Just a fraction of prescriptions for the abortion pill mifepristone were filled at brick-and-mortar retail pharmacies after federal drug regulators lifted longstanding dispensing limits, according to a new USC study in JAMA.
The U.S. Food and Drug Administration (FDA) in January 2023 permanently removed rules requiring patients to obtain mifepristone—the first of two drugs used in medication abortion—in person at a clinic or hospital. That change meant in-store and mail-order pharmacies could provide the drug when it was prescribed by a certified provider, a shift expected to broaden access nationwide.
Since then, pharmacies have filled about 2,700 mifepristone prescriptions per month, researchers found. Nearly all have been dispensed by mail-order pharmacies in states where abortion is legal and can be prescribed via telehealth (27 states and Washington, D.C.).
In these states, in-store pharmacies accounted for less than 2% of individuals using pharmacies to fill their mifepristone prescription since the FDA updated dispensing requirements under the drug safety program known as Risk Evaluation and Mitigation Strategies (REMS). These were largely fills at independent pharmacies rather than chains (92% vs. 8%).
"Our findings show how critically important mail-order pharmacy dispensing of mifepristone has been in the post-Dobbs era, with dispensing levels immediately rising sharply after the REMS change," said first author Christopher Scannell , a nonresident scholar at the USC Schaeffer Institute and senior research associate at the USC Mann School of Pharmacy and Pharmaceutical Sciences.
Yet, the findings also suggest significant access gaps in states with stronger legal protections for abortion. While mail-order telehealth may offer patients privacy and convenience, particularly in areas with limited provider options, it may not work for everyone. Patients who need mifepristone quickly, lack steady internet access or a mailing address, or seek pharmacist counseling may prefer to obtain the medication in person.
"It's striking how few retail pharmacies, particularly chains, are dispensing mifepristone in states where abortion is legal and telehealth is permitted," said lead author Dima M. Qato , a senior scholar at the Schaeffer Institute and the Hygeia Centennial Chair at the USC Mann School. "This finding underscores the need to identify and address barriers in the implementation of mifepristone dispensing at retail pharmacies in states where abortion is legal. The failure to do so may undermine efforts to expand access to medication abortion in the current legal landscape."
Notably, pharmacy chains have faced pressure from both abortion rights advocates and opponents since the FDA policy change. Two of the largest chains, CVS and Walgreens, announced they would offer mifepristone in certain locations where it is legal. Costco said it would not carry it, and some have not stated a position.
In the 11 states where abortion is legal but with restrictions on telehealth, retail pharmacies have played a much bigger role. About 61% of mifepristone fills in these states have been at retail pharmacies.
The study also shows a shift in who is providing care. While OB-GYNs still perform most in-person abortions, the policy change appears to have made it easier for other primary care physicians and advanced practice providers, such as nurse practitioners, to provide medication abortion through mail-order pharmacies.
The researchers compared a two-year period following the FDA policy change with the two years preceding it. The study relied on individuals' reported state of residence, which some patients may misrepresent to obtain mifepristone. Future research should evaluate the role of shield laws in facilitating medication abortion in restrictive states.
About the study
Other authors are Pragya Kakani and Rebecca Myerson. Please see the study for author disclosures.
