From Mr P. Walton, MRPharmS
SIR,-There seems to be, from within and without the pharmacy profession, a desire to make Levonelle 2 available over the counter as a P medicine. As one of the first 16 pharmacists in the country to supply emergency hormonal contraception, I think that great care is needed before any decision is made regarding the extension of supply without a safeguard of a protocol signed by the patient, which proves that information regarding EHC and alternative methods of postcoital contraception has been given verbally by the pharmacist. It is my experience that people do not necessarily read, and/or understand information provided on an included patient information leaflet. I believe that the vast majority, if not all, of the pharmacists in the Manchester pilot stated that they would prefer that supply be made on protocol rather than as a P over-the-counter medicine, but, bearing in mind the strong characters of the prime movers in achieving extraordinary success in this endeavour, the answers to the question could have been (slightly) biased.
Within the Manchester scheme, at least one youngster presented to obtain EHC, who, when questioned as per the protocol and in the framework of the excellent training, had not actually had sexual intercourse. This child could have had a great deal of mental anguish had the pharmacist not recognised the inadequacy of her knowledge and put her on the right path. Indeed, the girl returned to the pharmacy with a box of chocolates and a great deal of thanks. It would be no good putting an age limit on pharmacy only supply of EHC. Others who are older would be willing to obtain it for the age excluded, and offer their advice, however incomplete or inadequate or dangerous.
There is indeed a possibility that supply of EHC without proper counselling could increase the risk of unwanted pregnancy, especially in the most vulnerable young. When I have been counselling as per protocol, and telling my clients that they have a 95 per cent chance of not getting pregnant if they use EHC within 24 hours, they have been delighted. When I have explained that this figure means that they have more than 500 per cent more chance of getting pregnant than if they had used one of the better alternative methods of long-term contraception, they seemed sobered. In at least one case, a client decided that she wished to go and have a coil fitted as a form of postcoital contraception because of its vastly increased efficacy when compared with EHC. On counselling a 15-year-old child who presented with her mother, having given EHC, and having dispelled any fear that extended contraceptive advice from the family planning clinic or her general practitioner may not be confidential, and thus was highly unlikely to cause any legal problems for the long-term boyfriend, the mother and child agreed that the next (though now less urgent) stop was the family planning clinic.
I have been asked why I am more than willing to supply paracetamol over the counter and yet I would resist supplying EHC in the same way, even though it appears so much safer than paracetamol on paper. The answer is that pregnancy and all the issues that surround it cause a great deal of often unnecessary anxiety. When my wife and I were trying for our second child, my wife developed a craving for a well known brand of fruit punch. Unfortunately the elation on finding she had become pregnant became great sadness, when it was found that she had a hydatidiform mole. She searched every avenue as to what could have caused this tragedy, and finally decided that the only thing that she did that was different to her previous pregnancy was drink this probably innocuous liquid, and thus she has not touched a drop of the stuff since. Pharmacists are most reluctant to supply medicines in pregnancy, and yet if EHC becomes a P medicine, we will be supplying a very potent medicine to a girl who has a one in 20 chance of becoming pregnant, without necessarily giving verbal advice on the facts regarding this pregnancy as we know them. When anything goes wrong, as things do in a percentage of all pregnancies, it is my view that some of these women will blame themselves for availing themselves of this product. They may not seek to reassure themselves as to whether EHC could be a cause, and thus live with haunting thoughts of self blame. Part of the Manchester protocol involves telling the patient about "possible effects on the foetus", ie, that we know of none, but that in any pregnancy there is a chance of problems unrelated to this product, or a very slight chance of as yet unknown problems with using the product.
We have a section of society which, for religious or high moral reasons, is actively trying to foster the belief that EHC and abortion are one and the same thing. In those who have not been advised on how EHC works, this could cause real future psychological problems if believed. The Manchester protocol involves explaining, in terms the client understands, how EHC works and how it differs from abortion. This is important because, if clients believe that EHC works as an abortifacient, it seems to me as sure as night follows day that some pregnant women will use it in a misguided attempt at procuring their own do-it-yourself abortions.
If EHC becomes a P medicine, it eludes me how pharmacy owners will employ pharmacists or counter staff who for their own moral, religious or ethical reasons do not wish to supply EHC over the counter. Will companies really remove the stocks from their shelves each time they get a pharmacist who objects to being forced into a supply chain against his or her will? Will there become a brand of "EHCism" that discriminates against non-providing pharmacists? This is not a major problem for protocol supply as the product is not kept on the counter, and it is widely recognised that only certain willing and specially trained pharmacists undertake the supply function. If all are allowed to supply and some refuse to do so there will be conflicts.
If EHC is offered through pharmacy in dual format, ie, as a free supply on protocol or a paid-for supply over the counter, then I fail to see how we could effectively operate the service without our advice being viewed by the client as being potentially tainted for profit. There would also be potential allegations of and opportunities for fraud.
Pharmacists are tentatively making moves for a prescribing function. Critics are waiting to pounce from a great height on any error. I sincerely hope that EHC supply follows the Manchester scheme, which has been robustly tested and found not to be wanting.
Philip Walton
Swinton, Manchester