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Internet access to controlled prescription drugs Internet access to controlled prescription drugs – by Lynne Wilkinson, Information officer, NCCDP The Internet is increasingly used to access health information and to purchase medical products and some prescription medications, including controlled drugs. Online sales have soared since the first online pharmacies appeared in 1999 as buying drugs on the Internet is more convenient for many people such as the disabled or housebound for whom a trip to the local pharmacy might prove difficult. The convenience of buying online 24 hours a day is another reason that pharmacy websites are becoming so popular. Medicines are often cheaper online and the Internet provides an element of privacy for those who are too embarrassed to discuss their conditions face to face. Pharmaceutical products available to UK buyers for example include appetite suppressants (e.g. Reductil®) and drugs for treating erectile dysfunction (e.g. Viagra®) and tobacco dependence (Zyban®). A prescription for these products in the UK would only usually be received after a thorough GP consultation, and used for treatment of specific, diagnosed disorders. The GP would also consider if a patient was suitable to receive such treatments based upon other concerns such as their medical history, concomitant use of other medicines, or likelihood of compliance to the regimen. The patient is also usually followed up and encouraged to report back to the GP after a couple of weeks and advised to report any untoward responses to treatment. The availability of medicines on the Internet without face-to-face consultation may circumvent these important checks. In the USA, the National Centre on Addiction and Substance Abuse (CASA) at Colombia University and Beau Dietl & Associates (BDA) have been studying the availability of controlled prescription drugs over the Internet since 2004 and their publication of findings in 2006 show that the number of websites selling medications without requiring a doctor’s prescription has increased. During a one week period in February 2006, 344 websites were identified as either advertising or selling controlled prescription drugs and for the third year, the total number of sites selling drugs increased (157 in 2004, compared with 160 in 2005 and 185 in 2006). The study found that 89% of sites selling controlled prescription drugs have no prescription requirements whatsoever. This was down slightly from 94% in 2004 but the number of websites stating that they do not require a prescription has increased every year (147 in 2004, compared with 152 in 2005 and 165 in 2006). Before legitimate online pharmacies dispense drugs, a valid prescription from the patient or the patient’s doctor is required but prescription drugs can be bought for illegal purposes through unlicensed websites where no prescription is necessary. In the UK, the Medicines Act 1968 regulates drugs that are available for medicinal purposes, and pharmacists can only sell prescription-only drugs if they have been prescribed by a licensed doctor. Furthermore, possession of medicines without a prescription is an offence. These online illegal pharmacies are based both in the United States and Europe and they sell a range of prescription medications, including controlled drugs. Many advertise that no prescription is necessary but others require that the patient complete an online questionnaire instead of obtaining a prescription. This is known as an online consultation. Since 2004 there has been an increase in the number of Internet pharmacies offering this service. The patient fills out the questionnaire online and a doctor affiliated with the online pharmacy reportedly evaluates the questionnaire before authorising the pharmacy to send the medication to the patient. There is no face to face consultation and no medical examination involved. Medical records are not required, and there are no lab tests or follow-ups. Some websites offer an online consultation free of charge but others refer patients to “script doctors” (in the USA) who require a fee before the medication is dispensed. According to the British Medical Association’s guidance for GPs, drugs should never be prescribed as a result of an online consultation unless for a repeat prescription. The BMA considers that in the UK, doctors are behaving unethically and maybe illegally, if they prescribe medications not licensed in this country. The Faculty of Pharmaceutical Medicine advises doctors that they have a duty to inform the Medicines Control Agency about any instance where medicine has been distributed over the Internet, which bypasses national legislation. The Medicines Control Agency investigates any report of illegal prescribing involving the Internet. Because controlled prescription drugs have become more readily available, they are increasingly being used for purposes other than which they are meant to be prescribed. Young people are especially at risk because there is nothing in place to prevent the purchase of drugs from illegal websites. In a previous study by Beau Dietl and colleagues, a thirteen year old girl was provided with a credit card and while under supervision bought Ritalin online just by giving details of her height, weight and age. As there are so many Internet pharmacies that it is difficult to know the precise number selling drugs directly to patients and because it is so easy to create and remove websites, tracking them and monitoring them is almost impossible. Many of the large online pharmacies have multiple portal sites where independent websites all connect to one online anchor pharmacy and the number of anchor pharmacies, which actually sell the drugs is increasing, making it difficult to locate. Benzodiazepines (‘tranquilisers’) are the most frequently offered controlled prescription drugs on the Internet with opioids being the second most readily available. In 2006 eight percent of the websites identified sold stimulants such as Ritalin and Adderall (see endnote i) while two sites sold barbiturates (‘stronger’ tranquilisers, rarely prescribed to new patients in the UK because of high incidence of side effects). CASA has made a number of recommendations to address the problem in the US, many of which are also applicable to the UK, including legislation to prohibit the sale or purchase of controlled prescription drugs without an original copy of a prescription issued by a licensed doctor, who must also be licensed in the state of purchase. Furthermore, the prescription must be based on a physical examination and evaluation. CASA also suggests that higher penalties should be imposed for selling controlled drugs illegally to minors. Internet search engines could provide warnings that the sale and purchase of controlled prescription drugs over the Internet from unlicensed pharmacies and doctors and without prescriptions are illegal. Sites that fail to require a legitimate prescription for selling controlled prescription drugs could be blocked and the report suggests that public service announcements should be developed which automatically appear when Internet searches for prescription drugs are conducted. Postal services and shipping services should train their staff to recognise potential signs of pharmaceutical trafficking and know how to respond in the event of suspicious activity. CASA suggests that the federal government should co-operate with Internet search providers, shippers, and financial institutions in creating a national non-profit clearinghouse to identify and shut down illegal pharmacies and the State Department should help foreign governments to shut down Internet sites that are selling controlled drugs illegally to US citizens. While the report discussed the situation in the US, the sale of controlled prescription drugs from unlicensed Internet pharmacies has public health implications for the UK and the rest of Europe. Purchasing prescription drugs from illegitimate websites carries many risks. Potential side effects can result from dangerous drug interactions or from inappropriately prescribed medications and the drugs purchased may be contaminated. Medications bought from illegal sites may have been improperly manufactured and may contain dangerously high doses of the drug, so that the patient could unknowingly overdose. There is also the chance that the drugs are not the genuine product and it is difficult for people to know what they are actually getting. Even if they are getting a genuine product it could possibly be out of date. In the UK, the Medicines and Healthcare Products Regulatory Agency (MHRA), the Government agency responsible for ensuring the safety of medicines and their proper distribution, is working with the Royal Pharmaceutical Society to produce a symbol that will indicate online pharmacies, which have been approved and are safe to use. This symbol is to be widely publicised and a list of approved sites will be made available to the public. These sites will provide contact details: an Internet address, a phone number and a postal address, which includes the country of origin. The MHRA Enforcement Team continually monitors Internet sites, particularly those that sell prescription only medicines. Spot checks are made to see whether the Internet sites selling prescription only medicines are based in the UK. If they are, the MHRA Enforcement Team takes action and a number of prosecutions have taken place. Overseas sites are referred to the appropriate regulatory body in that country. The MHRA is working in association with the UK Government and other regulatory and health bodies, to ensure that there is proper guidance in place to support the safe purchase of medicines over the Internet. References:
General Practitioners Committee (2001) Consulting in the modern world: Guidance for GPs. BMA, London. MHRA. Buying medicines over the Internet : http://www.mhra.gov.uk/home/idcplg?IdcService=SS_GET_PAGE&nodeId=254 The National Centre on Addiction and Substance Abuse at Colombia University (2006) “You’ve Got Drugs!” Prescription Drug Pushers on the Internet: 2006 Update. New York |
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