“Are you pregnant or planning to become pregnant?” asked the pharmacist.
Writer Annie Noblin, 40, of West Plains, Missouri, had come in to pick up her prescription for methotrexate for her rheumatoid arthritis (RA). Before that there had never been a problem. But since Roe v. calf on June 24, 2022, things had changed. Missouri is in a trigger state where tough anti-abortion laws have been “triggered”.
What does an RA drug have to do with abortion?
Sometimes methotrexate is used off-label to terminate ectopic pregnancies, and use during pregnancy can cause miscarriage or birth defects. Women with RA in states with restrictive abortion laws are now being targeted.
Invasive health issues, refill delays
Noblin had received a text message earlier in the day that her prescription was being held. After hours of not hearing anything, she finally went to the pharmacy, where she was told that her rheumatologist needed to confirm that this was not being used for an abortion. And she had to reveal if she was pregnant or planning a pregnancy.
“I was pissed off,” she says. “It felt so intrusive. Why are my reproductive plans anyone’s business? The pharmacist said she could not give me the medicine until I answered. I was then forced to reveal my private personal information.
“And now I have to do that every time I try to fill a prescription. Because I can’t stand on principle; I need to have this drug,” she says, adding, “And what if I get pregnant? Am I then liable for what happens?”
What the anti-choice page says about the patients’ predicament
When asked to comment on the matter, Laura Echevarria, communications director and publicist for the National Right to Life Committee, responded via email: “This is absurd. No law passed or proposed by the pro-life movement would prohibit doctors from prescribing methotrexate for arthritis. … There are no pro-life laws designed to prevent the drugs used to treat arthritis from being administered.”
Concerns about methotrexate access are real
And yet Steven Newmark, Director of Policy and General Counsel of the Global Health Living Foundation, confirms that access to methotrexate in our post-war era is…roe World. “We’ve heard from women in certain states who have had triggers as the law progresses Dobbs Decision that they were denied access to their FDA [U.S. Food and Drug Administration]–approved medication for her chronic condition. In certain cases, additional barriers were introduced or more questions were asked. In certain cases we have heard from people who have been rejected outright.”
Pharmacists are in the midst of conflict
Some states are trying to clear up the matter. The Kentucky Board of Pharmacy has issued the following emergency rule:
“Any prescription or doctor’s order for a drug known to potentially cause termination of pregnancy will be considered by a pharmacy as for indications other than termination of pregnancy. A pharmacy issuing such a prescription or medical order need not verify that the prescription or medical order does not violate any provision of this chapter or KRS Chapter 216B.”
But when contacted, Amy Thibault, senior director of external communications at CVS Pharmacy, replied via email: “Laws in certain states restrict the dispensing of drugs for the purpose of inducing an abortion. These laws, some of which carry criminal penalties, have forced us to require pharmacists in these states to certify that the intended indication is not for abortion before they can fill a prescription for methotrexate or misoprostol.”
What is the duty of the pharmacist?
The American Pharmacists Association (APHA) sounded the alarm in its July statement, saying: “Today, in response to the US Supreme Court’s recent decision in Dobbs vs. Jackson Women’s Health Organizationthe US Department of Health and Human Services [HHS] Office for Civil Rights (OCR) published guidance [PDF] for Pharmacies, which sets out their obligations under federal civil rights laws, conflicts with some state laws and raises concerns for our nation’s pharmacies and pharmacists.”
In addition, APHA says, “The guidelines also deprive a pharmacist of professional judgment to ‘make determinations regarding the suitability of a prescribed drug for a patient; or advising patients about medication and how to take it.’ The implications of the guidelines have the potential to cause far-reaching unintended consequences beyond reproductive health services.”
Pharmacist group calls for clear guidelines
Meanwhile, E. Michael Murphy, PharmD, Advisor on Government Affairs at APHA says, “We have urged federal and state policymakers to take action to ensure patients continue to have access to FDA-regulated medications and evidence-based patient care services to have. It’s a complicated question because the laws and regulations are different in each state. We encourage our members to refer to state laws and regulations. … And we encourage policymakers to provide healthcare professionals with explicit guidance on how to navigate these confusing regulations.”
Healthcare providers are also restricted
“Physicians have found themselves in an impossible situation trying to fulfill their ethical duty to put the health and well-being of patients first,” said American Medical Association (AMA) President Jack Resneck Jr., MD when delivering his testimony (PDF) to the House Committee on Energy and Commerce Subcommittee on Oversight and Investigations on July 19, 2022. “We have only just begun to assess the full impact of the Dobbs decision,” he said, adding : “At this point, we have more questions than answers.”
In the meantime, Thibault says, CVS encourages providers to include their diagnosis in the prescriptions they write so pharmacists know immediately what the drug is for.
What can prescription holders do? Ultimately, the law is on the patient’s side
Section 1557 of the Patient Protection and Affordable Care Act is a federal law that broadly prohibits sex discrimination in federally funded healthcare programs and activities. The HHS Office of Civil Rights is responsible for enforcement. “These guidelines state that pharmacies generally may refuse to dispense medications related to reproductive health, including but not limited to misoprostol and methotrexate,” said Michelle Banker, director of reproductive rights and health disputes at the National Women’s Law Center.
The reason, she continues, “is that rejection can constitute sex discrimination, which includes discrimination based on pregnancy. It would also include discrimination based on disability, including certain autoimmune diseases that methotrexate is used to treat.”
Remember: pharmacies must fulfill prescriptions for medicines
Banker adds that another nuance is that it is possible for an individual’s pharmacist or a pharmacy employee to invoke certain federal statutes that allow this type of denial on religious grounds in certain limited circumstances, but those denial provisions do not apply for the pharmacy itself. If a person at the pharmacy refuses to fill a prescription, someone else at the pharmacy must do so.
What to do if you are refused medication?
Go to section 1557. Bring a copy of Guidance to Nation’s Retail Pharmacies: Obligations under Federal Civil Rights Laws to Protect Access to Comprehensive Reproductive Health Care Services. On page 3 it lists two examples of how refusal to take methotrexate may constitute discrimination based on sex or disability. For example, Noblin could use this to refuse to provide intrusive, personal information. If you are willing to do so, you may also file a complaint with the HHS Office for Civil Rights or file a lawsuit against the discriminating party.
Other avenues for help
The Arthritis Foundation recommends the following:
- Contact the toll-free helpline at 800-283-7800 for personalized support from licensed social workers and trained staff.
- Ask your doctor to write the purpose of the prescription on it – this way the pharmacist will be informed that the prescription is not for an abortion.
- Patients can also try mailing their prescription to another pharmacy, mail order, or consider alternative medication options with their doctor if they are having problems.
Global Healthy Living Foundation and CreakyJoints The Global Healthy Living Foundation and CreakyJoints, advocacy groups, encourage people to reach out to their elected officials to educate them about the importance of this vital drug. To share your story with CreakyJoints, tweet at @zoerothblatt.