Abortion pill dispensing by doctors and not pharmacists could hinder access: CMAJ comment

To ensure equal, safe access to abortion for women across Canada, the federal government should lift its requirement for physician-only dispensing of the gold standard drug for medical abortion, a doctor and pharmacist argue.

Medical abortion has potential to reduce rural/urban disparity but MD-dispensing could entrench inequity

A doctor gives a woman RU486 pills at clinic in France, where it's been available since 1988. (Manoocher Deghati/AFP/Getty)

To ensure equal, safe access to abortion for women across Canada, the federal government should lift its requirement for physician-only dispensing of the gold standard drug for medical abortion, a doctor and pharmacist argue.

Mifepristone, also known as RU-486, was approved by Health Canada in July 2015 but is not yet available.

Marketed in Canada as Mifegymiso, the two-step abortion process involves taking two medications. First, mifepristone blocks the production of progesterone, a hormone that prepares the uterine lining for pregnancy, and then a day or two later a woman takes the drug misoprostol, which causes contractions, essentially inducing a miscarriage.

The French company that applied for mifepristone to be approved in Canada requested physician-only dispensing as a "restrictive distribution and administration program" safety measure.

In a commentary published in Monday's issue of the Canadian Medical Association Journal, Dr. Wendy Norman, a family physician, and Judith Soon, an assistant professor in the faculty of pharmaceutical sciences at the University of British Columbia, outline several reasons why they believe pharmacist dispensing of mifepristone would be better.

In Canada, 96 per cent of abortions are performed surgically, mostly in clinics in large cities, research suggests.

Norman and Soon say medical abortion has the potential to reduce the disparity between urban and rural areas for abortion services. But physician-only dispensing of mifepristone is likely to entrench the current inequitable access in rural areas, as doctors are less likely to be able to obtain the approvals they need to dispense it.

In the commentary, they say physician-only dispensing would require doctors to obtain special training and authorization to order, stock, manage and sell mifepristone.

Abortions 'promptly and conveniently'

Soon called Canada's high rate of surgical abortions costly and time consuming. 

In Scandanivian countries, the medical abortion rate is about 50 to 70 per cent of all the abortions in the country.

"What they feel is that these are relatively early abortions, under nine to 10 weeks. This is an indicator of a good health care system in that women can get their abortions promptly and conveniently and so I think hopefully we'll be able to work towards [that]," Soon said in an interview. 

Judith Soon calls physician-only dispensing 'old-fashioned.' (CBC)

In the U.S. for instance, where physician-only dispensing is required, about 10 per cent of abortions are performed medically — a decade after the option became available, a 2011 study suggests.

In contrast, Australian researchers documented improved access to medical abortion after it was introduced there with pharmacist dispensing.

Soon called physician-only dispensing "an old-fashioned route."

"Physician-only dispensing will limit the availability of mifepristone, introduce a conflict of professional interest and, in many cases, deny access to abortion for women and communities where it is needed the most," the commentary says. "We call on the federal government to act now to ensure equal, safe access to abortion for women throughout Canada."

Last week, Health Canada published a list of myths and facts about medical abortions.

The regulator said no other country requires fewer medical appointments to access the drug than Canada. Health Canada said it's estimated that up to one in 20 women who use this drug will require a follow-up surgical procedure because their pregnancy is not successfully terminated.

Health Canada also called it a myth that pharmacists are not permitted to dispense it.

Doctors not required to stock drug

"As with any medication, a prescription for Mifegymiso can be filled by a pharmacist. Physicians are not required to order the medication themselves or stock it in their offices. ‎It is simply delivered to the doctor's office instead of being picked up by the patient, similar to how patients currently access some vaccines and fertility treatments."

B.C.'s regulatory colleges for doctors and pharmacists are considering a workaround for physicians in a province where doctors are prohibited from selling medications and restricted from dispensing. Soon called this "an elegant and brilliant suggestion."

A spokesman for Health Canada said the decision to prescribe a particular medication for an individual involves the health care professional's use of his or her own judgment and discussion with the patient.

"It is within the purview of a practitioner and pharmacist to prescribe and dispense a drug in a manner that falls outside the recommendations and conditions of use as approved by Health Canada. The product monograph does not bind healthcare professions; however, doctors and pharmacists who prescribe drugs off-label are accountable for their decisions taken in the interest of their patients," the spokesman for Health Canada said in an email.