Two drugs used in pregnancy care are now under lock and key in Louisiana after a new law took effect Tuesday.
The drugs, mifepristone and misoprostol, are used for abortions, but are also routinely used to manage miscarriages, induce labor, insert IUDs and stop hemorrhaging in pregnant and postpartum women. Before now, a prescription was required to obtain the two drugs, but there were no criminal penalties for possessing them.
Now, possession of either of the drugs without a prescription could be punished with up to five years in prison and a $5,000 fine. Women who are currently pregnant are exempt from penalties.?
Because the drugs are a Schedule IV dangerous controlled substance alongside medications such as Valium, it also impacts how health providers can store and access the drugs within the hospital. Information about who has been prescribed the drugs is tracked by the Board of Pharmacy.?
Louisiana’s largest hospitals said they are prepared to adapt to the law. But already, doctors have said, the law is impacting care.
"There are unintended consequences," said Dr. Veronica Gillispie-Bell, a New Orleans area OB-GYN who has testified before Congress on improving maternal outcomes. "People start questioning things when there is criminalization associated with it."
Louisiana will be the first state to classify misoprostol and mifepristone as scheduled drugs.?
The law
Providing an abortion, including medication abortion, has been banned in Louisiana since the summer of 2022 when the U.S. Supreme Court overturned Roe v. Wade.
The new law that takes effect Tuesday was sponsored by state Sen. Thomas Pressly, R-Monroe, in this year’s legislative session and crafted with Louisiana Right to Life.?The bill was introduced to the legislature after Pressly’s sister’s husband secretly gave her misoprostol in a failed abortion attempt.?The amendment reclassifying mifepristone and misoprostol as controlled dangerous substances was added after the bill initially passed through the Senate and is the first of its kind in the U.S.
Sen. Thomas Pressly, seen here with Gov. Jeff Landry, used a Trojan Horse approach to passing new burdensome restrictions on access to potentially lifesaving abortion care.
Though the use of both drugs together is the most successful way to empty a uterus, misoprostol alone can also be used to induce an abortion or for a miscarriage. Some hospitals do not carry mifepristone due to federal regulations that limit its use, but misoprostol is used regularly in obstetric care unrelated to abortion.?
Louisiana Right to Life said the law is meant to stop forced abortions and stanch the flow of abortion medication from other states and countries through the mail.?
"We believe the law will do just that," said Sarah Zagorski, Louisiana Right to Life communications director. Zagorski acknowledged there would be confusion, but said providers should look to guidance from the state attorney general and Louisiana Department of Health.?
"With any new law coming into effect, there’s going to be changes in procedures and policies. We recognize that," said Zagorski. "That’s also why the department gave until Oct. 1 to try to get these things in place."
‘Immediately, I’m told no’
But some doctors said they started seeing the impact before the law even went into effect. On Sept. 30, Dr. Nicole Freehill tried to prescribe misoprostol to a patient for IUD removal and insertion. IUDs are a type of birth control that can be very painful to remove and replace, so many doctors prescribe the medication to soften the cervix.
But when Freehill, a New Orleans-based OB-GYN, put in the order, along with two diagnosis codes indicating what the drug was needed for, she got a message saying the prescription needed a prior authorization from the patient’s insurance companies.
Prior authorizations are a time-consuming process that requires doctors to prove the treatment is necessary to reduce waste and cost. They are typical for very expensive procedures, such as MRIs, or brand name drugs that might have cheaper generic alternatives. They require doctors to send a form to the insurance company and possibly schedule a phone call to prove the patient needs it.
The new law does not require prior authorizations for the two drugs. Freehill had never encountered the request before, even though she prescribes misoprostol weekly. She eventually got a message back from the insurance company that said it was a state-mandated prior authorization to make sure the medication wasn’t being used for an elective abortion.
"I did exactly what I'm supposed to do, even ahead of the law," said Freehill. "Immediately, I'm told no."
Before the new law went into effect, misoprostol was about 45 seconds from Freehill’s fingertips on an obstetric hemorrhage cart wheeled into high-risk and emergency procedures on the labor and delivery floor. Now, it will be stored elsewhere, she said. In drills, it took a nurse two minutes to override the locked machine and get the drug.
Dr. Jennifer Avegno, head of the New Orleans Health Department, said last week there was a report of a nurse practitioner who was not comfortable prescribing misoprostol as a controlled substance. A doctor had to put the call in instead.
"These are the things we’re going to start seeing – people acting out of fear, out of confusion and out of misinformation, and all of that resulting in patients not being able to access the medication," she said.
Hospital response
Ochsner Health, Louisiana’s largest health system, said misoprostol would be "readily and immediately available in labor & delivery units across the system, including in emergency situations." Ochsner systems do not carry mifepristone, a policy in place prior to Act 246.
"All controlled substances and the majority of non-controlled substances are stored in locked drawers," said Dr. Robert Hart, chief physician executive, in an emailed statement.
Misoprostol can only be prescribed at Ochsner with certain diagnosis codes in the patient’s medical record, which is the case with all controlled substances, said Hart.
LCMC Health operates five birthing hospitals in the New Orleans area: West Jefferson Medical Center, East Jefferson General Hospital, Lakeside Hospital, Lakeview Hospital and Touro Infirmary.
Several different professions across the system came together to ensure "rapid access to medications to treat hemorrhages related to childbirth that are compliant with the law," said Dr. Stacey Holman, OB-GYN and head of?LCMC Health Maternal Quality, in an emailed statement.
Holman said?the hospitals are committed to safety "despite the?real and substantive changes in routine practice that result from the law."?
Woman's Hospital in Baton Rouge, the largest birthing hospital in Louisiana, said "misoprostol has always been and will continue to be securely stored in our medication dispensers, which are available in every patient care area."
Franciscan Missionaries of Our Lady Health System, which operates Our Lady of the Lake in Baton Rouge and other hospitals in Monroe, Lafayette and Bogalusa, said the medications would be "stocked in secure area on our units in Pyxis medication systems," referring to locked medication dispensers.
At Iberia Medical Center, a 159-bed hospital with seven labor and delivery rooms, the change is expected to mostly impact how the medicine is stored in the hospital’s pharmacy. Pharmacy technicians will no longer be able to restock Pyxis machines, said Brandi Collins, a pharmacy manager. That will now fall to pharmacists. Nurses will now have to go through an extra step when they take the medication out of the machines as they do with other controlled substances.
Rapides Regional Medical Center also moved the medication to the pharmacy safe, said Danielle Bryant, the director of pharmacy.