Plan B and mandatory office visits

[bananaface]

Is it ethical for Plan B prescribing physicians to require that established patients be seen in the office prior to prescribing? Why or why not?

This question relates simply to the ethics surrounding requiring an office visit, NOT whether or not it is ethical to prescribe post-coital contraception. Please save that discussion for another thread.

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[QuantumMechanic]

Is it ethical for Plan B prescribing physicians to require that established patients be seen in the office prior to prescribing? Why or why not?

This question relates simply to the ethics surrounding requiring an office visit, NOT whether or not it is ethical to prescribe post-coital contraception. Please save that discussion for another thread.

Assuming that the patient's history is well-documented and unchanged (the "established patient"), I see no reason for a physician to prescribe without an office visit. This is especially relevant since I think Plan B is more effective the sooner it is taken. As a result, this may prevent a costly abortion (plus most conservatives other than Catholics tend to not have a problem with this form of aborting a fertilized egg ).

 

[microbe hunter]

Plan B is emergency contraception. In emergencies, some of the conventional practices need to go out the window and patients need their treatment within 72 hours. The doctor's visit is not meant to be a barrier to effective access to treatment.

What other medications for disease states or syndromes actually require a doctor's visit, versus just a doctor's prescription given at any time?

At what point would the patient need to see the doctor? In those 72 crucial hours it not always be easy for a woman to do. However, it may be effective if women got preventitive prescriptions for Plan B before having intercourse.

Plan B, is prescription-only, so the woman's going to need a prescription. Should it have to be a 1:1 ratio between immediate need and office visits during crucial hours? I don't believe should have to be, I think it should be offered by health care providers as prevention. Anything less would seem like a penalty to the woman, which may stem, rather, from the politics of plan B than from a regard to patient treatment.

 

[Doctor Bagel]

well, plan b should be available otc, and then this wouldn't be an issue at all. but, no, i don't think a physician's visit should be required, assuming your physician knows your medical history. i knew someone online whose ob/gyn demanded that she take a $500 pregnancy test at a hospital before she would prescribe plan b, which to me seems like a ridiculous barrier to treatment. needless to say, this obgyn lost a patient.

i agree that in absence of otc plan b, preventative prescriptions are a good idea.

 

[Tryin2makeit1]

well, plan b should be available otc, and then this wouldn't be an issue at all.

I agree with the idea that plan B should be otc since it will prevent a costly doctor visit (if you don't have insurance) and save time in order to take the medicine. The only danger is that people may start abusing plan B and not using a plan A such as regular birth control. They might think, oh it's always going to be there so I can go ahead and have unprotected sex since I won't get pregnant when I take Plan B. They might not realize that Plan B is only for emergencies.

 

[Doctor Bagel]

I agree with the idea that plan B should be otc since it will prevent a costly doctor visit (if you don't have insurance) and save time in order to take the medicine. The only danger is that people may start abusing plan B and not using a plan A such as regular birth control. They might think, oh it's always going to be there so I can go ahead and have unprotected sex since I won't get pregnant when I take Plan B. They might not realize that Plan B is only for emergencies.

I'm skeptical that people will use Plan B as a form of routine birth control if it's available OTC. I think it would be interesting to see a study of who uses it now and why just to get an idea of the market. My guess is that most people who use it are people who also use other forms of bc. I used it once after having a condom break, and I would guess people in that category make up a huge chunk of Plan B users. From what I remember, it cost me like $20 to get those two pills (and this was from a student pharmacy no less), so if anything, the cost would be prohibitive for such usage.

Also, my understanding is that Plan B is a very benign medication, so relying on it as a main form of birth control might not be that big of an issue. Presumably, these users would either not have sex that often or they'd be using it in conjunction with something like natural family planning, so it's not like they would take Plan B every other day. At $20 a package, who could afford that?

Of course, if we just had decent sex ed in schools instead of abstinence based education that has been shown to be a complete failure, maybe we wouldn't have to worry about women being so ignorant about birth control.

 

[t33sg1rl]

OK, I really am not sure of my information here, so if anyone knows, please correct me.

I thought Plan B contained the exact same hormones as birth control. Before Plan B, I distinctly remember being told that we could use regular birth control pills (not mini pills) as emergency contraception. I don't remember how many or when to take them.

So if I'm remembering correctly, Plan B is nothing more than high-dose birth control pills... which can then cause serious side effects, and needs a prescription. Just putting a warning on the box about how often Plan B can safely be used and who shouldn't take it probably won't be enough, just as it is not enough for birth control pills.

Requiring an office visit:
No, I don't think so. The physican can collect relevant info over the phone before prescribing-smoking, STD concerns, other medications-even if she doesn't have previous medical records or other info.

 

[Doctor Bagel]

OK, I really am not sure of my information here, so if anyone knows, please correct me.

I thought Plan B contained the exact same hormones as birth control. Before Plan B, I distinctly remember being told that we could use regular birth control pills (not mini pills) as emergency contraception. I don't remember how many or when to take them.

you're right that you can use regular birth control pills as emergency contraception. however, plan b is different from most birth control pills because it doesn't have estrogen -- so, basically it's like a concentrated mini pill. about the side effects and being available otc, my understanding is that the higher risk of strokes associated with birth control pills comes from the estrogen, so maybe plan b doesn't have that. also, the majority of doctors who voted on making plan b otc at the fda agreed that it was safe to be otc. as far as i understand, that's not even under dispute. instead it was blocked for purely political reasons and on the claim that there was no way to stop girls under 18 from taking it.

here's an interesting article from planned parenthood about emergency contraception. while it talks about more than plan b, it does discuss the whole otc debacle at the fda, the risks of plan b, and refutes the claim that women with easy access to plan b (preventative prescriptions) use it as a primary form of bc.

http://www.plannedparenthood.org/pp...dicalinfo/ec/fact-emergency-contraception.xml

 

[docB]

i knew someone online whose ob/gyn demanded that she take a $500 pregnancy test at a hospital before she would prescribe plan b, which to me seems like a ridiculous barrier to treatment. needless to say, this obgyn lost a patient.

i agree that in absence of otc plan b, preventative prescriptions are a good idea.

The reason for a preg test on pt's demanding Plan B is to ensure that they are not already pregnant. Their BHCG should be undetectable if they are an appropriate candidate for Plan B. If you give an already pregnant woman Plan B (which is cat X in pregnancy) and the eventual baby has problems then you get to had your house over to the mom and raise the kid 'til it's 18 or longer.
The reason for the office vist is also for billing. You can't bill for a call in script.

 

[sdn1977]

Plan B does not require a MD generated prescription in CA. Pharmacists are allowed prescribing privileges for Plan B after completing a certification course. The woman just needs to present herself to a certified pharmacist, fill out a very short form (documenting LMP, time/date of unprotected intercourse, allergies, etc..) and we dispense it. It works very well in CA and is available 24 hrs/day, 7 days a week, 365 days a year. Providers can be found on Not-2-Late.com for the US & British Columbia. No office visit is required and insurance usually covers it, but it is $30 if paid without insurance. The system works as well as it possibly can given Plan B's non-OTC status, but I'm hopeful it will become OTC soon! (btw....I'm a CA pharmacist and in my experience, I provide Plan B mostly to educated, 30-something, married women who have had a contraceptive failure)

 

[bananaface]

The reason for a preg test on pt's demanding Plan B is to ensure that they are not already pregnant. Their BHCG should be undetectable if they are an appropriate candidate for Plan B. If you give an already pregnant woman Plan B (which is cat X in pregnancy) and the eventual baby has problems then you get to had your house over to the mom and raise the kid 'til it's 18 or longer.
The reason for the office vist is also for billing. You can't bill for a call in script.

Birth defects are associated with levonorgestrel use later in pregnancy. If a woman *just* got pregnant, it's not going to harm the implanted fetus or disrupt pregnancy. The only contraindication for Plan B is undiagnosed vaginal bleeding.

 

[docB]

Birth defects are associated with levonorgestrel use later in pregnancy. If a woman *just* got pregnant, it's not going to harm the implanted fetus or disrupt pregnancy. The only contraindication for Plan B is undiagnosed vaginal bleeding.

The reason for any drug to be prescription only rather than otc is so that the prescriber can be liable for untoward results, real or perceived. Juries don't understand or pay attention to EBM.

 

[stookie]

I have a cousin that thinks plan b involves sabotaging her boyfriend so she can get pregnant and he won't leave her. What a ******

 

[Doctor Bagel]

The reason for any drug to be prescription only rather than otc is so that the prescriber can be liable for untoward results, real or perceived. Juries don't understand or pay attention to EBM.

i'm saddened that doctors provide inappropriate care (at a significant cost to their patients) to avoid liability. i think the studies are pretty solid in showing that plan b does not cause damage to a fetus at eary stages of pregnancy -- do you really believe someone who prevail at a lawsuit with a totally meritless claim? i'm ignorant about malpractice law and its realities, but my sister did malpractice defense for a while, and she said all the suits that actually lasted were for very gray situations with very dire consequences. it doesn't sound like this fits in with that description.

you've got me wondering, though, how many doctors are out there practicing bad medicine because of fear of getting sued. is this practice reasonable or based on paranoia? don't know.

also, if a jury makes a verdict that goes against ebm, shouldn't a judge get that and throw it out. judges aren't medical practitioners, but they are well-educated people capable of understanding the concept of ebm. is the ama involved in judge elections? it sounds like they should be.

as for plan b, making it available otc seems even better now. it can protect doctors from meritless lawsuits and from practicing bad medicine to avoid them.

 

[docB]

i'm saddened that doctors provide inappropriate care (at a significant cost to their patients) to avoid liability.

Defensive medicine is a pervasive problem in American medicine born of the current malpractice crisis. Be as sad as you want but facts are facts.

i think the studies are pretty solid in showing that plan b does not cause damage to a fetus at eary stages of pregnancy --

Juries don't do studies. And what if the patient suffers an untoward event, anything from allergic reaction to a PE? A plaintiff's lawyer will argue that without a preg test you didn't know if the pt was an appropriate candidate for Plan B in the first place. If the pt was already pregnant then the damaging treatment you prescribed was unnecessary. Every juror knows that a preg test costs $10 at Walgreens so they'll nail you to the wall if they think you tried to save $10 and gave the plaintiff a PE in the process.

do you really believe someone who prevail at a lawsuit with a totally meritless claim?

Absolutely. For examples look at the number of successful suits for cerebral palsy and silicone breast implants. Merit means nothing.

i'm ignorant about malpractice law and its realities, but my sister did malpractice defense for a while, and she said all the suits that actually lasted were for very gray situations with very dire consequences. it doesn't sound like this fits in with that description.

So what does it mean to the doc if the suit doesn't last. You have to go on your own time to depositions, lawyer consultations, chart review. There's the stress. That's even for the one's that go away quickly. For the suits that last you're talks years wasted time and effort. As you point out those often involve "gray areas" so you may not have done anything wrong but you're still treated like a criminal for years.

you've got me wondering, though, how many doctors are out there practicing bad medicine because of fear of getting sued. is this practice reasonable or based on paranoia? don't know.

Reasonable is in the eye of the beholder. In medicine if something bad happens and you could have tested for it and didn't you're screwed. If nothing is found you were defensive.

also, if a jury makes a verdict that goes against ebm, shouldn't a judge get that and throw it out. judges aren't medical practitioners, but they are well-educated people capable of understanding the concept of ebm. is the ama involved in judge elections? it sounds like they should be.

Judges will go with what the juries find except in very unusual circumstances. If the jury doesn't buy the EBM then that's just tough for the doc. Ask Dow Corning how valuable EBM is in court.

as for plan b, making it available otc seems even better now. it can protect doctors from meritless lawsuits and from practicing bad medicine to avoid them.

I'd like to see Plan B OTC as well. I would definitely like to get these people out of my ER.
Your judgement about what constitutes bad medicine is harsh. Remember that when you're the one signing the scripts and the dc orders and what not the you have to be able to go home and sleep at night. We all live with that naggin thought in the back of our minds about getting sued. You can always be sued at any time for any reason. All you can do is the best you can to protect yourself from the biggies.

 

[bananaface]

I have a few reservations against Plan B being a straight OTC product.

1) Advanced provision (ie: having them on hand for future potential need) significantly increases the number of missed doses for those on BC pills.
2) We would have to deal with possible tampering by people trying to scare others away from using the product.
3) There would not always be a healthcare provider available to provide counseling and clarify misconceptions. Alot of women come in unsure of the mechinism of action of the drug. If would be unfortunate if there were a slew of women running around feeling all guilty thinking they had had an abortion.
4) Many insurance plans would stop covering Plan B if it goes OTC, making it less accessible for some patients. Those for whom increased cost would be an issue would be more likely to use state aid monies at a later time.

Personally, I'd like to see it as either a pharmacist prescribed item, or OTC but always behind the counter, as pseudoephedrine is going. At a minimum counseling needs to be available and tampering prevented.

 

[scpod]

you've got me wondering, though, how many doctors are out there practicing bad medicine because of fear of getting sued. is this practice reasonable or based on paranoia? don't know.

There was a survey done that showed 93% of the respondents practicing defensive medicine "sometimes" or "often." While there are many arguments about the "true" cost of defensive medicne, several estimates are above $100 Billion per year. Other studies have shown that most victims do not file claims and 2/3 of the ones who do receive no compensation. Most suits with merit are not filed because there is no money in them. A lawyer will not take a case on contingency if there is no money in it. Hence, the biggest problem with the medical malpractice system. Only those cases with the potential for large jury awards are filed. However, the average doctor who is named in a suit (even if he had nothing to do with it) spends over $40,000 just to have his name removed from the suit. Would that make you paranoid?

 

[sdn1977]

I have a few reservations against Plan B being a straight OTC product.

1) Advanced provision (ie: having them on hand for future potential need) significantly increases the number of missed doses for those on BC pills.
2) We would have to deal with possible tampering by people trying to scare others away from using the product.
3) There would not always be a healthcare provider available to provide counseling and clarify misconceptions. Alot of women come in unsure of the mechinism of action of the drug. If would be unfortunate if there were a slew of women running around feeling all guilty thinking they had had an abortion.
4) Many insurance plans would stop covering Plan B if it goes OTC, making it less accessible for some patients. Those for whom increased cost would be an issue would be more likely to use state aid monies at a later time

Personally, I'd like to see it as either a pharmacist prescribed item, or OTC but always behind the counter, as pseudoephedrine is going. At a minimum counseling needs to be available and tampering prevented.

Altho I respect your opinion - I disagree on many levels! A few thoughts from my own experience:
1. I can't seem to follow that having Plan B accessible will promote missed BC doses - that has not been shown during the many years it has been studied - nor does it make sense logically. That is the same logic that has the "moral majority" claiming sex education promotes promiscuity!
2. Tampering of medication is always a problem, but it is more prevalent in prescription only products than it is in over the counter products! The most recent recall for tampering is Tamiflu! Again - why would you think there is more chance of tampering with Plan B than with Trojans?
3. My personal experience with prescribing/dispensing Plan B is that there is very little counseling/education done on a face to face basis (yes....the last day I worked before the holiday I prescribed/dispensed 4 packets of Plan B). The counseling/education is done over the telephone - anomyously. Women (and men) call for information - is it available, how & when it works, where they can get more info.. then when they actually are ready to come get it - I just explain how to take it, possible side effects, etc - ask if they have any questions - its always a no!
4. Yes - you are correct - when a product goes OTC (ie Claritin, Prilosec, etc...) usually (altho not always!) insurance coverage goes away..But...you are mistaken - it becomes more accessible because it is available ALWAYS!!! $30 is an extremely low price to pay for peace of mind for a couple!
The biggest problem with OTC status is its size!!!! It is a very small product (about 3x3 inches and flat) which makes it easily stolen. I'd guess there would be pressure to increase the packaging so shoplifting would be more difficult (altho one of the most shoplifted products is vaginal antifungal products and those are large packages!)
But...take all this with a grain of salt - I am absoutely opposed to pseudoephedrine changes. It will not reduce the accessibility and does nothing to prevent customers (because they are not patients!) coming back in over and over to purchase their 3 boxes (which is exactly what they do!) We do not keep it in the pharmacy - it is kept lock up with the Nicorette products and the courtesey clerks get it when they go thru the check out line. Those who want to manufacture drugs will not be put off by this law. I'm guessing it will be like prohibition - the law can't last like its written! I don't know of any of my colleagues want to get involved in this!

 

[Doctor Bagel]

But...take all this with a grain of salt - I am absoutely opposed to pseudoephedrine changes. It will not reduce the accessibility and does nothing to prevent customers (because they are not patients!) coming back in over and over to purchase their 3 boxes (which is exactly what they do!) We do not keep it in the pharmacy - it is kept lock up with the Nicorette products and the courtesey clerks get it when they go thru the check out line. Those who want to manufacture drugs will not be put off by this law. I'm guessing it will be like prohibition - the law can't last like its written! I don't know of any of my colleagues want to get involved in this!

in oregon, they passed a law that requires you to have a prescription to get pseudoephedrine. luckily, it hasn't gone into effect yet, but it seems ridiculous to me. one, it's been established the majority of meth now comes from large drug cartels in places like mexico, so stopping the home production isn't going to make a huge dent. two, for people without insurance or with high deductible plans (me!), it'll be a huge burden to have to see a doctor to get a prescription to buy some stupid sudafed. it costs me $100 to see my doctor for ten minutes. that's a ridiculous burden to place on me to buy the one known effective otc decongestant.

anyway, getting back to plan b, those are good points in support of making it available otc. the defensive medicine thing is very scary. actually, it's clearly unethical of a doctor to do it, but i can see one's motivation.

 

[LADoc00]

I have a cousin that thinks plan b involves sabotaging her boyfriend so she can get pregnant and he won't leave her. What a ******

How illegal is it to slip a girl plan B?

 

[bartleby]

There are plenty of people who think that all forms of contraception should be illegal. Does that mean condoms shouldn't be sold OTC in drug stores?

We would have to deal with possible tampering by people trying to scare others away from using the product

 

[bananaface]

There are plenty of people who think that all forms of contraception should be illegal. Does that mean condoms shouldn't be sold OTC in drug stores?

Nope. I was just anticipating one potential complication. Some nutjobs burned down the Planned Parenthood in my town. Many of them think Plan B is an abortifacient. I would think that condoms don't piss them off nearly as much as Plan B.

 

[Doctor Bagel]

Nope. I was just anticipating one potential complication. Some nutjobs burned down the Planned Parenthood in my town. Many of them think Plan B is an abortifacient. I would think that condoms don't piss them off nearly as much as Plan B.

It makes one wonder why ignorance about Plan B is so pervasive. Most people who oppose Plan B have no issues whatsoever with bc pills, when they both function in the same way. With catholics, it makes sense because they already believe bc pills are abortifacient, but they're the only group I know of that opposes bc pills on moral grounds.

But wouldn't not letting Plan B be otc because of fear of tampering just be a way of letting them win? Also, I think it'd probably be behind the counter anyway. I have no clue if that's ideal or not, but I doubt we'll see it be allowed otc without more stringest regulations than tylenol.

 

[DropkickMurphy]

Why not make it OTC, but behind the counter, like pseudoephedrine is now due to the meth lab problems in many places? That would preclude tampering....of course then you would probably run into the issue of prostelytizing pharmacists.....

 

[Audio]

Plan B is over-the-counter in Canada. I had no idea you need a prescription for it in the States.

 

[sdn1977]

OTC, but behind the counter does not preclude drug tampering!!! I receive approximately 5 recalls per year for drug tampering all of which are prescription medications (behind the counter!) Most of the tampering does not come from consumers (ie the Tylenol tampering of years ago)...rather it is from products which are labeled and "appear" to be legitimate, but the "drug" has no active ingredient (Procrit, Epogen and most recently - Tamiflu among others). The other common source of tampering is from nonactive or contaminated raw ingredients which are then manufactured legitimately, but later found to not conform to standards, but have already been distributed. The course a drug takes to become manufactured and distributed within North America is very complicated and convoluted - most of them are not made here and most raw ingredients are imported, which is how this all gets introduced. Recalling a product is extremely expensive, time consuming and difficult. But, most important is the toll it takes on patients who need the actual drug and are not sure they ever got it or what the repercussions of receiving a fradulent drug might involve. Finally, IMO, behind the counter OTC's should be reserved for those medications in which consultation with a pharmacist is absolutely necessary - Plan B does not fit this category (nor does any other drug in California, by the way!) By the time a woman has decided she needs Plan B - nothing I can say will change that (nor do I want to!!!) She needs to deal with the immediate need (she has 72 hours - 5 days at most!) - she can always utilize me or the many, many other sources of contraceptive planning at other less stressful times (have you ever been in this situation - I have - its stressful). I want her to have access at all times - not just the 12 hours a pharmacist might be available. The information in the Plan B itself stresses not using it as a source of contraception and provides reproductive education at a level which is understandable for those with basic reading skills. As a pharmacist, I am always happy to educate, but currently I see the legalities as a barrier to access, not as a facilitator to education!

 

[nikibean]

Hey,

I work at Planned Parenthood and am an HSS where I give out Plan B on a routine basis- we advance prescribe it to people who come in for birth control evaluations.
Sometimes, I honestly don't understand why I need to sit with a woman and ask her a bunch of questions that allow her to get the medication. It will not disrupt an implanted pregnancy, it has very few side effects (and yes, you can take four OC's -usually Levlen- at once, then four OC's 12 hours later, which *does* cause nausea).
If Plan B were OTC, it would free up much more time for other services - up to 25% of the visits in the day are for Emergency Contraception...
On the other hand....
we also offer gonorrhea/chlamydia testing when we offer the Plan B, and I know that
many many women would not have that done and would go on for months being undiagnosed- especially since chlamydia is asymptomatic in 60% of women
if we were to not ask that question, "would you like me to send your urine off today for..."
It also allows women to ask questions regarding contraception, and from teens it's usually "does this make you gain weight?" It gives me time to deconstruct some myths and to let the patient gain some more info.
I see both sides. Sometimes an EC visit takes me 5 mintues, sometimes it turns into an opportunity to get someone on a new form of birth control or to do testing for STI's.
That's my opinion.