AMA Seeks to Improve Access to Morning After Pill

(Orlando) -- It's Friday night on a holiday weekend and you won't be able to talk to your doctor until Tuesday. But you can't wait that long -- you've got reason to be believe you may be pregnant.

The situation describes the plight of many women seeking emergency contraception pills, sometimes known as "morning after" pills. Since they must be taken within 72 hours of Sexual intercourse in order to be effective -- the sooner the better -- ready access is critical; yet in most areas a prescription from a doctor is required, and in many areas pharmacies do not stock the drugs.

This week, physicians at the meeting of the American Medical Association's House of Delegates approved motions designed to improve access to emergency contraception. Members of the policy-making body passed the recommendations of a report by the association's Council on Medical Service (CMS) calling on the AMA "to enhance efforts to expand access to emergency contraception, including making emergency contraception pills more readily available through hospitals, clinics, emergency rooms, acute care centers, and physicians offices."

And the association will also "support and monitor" efforts by manufacturers of emergency contraception seeking approval from the FDA to market the agents over-the-counter, according to the report approved by the House.

There are two morning-after pills on the market: Preven and Plan B. Both were approved for use in the U.S. during the past two years.

In a press conference following the House action, AMA Trustee Edward J. Hill, MD, said it is not the AMA's job to recommend drugs for over-the-counter status. "We do not want the implication that AMA supports over-the-counter status for any drug," Hill says. "That is the FDA's job."

A statement released by AMA following the House action sought to clarify the association's position on over-the-counter status. According to that statement, "If the FDA determines that [emergency contraception pills] are safe for over-the-counter use, the AMA would support that increased access."

Joseph P. Annis, MD, of the CMS and a delegate from Austin, Texas, said physicians frequently neglect to educate patients about emergency contraception during regular family planning counseling. And many low-income and uninsured women may be unable to access emergency contraception, even during regular hours, he said.

"This is an access issue," said Annis. "The more we looked at this, the more we talked about how most unintended pregnancies occur among uninsured and low income women for whom access is a problem. And once we started to talk about access, we had to think about how to make this more accessible."

Most of the recommendations in the report call for physicians to educate their patients about the availability of emergency contraception. But clearly, over-the-counter status was the most controversial aspect of debates about the issue. During hearings on the subject, Richard W. Whitten, MD, a delegate from Olympia, Washington, informed physicians about a pilot project in his state in which physicians formed collaborative arrangements with pharmacies to dispense emergency contraception over-the-counter.

As of March 2000, 146 pharmacies were participating in the project, with a total of 11,969 emergency contraception prescriptions filled. Forty-two percent of women receiving emergency contraception under the system did so after regular business hours, and 70% received emergency contraception services within one day of unprotected intercourse, Whitten reported.

When asked if AMA would support similar state pilot projects, Hill said the association would be supportive if the projects "were under the supervision of a physician."

Emergency contraception provide a short, high dose of combined estrogen and progestin thought to suppress ovulation, and have been shown to be approximately 75% effective in preventing pregnancy when taken within 72 hours after unprotected intercourse, with greater success the earlier the pills are used, according to the AMA report.

But some physicians at the meeting said the mechanism of action is uncertain depending on when it is taken, and that the "morning after" pill may, in some instances, be acting not as a form of contraception but as a form of abortion.

John Littel, MD, of Kissimmee, Fla., and a board member of the National Catholic Medical Association, said that in some instances the pill will not be preventing ovulation, but will be preventing the implantation of an already fertilized egg. "Most physicians and patients believe human life begins at fertilization and that to take the morning after pill violates their basic morality," Littel said.

Joseph M. Heyman, MD, chair of the Council on Medical Services and a delegate from West Newbury, Mass., underscored the importance of making the pill readily accessible, if it is going to be used at all. "The sooner the pill is taken [following intercourse] the more definitely the mechanism of action is delaying or preventing ovulation," Heyman tells www.domain.com. "If it is taken later, it may be preventing implantation."