On July 13, the US Department of Health and Human Services (HHS) notified pharmacies that refusing to fill prescriptions for drugs containing ingredients that can induce abortion or prevent pregnancy may be a violation of federal civil rights law.
The new guidance, which targets around 60,000 retail pharmacies across the country, reveals how withholding certain drugs would discriminate against customers based on gender or disability. These drugs include contraceptives, abortion drugs, and several non-abortion drugs used to treat conditions such as rheumatoid arthritis, ulcers, and multiple sclerosis.
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Experts are concerned that some pharmacists in states that have passed abortion restrictions may be reluctant to dispense common drugs, even when they were prescribed for purposes other than reproductive health. “Reproductive rights are not just a women’s issue, nor are they just an issue [obstetrics] problem,” said Sarah K. Lahew, assistant professor of clinical neurology at the University of California, San Francisco, in an email. “Abortion restrictions will affect care provided by the majority of US medical specialties.”
Abortion drugs with many uses
The HHS document describes several situations in which refusing to fill a prescription can be discriminatory. These include prescriptions for mifepristone and misoprostol, which are used to treat both abortion and miscarriage. Mifepristone blocks the hormones needed to keep the pregnancy going, while misoprostol causes the cervix to soften and the uterus to contract and empty.
“Because these are the drugs also used for first-trimester abortions, some pharmacists have reportedly not prescribed them to patients who miscarry despite a valid prescription for fear of violating their state’s abortion laws,” Catherine O’Connell White, an associate professor of obstetrics and gynecology at Boston University School of Medicine and a gynecologist at Boston Medical Center, said in an email. “Restricting access to mifepristone and misoprostol takes away the choice for people who have a miscarriage to manage their pregnancy loss with medication and avoid a procedure. It makes the already difficult experience of pregnancy loss even worse.”
Misoprostol is also prescribed to people who suffer from very heavy bleeding during a miscarriage. If these patients cannot fill a misoprostol prescription at the pharmacy, White wrote, they face a higher risk of bleeding, needing a blood transfusion, or death.
Misoprostol was developed in the 1970s to treat stomach ulcers. It’s still used to prevent ulcers associated with long-term use of anti-inflammatory drugs like ibuprofen, White explained. The drug protects the stomach by reducing acid secretion, increasing mucus production and altering blood flow in the lining of the organ.
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Another drug with a variety of uses is methotrexate. The drug was first introduced in the 1940s as a chemotherapy agent due to its ability to prevent cells from making and repairing DNA, and is now used to treat a variety of cancers. Methotrexate also suppresses the immune system and is prescribed for multiple sclerosis, myasthenia gravis, rheumatoid arthritis, psoriasis and Crohn’s disease, LaHue explained.
In addition, methotrexate can be used to terminate an ectopic pregnancy – which occurs when a fertilized egg grows outside the uterus – by disrupting the metabolism of folic acid to stop cell growth. “If the pharmacist does not release this medication, the patient is forced to undergo a surgical procedure in which they will likely lose one of their fallopian tubes,” White wrote. Without surgery, an ectopic pregnancy can rupture and lead to hemorrhage and death. “Simply put, abortion care cannot be separated from other pregnancy care,” she added.
According to a recent statement from the Arthritis Foundation, people in states like Texas are reporting difficulty getting prescriptions for methotrexate. If a pharmacy refuses to fill a prescription for methotrexate because it will terminate an ectopic pregnancy, it may be discriminating on the basis of sex, according to HHS. And if a pharmacy refuses to fill a customer’s rheumatoid arthritis prescription for methotrexate because of other uses, that could be disability discrimination, the department’s policy states. Similarly, if a pharmacy refuses to fill a customer’s prescription for mifepristone and misoprostol to treat a miscarriage or misoprostol for severe and chronic ulcers, it may be discriminatory on the basis of gender and disability, respectively.
Some pharmacies also refuse to stock or dispense contraceptives based on misconceptions about how the treatments work. Birth control pills, morning-after pills, IUDs and other contraceptives prevent pregnancy — they don’t cause abortions, White emphasized. If a pharmacy refuses to fill a prescription for emergency or hormonal contraception, but provides other contraceptives such as condoms, that could be considered sex discrimination, according to HHS.
Ripple effects of Roe v. Wade reversal
The Supreme Court’s recent decision to end a long-standing abortion right in the U.S. may also make certain non-abortion drugs that can affect fetal development less available, explained LaHue, who published an article in the magazine JAMA Neurology earlier this month about how the decision will impair the ability of neurologists to properly care for their patients.
Several common drugs for neurological disorders have teratogenic effects, meaning they can interfere with the development of an embryo or fetus. These include the multiple sclerosis drugs teriflunomide and fingolimod and an anti-seizure drug called valproate. Often, people of childbearing potential must use birth control to be prescribed teratogenic drugs, LaHue explained.
“However, no contraceptive is 100 percent effective, and some medications (especially anti-seizure medications) can even reduce the effectiveness of contraceptives.” So an unwanted pregnancy with these drugs is realistically inevitable,” she wrote in her email. “Doctors may be reluctant to prescribe them in states where abortion is banned, and we may also see an increase in serious birth defects in those states.”
Many cancer drugs can also be teratogenic. This raises the possibility that in some areas a sick patient who becomes pregnant may be ineligible for certain treatments. “Limitations on reproductive health will limit management options for women with life-threatening diagnoses during pregnancy,” noted LaHue.
Additional concerns include medications that have not yet been shown to be safe during pregnancy. Many drugs don’t have data answering this question, LaHue mentioned. “In these cases, it is safer for the fetus to avoid such drugs, but this may mean that treatment is withheld by the mother not because of evidence of harm, but because of a lack of evidence,” she added. “We need pharmaceutical companies to study teratogenic risk profiles to reduce disparities in care between medical specialties.”
HHS, meanwhile, stressed that it is committed to “rigorous enforcement” of civil rights laws to protect the health of people who are pregnant or have a miscarriage. Among her civil rights enforcement responsibilities, she is responsible for protecting the rights of women and pregnant people to be able to access care that is free from discrimination,” the agency wrote in its new pharmacy guidance. “This includes their ability to access reproductive health care, including prescription drugs from their pharmacy, without discrimination.”