Back in May, Louisiana became the first state in the US to reclassify two of the most common medications used for abortions as “controlled dangerous substances”. Despite controversy and protests from both doctors and reproductive rights advocates, the change, as of October 1, is now in effect.

But what does that mean for patients who need these medications and the doctors who care for them? It’s a complex – and, frankly, worrying – picture.

Which medications does the new legislation affect?

The legislation affects two specific medications: mifepristone and misoprostol. These are best-known for their use in medical abortions – the most common type of abortion in the US, received by nearly 300,000 patients in the country each year.

Generally, a person wanting to end their pregnancy will take one of each pill. First, you take mifepristone, which blocks progesterone – the hormone responsible for preparing the endometrial lining of the uterus for pregnancy, and then keeping it nice and thick if conception does occur. 

With decreased levels of progesterone, the uterine lining thins out, making it harder for any embryo or fetus to stay attached. At this point, the misoprostol steps in: between 24 and 48 hours after the mifepristone dose, you take your second pill, and it causes your uterus to contract, expelling the now non-viable pregnancy.

It’s a safe and effective procedure, used for decades across nearly 100 countries worldwide. The pills are considered core essential medications by the World Health Organization, meaning they are “minimum medicine needs for a basic health-care system”, and at least 16 countries have officially agreed with that designation within their own healthcare systems.

Neither drug, though, is limited to its use as an abortifacient. Mifepristone can be used to treat hyperglycemia in patients with Cushing’s syndrome – a condition in which the body is exposed to too much cortisol – and misoprostol can be used to prevent stomach ulcers, or to prepare the uterus for procedures such as IUD insertion. More critically, it can also be a vital drug to prevent hemorrhaging in labor – the cause of almost one in seven maternal deaths in the US.

“It’s just really jaw-dropping,” said Dr Nicole Freehill, a New Orleans OB-GYN and one of more than 250 doctors who signed a letter to Republican state senator Thomas Pressly – the bill’s sponsor who appeared to forget the name of one of the drugs while introducing the bill – in protest against the legislation back in May. 

“Almost a day doesn’t go by that I don’t utilize one or both of these medications,” she told NPR in May.

What does the new legislation say?

Abortion was already banned in Louisiana for any reason other than saving the life of the pregnant patient – an exclusion that doctors have previously pointed out is complex and, ironically, actively more life-threatening for both them and the fetus.

That ban included medical abortions, meaning it was already a crime to provide somebody with drugs to induce an abortion. However, since mifepristone and misoprostol have uses outside of abortions, they were still available for doctors to prescribe for other reasons – even if some pharmacists are already reportedly refusing to fill those prescriptions out of fear of prosecution. 

Now, however, even that limited access has been reduced. Both drugs are now classified in the state as Schedule IV controlled substances, requiring a special license to prescribe. 

Fall foul of the law, and you face a hefty punishment. Previously, physicians found guilty of performing an abortion in Louisiana faced up to 15 years in prison, $200,000 in fines, and the loss of their medical license. That’s still the case, but the drugs’ new classification adds further punitive measures: now, anybody knowingly possessing mifepristone or misoprostol without a valid prescription could be fined up to $5,000 and be sent to jail for one to five years.

Weirdly, there does seem to be one exception to this draconian punishment: pregnant people who obtain the drugs on their own are exempt from criminal liability.

“Under this law, or any abortion law, in Louisiana, we see the woman as often the second victim,” said Dorinda Plaisance, a lawyer who works with Louisiana Right to Life, the anti-abortion group which helped draft the bill, during the law’s hearing in April – ignoring the fact that more than 95 percent of women stand by their decision to have an abortion years after the event.

“So,” she said, “Louisiana has chosen to criminalize abortion providers.”

Why are doctors concerned?

There are many reasons this reclassification has raised eyebrows, not least of which is the fact that there’s simply no precedent for the move. 

That’s because a Schedule IV classification is typically reserved for drugs like opioids or benzodiazepines – things which carry a risk of dependence or abuse. That, of course, is not the case for either misoprostol or mifepristone: “There is no risk of someone getting hooked on misoprostol,” Dr Jennifer Avegno, a New Orleans emergency physician and the director of the New Orleans Department of Health, told NPR.

“To classify these medications as a drug of abuse and dependence in the same vein as Xanax, Valium, Darvocet is not only scientifically incorrect, but [a] real concern for limiting access to these drugs,” she said.

And limited they will be. The drugs’ reclassification means that prescribing them, even for legal reasons, can be prohibitively difficult and potentially dangerous for doctors in the state. Physicians will need a special license to prescribe them; their use and dispensing will be tracked by state monitoring agencies, and accessible by licensing bodies and law enforcement agencies.

Even if everything goes smoothly in terms of obtaining the drugs, doctors worry that patients who need these medications may be afraid to take what is now considered a “dangerous” substance.

“Controlled substances require more complex coordination by pharmacists, patients and providers, with increased documentation and often longer waits for patients,” notes the letter signed by Freehill and more than 250 other doctors in the state. “Overall, this results in fear and confusion among patients, doctors, and pharmacists, which delays care and worsens outcomes.”

More practically, the change in law also means a change to how the drugs are handled in hospitals – places where quick access to misoprostol in particular can sometimes be the difference between life or death. 

Rather than being kept in so-called hemorrhage carts, which can be wheeled into hospital rooms to dispense lifesaving medication to hemorrhaging patients, misoprostol will now need to be stocked outside of patients’ rooms, under lock and key.

When Freehill’s hospital ran drills to practice retrieving the drug under the state’s new regulations, it took two minutes, she told The Guardian – a big increase from the 15 seconds or so it previously would have taken. 

“A lot of people might go: ‘Oh, two minutes, that’s really fast.’ And yes, in the long scheme of things, that’s fast,” Freehill said. “But when you have someone who is actively hemorrhaging – in two minutes, they can lose hundreds of cc’s of blood.” 

“Those seconds count,” she explained. “I’m definitely worried about what’s going to happen to patients who are hemorrhaging.”