Pharmacy leaders are praising a new Washington state initiative that trains pharmacists to prescribe abortion medications via telehealth, calling it a potential model for other states seeking to increase access to reproductive healthcare.
The nonprofit Pharmacist Abortion Access Project (PAAP), in partnership with an online pharmacy called Honeybee Health, recruited and trained 10 pharmacists to prescribe mifepristone and misoprostol, the standard FDA-approved medication abortion regimen, to pregnant patients in the state who are up to 10 weeks’ gestation.
Pharmacy experts noted that the model is consistent with existing practice policies. For example, ASHP has a policy that asserts patients’ rights to comprehensive sexual and reproductive healthcare, including model legislation articulating the authorization of a pharmacist to voluntarily offer preventive services, patient assessment and patient care services for sexual and reproductive health conditions when consistent with the pharmacist’s training and standard of care.
“That policy emphasizes that reproductive healthcare does include access to medication abortion, and pharmacists are in a perfect position to provide access to those medications. So it is exciting to see this initiative in Washington,” said Anna Legreid Dopp, PharmD, ASHP’s senior director of Government Relations. “This great innovation at the state level enhances patient access to care through pharmacists, and we would hope this could serve as a model for other states.”
However, other states’ laws may not grant medication abortion prescribing privileges to pharmacists, noted Kathi Hoke, eastern region director for the Network for Public Health Law. “Washington State explicitly allows pharmacists to prescribe the medication, broadening their authority,” she said. “I don’t think any other states have such a provision.”
Maryland, for example, “expanded the types of health care professionals permitted to provide abortion care but did not explicitly include pharmacists,” Ms. Hoke said. “General language in that statute could permit pharmacists to prescribe if regulations on the scope of their practice allowed that.”
Some states also prohibit the provision of abortion drugs via telepharmacy, regardless of the prescriber. According to the Reproductive Health Initiative for Telehealth Equity and Solutions, 26 states and the District of Columbia currently permit telehealth for medication abortion (TMAB); 20 states and four territories banned TMAB entirely; and four states (Alaska, Georgia, North Carolina and Utah) permitted only hybrid TMAB due to state-mandated policies requiring a patient to have an in-person interaction.
“This issue is being hotly litigated throughout the country,” Ms. Hoke said. Last year the Supreme Court avoided answering questions on the FDA’s approval and regulation of medication abortion drugs. “They found the plaintiffs challenging the FDA lacked standing, but a case will eventually get there, likely in 2025.”
As these cases unfold, the mandate in Washington state is clear: “Reproductive rights are valued and protected [here],” said Frank Ameduri, a spokesperson for the Washington State Department of Health, which regulates pharmacy practice in the state. “Access to [abortion] medications is a critical piece of those reproductive rights.”
Conscientious Objectors a Concern?
For health-system leaders concerned about conscientious objectors refusing to participate in a medication abortion telepharmacy program, Anna Legreid Dopp, PharmD, ASHP’s senior director of Government Relations, stressed that the Washington state pilot and any follow-up programs involved voluntary pharmacist participation. Therefore, no pharmacist would be required to prescribe medication abortions if they had moral or religious objections, she noted.
As for supporting pharmacists who decide to participate, “our policy affirms that healthcare workers should be able to provide reproductive healthcare according to their clinical judgment and their conscience without fear of legal consequence, workplace sanctions, social stigmatization, harassment or harm,” Dr. Legreid Dopp said.
A History of Innovation
Pharmacists in Washington have had prescribing authority since 1979, noted Don Downing, BSPharm, a clinical professor emeritus at the University of Washington School of Pharmacy, in Seattle, who co-directs the PAAP initiative. More than two decades ago, he noted, “we began to train pharmacists to prescribe contraception, and they soon became the largest prescriber of emergency contraception in the state.” As a result of that program, “pharmacists were seeing more emergency contraception patients in a month than all the doctors in the state were seeing in a year.”
In January 2023, the FDA updated the Risk Evaluation and Mitigation Strategy (REMS) requirements for mifepristone, permanently removing the in-person dispensing requirement for the drug, adding a new pharmacy certification process and opening the door to telehealth options. In the case of the PAAP program, telepharmacy was chosen based on input from pharmacists who expressed concerns about being threatened by anti-abortion activists, as well as surveys in which some 75% of women said they would prefer a virtual visit over in-person for medication abortion, Mr. Downing noted.
A total of 43 patients were prescribed medication abortion during the PAAP pilot, which used a number of different pharmacists, including some who in their “day jobs” are employed by faith-based health organizations. Any pharmacist licensed in the state of Washington could participate, “as long as they were willing to go through our training program,” Mr. Downing said. “We recruited all of our pharmacists with the stipulation that we would not allow them to prescribe medication abortion during their regular work hours, therefore bypassing the requirement for permission from their manager, store or chain.”
Anti-abortion organizations have criticized the PAAP pilot. In a statement quoted by The New York Times, Ingrid Skop, MD, the vice president and director of medical affairs at of the Charlotte Lozier Institute, said, “Pharmacists, who do not receive clinical training, should not be distributing these dangerous drugs. By pushing these medically unsupervised abortions, the FDA and abortion advocates continue down the slippery slope of chipping away at medical standards for women seeking abortion.”
Dr. Skop’s inaccurate claim that pharmacists do not receive clinical training “stopped me in my tracks,” Mr. Downing said. “You have to provide an incredible amount of clinical training in order to be accredited as a pharmacy school,” including experiential, interprofessional clinical training and residencies. “Maybe before [such critics] speak up, they ought to know what they’re talking about.”
2 Decades of Safety Data
With more than 20 years of data since medication abortion was first approved in the United States, a substantial body of evidence indicates that it is both safe and effective.
A 2022 cohort study of more than 3,700 patients who were screened for medication abortion using patient history alone, without pelvic exam or ultrasound (relevant to the PAAP initiative approach), found that the medication was about 95% effective in terminating a pregnancy, and serious complications were rare (JAMA Intern Med 2022;182[5]:482-491). And a massive British study of medication abortions managed by telehealth, involving more than 50,000 patients, found that the drugs were 99% effective, and serious outcomes occurred in only 0.02% of cases (BJOG 2021;128[9]:1464-1474). Two studies that have been cited in court arguments in opposition to medication abortion, claiming that the drug is not safe and effective, have since been retracted.
Daniel Majerczyk, PharmD, an associate professor of clinical sciences at Roosevelt University College of Science, Health and Pharmacy in Chicago, and a co-author of a 2024 opinion endorsing pharmacist prescribing of mifepristone, agreed (J Am Coll Clin Pharm 2024;7[3]:270-278). “Pharmacists clearly undergo extensive clinical education during their training, and patient care programs like the PAAP also provide very specific training for prescribing mifepristone, ensuring that pharmacists are well prepared to manage the process safely,” he noted. Moreover, “characterizing mifepristone as a dangerous drug is definitely not supported by the evidence, and the FDA’s decision to allow certified pharmacies to dispense mifepristone reflects both [the drug’s] safety and the qualifications of pharmacists to manage it.”
Illustrating that point, one recent study found that mifepristone is about 95% effective in terminating a pregnancy, and serious complications are rare (JAMA Intern Med 2022;182[5]:482-491).
Mifepristone safety came up during confirmation hearings before the U.S. Senate on Jan. 29, 2025, for HHS nominee Robert F. Kennedy, Jr. Mr. Kennedy noted: “President Trump … [said he] wants me to look at [mifepristone] safety issues, and I’ll ask NIH [National Institutes of Health] and FDA to do that.” In response, Sen. Maggie Hassan (D-N.H.) entered into the record more than 40 studies documenting the drug’s safety.
Although pharmacist prescribing of mifepristone was not directly addressed during the hearings, it faces an uncertain future in the Trump administration, with the prospect of the FDA reviving rules requiring physician-only prescribing of mifepristone.
“I have conversations every single day about how are we going to provide for patients’ [reproductive]medical needs if the carpet is pulled out from under us,” Dr. Downing said. If federal officials try to limit the practice to prescribe, “I think we would be prepared to challenge that.”
The sources reported no relevant financial disclosures.
This article is from the February 2025 print issue.