Expanding DMPA access: Are pharmacists next?
Expanding DMPA access: Are pharmacists next?
Choosing depot medroxyprogesterone acetate (DMPA, Depo Provera, Pfizer, New York City) may free women from taking a daily pill, but they must return to providers' offices for quarterly injections. What if pharmacists could administer repeat injections?
A recent commentary outlines the benefits of pharmacist provision of the drug; however, such a program has yet to be set into permanent place.1
With the large number of pharmacies and their expanded hours of operation — nights and weekends — pharmacists could play a major role in increasing access to the contraceptive, says Carla Picardo, MD, MPH, author of the commentary. Pharmacist involvement also might impact the cost of DMPA administration, she notes.
"Rather than women filling a prescription at a pharmacy and making a second visit to her provider to receive the injection, a woman would need to only make one stop, decreasing the cost to both patient and health care system," Picardo explains. "The labeling charge of the pharmacy is eliminated, there is no duplication in co-payments for the patient, and patients may avoid missing work to receive their DMPA."
Pharmacists are familiar with injection delivery of drugs: all states excluding Florida, Maine, New Hampshire, New York, West Virginia, and the District of Columbia, now allow pharmacist vaccine administration.1 Since 1994, when the first ongoing program to train pharmacists in vaccine administration was initiated in Washington state, about 15,000 pharmacists and student pharmacists across the United States have been trained in immunization delivery.2
Providing broader access to the contraceptive injection may improve continuation rates. The existing data vary greatly on discontinuation rates for DMPA injections; some studies report discontinuation as high as 70% at six months of use.3
Taking the first step
The Oakland, CA-based Pharmacy Access Partnership designed a pilot program to look at use of pharmacists in delivery of DMPA. Funding for the two-year Health Step Injectable Contraception Program was provided by the David and Lucile Packard Foundation of Los Altos, CA.
The Health Step program called for specially trained pharmacists to partner with physicians and clinics to allow established DMPA patients to get re-injections at their regular provider or at a participating pharmacy. Since the inception of the Health Step demonstration program in 2003, 27 pharmacists, practicing in 26 pharmacies partnered with 19 clinics and offices in eight geographic areas around California. Women who elected to participate in the program were informed of the Health Step pharmacy access option and were given a prescription with refills, an injection card, and information about designated pharmacy locations.
A variety of training mechanisms, developed in collaboration with the Sacramento-based Pharmacy Foundation of California, were designed to help pharmacists incorporate the administration of injection-based contraceptives into their practice. Training options included a distance-based learning program and live clinical trainings. The Partnership also developed a web site for the Health Step program, www.healthstep.org, to include resources such as patient injection cards and educational material, as well as locations of participating providers and pharmacies.
As of September 2006, the funding stream for the demonstration program ended, and the Pharmacy Access Partnership does not have current plans to replicate it, says Nicole Monastersky Maderas, MPH, program administrator. Some pharmacists continue to provide DMPA injections to clients and have established a fee structure that works for the pharmacist and the client, independent of the reimbursement fee previously allotted to participating pharmacists as part of the Injectable Contraceptive Program, she states.
What is next?
Will pharmacists move toward provision of contraceptive injections? Picardo sees a trend toward such services.
Pharmacists are now required to earn a Doctorate of Pharmacy (PharmD) degree, rather than a Bachelor of Pharmacy (B. Pharm), degree in order to practice, explains Picardo. The addition of two more years of education allows for teaching skill sets such as injection administration and contraceptive counseling competency, she notes.
"As more women enter the pharmacy workforce, I would predict a growing interest in the areas of family planning," Picardo forecasts. "As more women demand this expanded reproductive health role from their pharmacists, these skills sets are more likely to be sought in new pharmacist hires."
Until access is broadened, clinicians can help DMPA users to continue with their injections by providing good counseling on side effects such as menstrual changes and by encouraging reminder systems, such as circling calendar dates, to return for reinjections.4
References
- Picardo C. Pharmacist-administered depot medroxyprogesterone acetate. Contraception 2006; 73:559-561.
- Hogue MD, Grabenstein JD, Foster SL, et al. Pharmacist involvement with immunizations: a decade of professional advancement. J Am Pharm Assoc 2006; 46:168-182.
- Halpern V, Grimes DA, Lopez L, et al. Strategies to improve adherence and acceptability of hormonal methods for contraception. Cochrane Database of Systematic Reviews 2006; 1:CD004317.
- Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology: 18th revised edition. New York: Ardent Media; 2004.
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