit Plan B over-the-counter Capital Corporation [Washington, DC], now a subsidiary of sales. Despite this recommendation, acting director Steven Barr Laboratories, Pomona, NJ). Preven, later sold to Barr Galson, of the FDA’s Center for Drug Evaluation and Research, Laboratories, is no longer being manufactured.No further declined the over-the-counter application in May 2004.
applications for dedicated emergency contraception products Galson stated that Barr Laboratories had ‘‘not provided adequate data to support a conclusion that Plan B can be used safely byyoung adolescent women for emergency contraception without the professional supervision of a practitioner licensed by law to administer the drug.’’ Of note, the joint committees had At least 37 countries permit emergency contraception discussed this issue and concluded that there was sufficient dispensation directly from pharmIn most of these information to deem it safe for this population. Barr Laboratories countries, women must consult a pharmacist to receive reapplied for over-the-counter status for Plan B for women older emergency contraception. In Norway and Sweden, emergency than 16 in July 2004, and the FDA agreed to reconsider this contraception can be obtained from pharmacy shelves revised application.Although a decision was due on January without the assistance of a pharmacist.On April 19, 2005, 21, 2005, the FDA delayed its decision because of an ‘‘inability Health Canada (the Canadian Ministry of Health) approved to review’’ all available informaThe Center for the sale of 0.75 mg of oral levonorgestrel without a prescription Reproductive Rights has filed suit against the FDA for failing to by pharmacists under a defined prescription algorithm. The algorithm assures standardized assessment, counseling, anddispensation practicThe schedule change for this medication permits the over-the-counter sale of Plan B.
Before this change, 2 provinces, Quebec and British Those who support the over-the-counter availability of Columbia, permitted these sales under a similar protoc emergency contraception make 4 central arguments for changing In the United States, emergency contraception is available emergency contraception’s prescription status. These include the without a prescription in California, Washington, Maine, New demonstrated safety of emergency contraception; the need for Mexico, Hawaii, and Alaska, under certain conditions.
equitable access to emergency contraception; the high societal Alaska, Hawaii, Maine, and Washington allow pharmacists to costs of unwanted pregnancy and prescription-only emergency Nonprescription Availability of Emergency Contraception in the United States contraception; and the absence of an increase in the incidence of know the timeline for acceptable emergency contraception pregnancy, unprotected sexual intercourse, or sexually prescription; in 2001, 40% of practitioners in an American transmitted diseases with emergency contraception usage.
health maintenance organization demonstrated similar According to the FDA Durham-Humphrey Drug knowledge deficiencies.Because of their religious beliefs or the Amendment Act of 1951, all medications should be available practice patterns or protocols at their health care institution, over-the-counter unless they are ‘‘dangerous, addictive, or so some health care providers may refuse or not be permitted to complex to use that a learned intermediary is required.’’ prescribe emergency contraception, even for survivors of sexual Grimes et Ellertson et al,and other advocates of over-the- assault.Although Directive 36 of the US Catholic counter emergency contraception argue that emergency Bishops’ Ethical and Religious Directives for Catholic Healthcare contraception meets none of the restrictions outlined in this Services permits emergency contraception for female sexual amendment and that the adverse effects of emergency assault survivors who are not pregnant, a recent study indicated contraception do not render it unsafe. As evidence supporting that only 5% of Catholic hospital EDs prescribe emergency their beliefs, they offer that (1) emergency contraception is contraception on request, and only 23% provide it for sexual nontoxic, has self-limited and generally mild adverse effects, rarely induces serious adverse events, and is safer than many Using a 1992-98 national database, Amey and Bishai over-the-counter medications; (2) no deaths, suicides, or adverse calculated that less than half of all women potentially eligible to medical events have been reported from overdose with receive emergency contraception after sexual assault were given emergency contraception; (3) emergency contraception is not it by their ED provider. Other reported access barriers include a teratogenic, and it poses no danger to the woman or her fetus woman’s lack of knowledge of emergency contraception and if taken during pregnancy; (4) emergency contraception lack of financial or other resources to obtain emergency regimens are equally suited for all women, and the regimens contraception.Foster et alreport that women might not are simpler than over-the-counter medications for other be prescribed emergency contraception because they are purposes; (5) emergency contraception’s only indication is unaware of its existence or how to obtain it.According to unprotected intercourse and a desire to prevent pregnancy, Free et even women educated about emergency which can be recognized by the patient; (6) emergency contraception may be embarrassed to ask a health care provider contraception does not require professional monitoring; and for it or have had negative experiences with providers in (7) the dose for emergency contraception is fixed and does attempting to obtain it. Other women may simply not be able not need to be adjusted based on the medical needs of the to afford prescribed emergency contraceptiondparticularly given the additional costs of being treated by a clinician, living Several authors report problems with access to prescription- too far from a place that offers it, or obtaining their health care only emergency contraception, even when it should ideally be from places where it is unavailable.
available. For example, when researchers posing as women who According to over-the-counter emergency contraception experienced a condom breakage called physicians listed as proponents, widespread over-the-counter emergency emergency contraception providers on an emergency contraception would overcome access difficulties by allowing contraception Web site, only 76% of 200 calls successfully patients to privately obtain emergency contraception whenever resulted in appointments or telephone prescriptions for they chose and at a lower cost.In support of this claim, emergency contraception.Studies note that for places that Killick and Irvingfound that a greater proportion of women ordinarily offer emergency contraception, access to emergency were able to take emergency contraception within 24 hours of contraception is reduced on nights, weekends, and unprotected intercourse when they were able to access dwhen patients are more likely to need emergency emergency contraception directly from a pharmacy without a contracepdand that quick access to emergency prescription. In focus groups of women in 4 European countries contraception from emergency departments (EDs) is not always that permit over-the-counter emergency contraception, participants expressed satisfaction that over-the-counter Health care provider knowledge deficienciesand availability eliminated time and cost barriers.As far as the religious beliefs about emergency contraception are other knowledge barrier to access, some authors believe that reported reasons for reduced access to prescription-based emergency contraception would be better marketed by emergency contraception. According to a 1990 study, one pharmaceutical companies if it were available over-the-counter quarter of general practitioners in the United Kingdom did not and that such marketing campaigns would increase knowledge *Directive 36 reads: ‘‘Compassionate and understanding care should be given to a person who is the victim of sexual assault. Healthcare providersshould cooperate with law enforcement officials, offer the person psychological and spiritual support and accurate medical information. A female whohas been raped should be able to defend herself against a potential conception from the sexual assault. If, after appropriate testing, there is noevidence that conception has occurred already, she may be treated with medications that would prevent ovulation, sperm capacitation, orfertilization. It is not permissible, however, to initiate or recommend treatments that have as their purpose or direct effect the removal, destruction,or interference with the implantation of a fertilized ovum.’’ Nonprescription Availability of Emergency Contraception in the United States of emergency contraception’s existence and recommended emergency contraception only through clinic visits. Women in the advance provision group were more likely to use emergency Over-the-counter emergency contraception proponents also contraception than women in the other groups; however, the argue that providing emergency contraception without a incidence of pregnancy and sexually transmitted diseases and prescription will reduce health care expenditures. Using a decision condom use were similar among all 3 groups. Three other model, Marciante et alcalculated the ‘‘physician cost’’ alone of studies report that repeated use of emergency contraception is prescribed emergency contraception using the Yuzpe method to uncommon among women with advance provision of be $67.26 for private payers and $36.60 for public payers. This estimate does not account for facilities costs, laboratory costs, and found that postpartum women in San Francisco who had nursing costs. Marciante et estimated a cost savings of $48 and advance provision of emergency contraception more than $158 for public and private payers, respectively, if emergency doubled their use of routine contraception to 80% during the contraception were available directly from a pharmacist rather than through a physician visit. They projected greater savings witha levonorgestrel-only based regimen. Trussell et almodeled the expected cost savings from advance provision of emergency contraception among women using barrier and behavioral Apart from moral objections to emergency contraception contraceptive methods. Compared to the costs of unintended usage, most opponents of over-the-counter emergency pregnancy, the projected cost savings through advance provision contraception argue that concerns remain about over-the- of emergency contraception (when emergency contraception is counter emergency contraception’s adverse health effects and prescribed before women need to use it) in a managed-care setting potential misuse by girls and young adolescents, that over- are $263 to $498 and in a public payer setting are $99 to $205.
the-counter emergency contraception will not create the social These cost savings are based on the assumption that widespread benefits proffered by the over-the-counter emergency access to over-the-counter emergency contraception and resultant contraception proponents, that it will decrease patient reliance greater usage would result in fewer unplanned pregnan on primary contraceptive measures, and that it will decrease Trussell et alalso estimate that emergency contraception opportunities for medical oversight of emergency contraception could result in a greater than 50% reduction in abortion rates if and counseling on safer sexual practices. Some particularly vocal it were used in all cases of observable contraceptive failure or opponents of over-the-counter emergency contraception include unprotected intercourse. In a study that examined over-the- Concerned Women for America, the Christian Medical counter emergency contraception impact on abortion rates, Association, the Family Research Council, the American Wells et alpredicted that during the first 4 months of a Association of Pro-Life Obstetricians and Gynecologists, and Washington State over-the-counter emergency contraception pilot program, 207 unintended pregnancies and 103 Over-the-counter emergency contraception opponents unintended abortions were prevented. At the completion of the mention concerns similar to those raised by acting FDA director pilot program, Gardner et observed a 5% reduction in Steven Galson about girls’ and young adolescents’ access to abortions and a 7% reduction in teenage pregnancy rates in over-the-counter emergency contracepOpponents 1998 but conceded that there was a similar decline nationwide are concerned about the safety of emergency contraception in for these characteristics. They concluded that a definitive adolescents because they believe emergency contraception has not statement on the effect of over-the-counter emergency been adequately tested for its adverse effects on these patients.
contraception on unplanned pregnancy and abortion rates They believe this concern is particularly relevant because would require a longer observation period.
adolescents are likely to use over-the-counter emergency Advocates of over-the-counter emergency contraception cite contraception. This contention is supported by studies several studies showing either no change or a decrease in the reporting that the majority of users of emergency contraception frequency of unprotected sexual intercourse and sexually are younger than 25 years.Additionally, they contend that this transmitted diseThey also note studies that show no vulnerable group may use over-the-counter emergency change or an increase in contraceptive use among older contraception indiscriminately and without regard to primary adolescents and women receiving emergency contraception prevention of pregnancy or sexually transmitted diseases.
either directly from a pharmacist or through advance provision Over-the-counter emergency contraception opponents further of emergency contraception prescribed from a clinic. For argue that the benefits of over-the-counter emergency example, a recent single-blind, randomized, controlled trial in contraception are not as significant as proponents say. There are a California by Raine et compared use of emergency few studies on the effects of advance provision and over- contraception, incidence of pregnancy and sexually transmitted the-counter emergency contraception to support this position.
diseases, and condom use over a 6-month period in 3 groups of A 2000 study of advance emergency contraception provision to women: one group received emergency contraception from a low-income women at a Title X clinic shows lower use of pharmacist without a prescription, one group was provided emergency contraception than anticipated,which suggests emergency contraception in advance, and one group received that emergency contraception may not have as much of an Nonprescription Availability of Emergency Contraception in the United States Table. ED studies of emergency contraception.
20% Of 204 female sexual assault patients received EC 5% Provided EC on request; 23% provided EC to rape victims; 55% of EDs would not dispense EC under any circumstances 79.5% Of EC requests were due to condom breakage; frequency of EC requests was highest on weekends 96% Of EDs received EC requests; 57% provided EC; 56% thought EDs should provide EC; 62% of respondentsopposed OTC EC.
Survey of 12 Catholic-run EDs in southern 8 Forbade physicians to prescribe EC after sexual assault Survey of reproductive health care, family 78% Of ED doctors had prescribed EC, generally to sexual assault victims, an average of 5.8 times per year Descriptive study of visits to a rural Welsh Comparison of visits by general practice registration Retrospective review of ED NPs’ prescription 100% Of NP-administered EC was given within 72 hours; 95% was given after negative pregnancy test; 71% was given after documentation of other medications or medical conditions The total EC requests decreased from 196 to 164; however, the number of requests by teens increased from 63 to 74;63% of requests occurred outside local pharmacy hours.
Of 69 responding departments, all were aware of EC; 83% prescribed ED; 56% prescribed EC appropriately; antiemeticswere routinely prescribed by 78.9% Of 102 responding departments, 38% of respondents never prescribe EC; 10% always prescribe EC; 44% prescribe only ifthe patient cannot consult a GP within 72 hours; and 8%have no fixed practice 47% Of non-Catholic EDs vs 6% of Catholic EDs offered routine EC counseling for sexual assault victims; 57% of non-Catholic EDs vs 41% of Catholic EDs had EC on site Total EC dispensation increased 8-fold; 81% was nonprescription EC direct from the hospital pharmacy 21% Of 94 eligible sexual assault patients received EC 20% Of Catholic hospitals prohibit prescription of EC, including without ‘‘conscience clause’’ laws EC for rape victims; individual physicians varied in theirrespect of these restrictions; no difference was observed inEDs from states with and without conscience clauses Knowledge/opinion studiesAbbott et al (2004) 77% Of women surveyed had heard of EC; of those who knew 20% More providers prescribed EC at least once a year; knowledge of proper EC use and indications was greatly Study participants described conflicting attitudes about ease of obtaining EC and their views on adolescent EC requests 88% Were willing to give EC to victims of sexual assault; this percentage was higher if the assailant was likely to be HIV-infected but lower if the patient had had consensual sex NY ED practitioners were more willing than other US ED practitioners to offer EC after sexual assault and afterconsensual sexual exposures CFFC, Catholics for a Free Choice; EC, emergency contraception; OTC, over the counter; NP, nurse practitioner; GP, general practitioner.
Nonprescription Availability of Emergency Contraception in the United States impact on unplanned pregnancies for this group. A major emergency contraception, and lack of knowledge or negative opinions prospective study of free, advance provision of emergency about emergency contraception by patients or ED providers.
contraception to all women in a community in Scotland showed Of particular relevance to the over-the-counter emergency no significant decrease in abortion rates among that community contraception controversy, studies from the United Kingdom by compared with other Scottish regions.An article from Sweden Kerins et and Mawhinney and Dornanexamined found no decrease in the abortion rate since emergency emergency contraception use in EDs 1 year before and 1 year contraception became available over-the-counter, but the authors after emergency contraception became available without a believed that this finding was due to lack of widespread use of prescription in the United Kingdom. Although the studies emergency contraception.Furthermore, in the involve only 3 EDs, both studies observed a decrease in aforementioned article by Raine et there was no decrease in emergency contraception requests after emergency contraception the incidence of pregnancy and sexually transmitted diseases was available over-the-counter. The Mawhinney and Dorna among women with advance provision of emergency study noted that there was a relative increase in requests for emergency contraception by teenagers and that most emergency Some over-the-counter emergency contraception opponents contraception requests occurred after local pharmacies were argue that emergency contraception usage without a clinician’s closeIn addition, a Minnesota hospital instituted a oversight will increase women’s engagement in risky sexual simulated over-the-counter emergency contraception program in practicesor result in emergency contraception being used as which they permitted direct emergency contraception provision regular contraception.In addition, some opponents are from the hospital pharmacy, without a physician prescription, worried that if emergency contraception were available over-the- through a standing order from hospital physicians.The counter, then the opportunity for medical oversight and study did not report the impact of emergency counseling that accompanies prescription writing would contraception on the ED directly but did comment that 81% disappear. Over-the-counter emergency contraception of all emergency contraception provided by the hospital opponents especially fear the loss of the chance to examine after institution of the protocol was directly from the pharmacy.
patients for the presence of sexually transmitted diseases, detect Apart from the apparent reduction in ED visits for emergency medical contraindications to emergency contraception, and contraception noted in these studies, over-the-counter screen for sexual abuse, assault, and domestic violence or other emergency contraception could affect emergency medicine health-related They also suggest that the absence of practice in the United States in a number of positive ways. It could counseling would lead to inappropriate, incorrect, and repeated also result in a reduction in ED health care expenditures for usage, particularly among adolescents and women with low levels emergency contraception (eg, less money spent on medications), of education. A few studies substantiate this worry. In the Endres the creation of a safety mechanism for emergency contraception et al2000 study of women presenting to an inner-city family provision (ie, patients could obtain emergency contraception planning clinic, only 18% of those given advance provision of elsewhere if they were not provided with it in the ED), and the emergency contraception used it correctly. According to Jackson removal of the ED from legal controversies on emergency et al,in a study comparing emergency contraception contraception provision. These potential benefits might be knowledge and behavior in low-income, postpartum women accompanied by adverse costs to patients, however. For example, given advance provision of emergency contraception versus although there are no studies examining this issue in the ED placebo, only 25% of study participants who received advance- setting, over-the-counter emergency contraception might provision emergency contraception knew the correct timing for discourage patients who need medical evaluations or treatments emergency contraception use at the end of the study period.
from receiving them. Until these potential impacts areunderstood, ACEP joins with other health professional organizations in supporting efforts for the nonprescription availability of emergency contraception. Future studies examining the impact of over-the-counter emergency The summarizes studies of emergency contraception in contraception should be helpful in further guiding emergency EDs.This list of studies was obtained by a medicine practice on this important subject.
MEDLINE search using the terms ‘‘emergency contraception,’’‘‘post-coital contraception,’’ ‘‘morning-after pill’’ and ‘‘accident Supervising editor: Debra E. Houry, MD, MPH and emergency department,’’ ‘‘emergency department,’’‘‘emergency room,’’ ‘‘casualty department,’’ and by hand search Funding and support: Dr. Merchant is supported by a Career of references from relevant journal articles. Sixteen studies Development grant from the National Institute for Allergy and concern emergency contraception use in the ED, and 5 examine Infectious Diseases, National Institutes of Health, K23 patient or provider knowledge or opinions on emergency contraception. As noted previously, some studies show lack of Publication dates: Received for publication May 9, 2005.
emergency contraception usage after sexual assault, comparatively Revision received June 21, 2005. Accepted for publication less usage at Catholic hospitals, variations in practice patterns for July 1, 2005. Available online September 13, 2005.
Nonprescription Availability of Emergency Contraception in the United States Reprints not available from the authors.
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