Not a day goes by when our email inboxes do not fill with advertisements for prescription drugs. Many of these emails promise to deliver drugs of all classes by overnight courier without a prescription. While there are legitimate online pharmacies, and the practice of telemedicine or cyber-medicine is gaining acceptance, this change in the way medicine is being practiced is rocking the foundations of the medical establishment. Being able to consult a doctor online, and obtain prescription drugs delivered to your doorstep by UPS has broad social and legal implications. The Internet facilitates making drugs available to those who may not be able to afford to pay US prices, are embarrassed to see a doctor face-to-face, or are suffering from pain, the treatment of which puts most doctors in direct conflict with the ‘war on drugs’ but on the other hand there is the question whether these pharmacies make drugs available to recreational drug users without the oversight of a licensed medical practitioner.
The Need for Alternatives
Medical care in the US has reached a point where it is expensive and impersonal which has caused the consumer to become generally unsatisfied with the medical establishment as a whole. Examples include the huge differences between the cost of drugs in the US and Canada, long wait times in US pharmacies, and poor service in general. Perhaps realizing this, US customs appears to tolerate the millions of Americans that visit Canada every year to buy their medications, as for the most part, these ‘drug buyers’ are elderly American’s that can’t afford the high cost of filling their prescriptions in the US.
Rather than to travel to Canada or Mexico millions of Americans are now turning to the Internet for both their medical needs. Telemedicine (or cyber medicine) provides consumers with the ability to both consult with a doctor online and order drugs over the Internet at discounted prices. This has resulted in consumers turning to online pharmacies for their medical needs, and in particular pharmacies with a relationships with a physician, which allow the consumer to completely bypass the traditional brick and mortar pharmacies, with the added benefit of having their physician act as an intermediary between the consumer and the pharmacy. According to Johnson (2005) this is as a result of consumers becoming very dissatisfied when it comes to dealing with both brick and mortar pharmacies and medical practitioners. As Johnson, notes, “Consumers are more likely to know the name of their hairdresser than their pharmacist.” When Johnson (2005) rated the various professions within the health care system, he found that pharmacists had the lowest interaction with their patients than did any other group. Today, as a result of this “consumers are buying 25.5 percent of their prescriptions online, opposed to 13.5 percent of which are picked up at a brick and mortar pharmacy” (Johnson 2005).
Drugs and Society
What has brought so much attention to online pharmacies is that it is possible to obtain just about any drug without a prescription online. Many of these prescriptions are for legitimate purposes purchased through an online pharmacy because the buyer is too embarrassed to visit the doctor or for other reasons including the unavailability of FDA approved drugs to the consumer. These drugs may include steroids that due to their misuse and being classed as a classed a category three drugs, are seldom prescribed by physicians. These drugs have a useful purpose to those suffering from any wasting disease such as AIDS, they also play a role in ant-aging (FDA, 2004).
The Doctor Patient Relationship
Today a visit to a doctor is generally brief, much of the triage it is done by a nurse or a nurse practitioner with the doctor only dropping in for a few minutes, if at all. In many cases the patient is seen by a nurse practitioner. One of the arguments against telemedicine or perhaps a better term is cyber-medicine, is that the doctor does not have a physical relationship with the patients and thus is in no position to make a diagnosis, and thus can not legally prescribe drugs.
Ironically when one compares the work up that one has to go through to consult with an online physicians and compares this to a face-to-face visit with a brick and mortar doctor, one finds that the online physician, in many cases, has a better understanding of the patient’s medical condition than does the doctor who meets face-to-face with the patient. In most cases before an on-line a doctor prescribes any type of medication they insist on a full blood workup they may also require that one has additional tests performed, for example.
The AMA, the federal government, and various states claim, however, that it is illegal for a doctor to prescribe drugs without a valid doctor-patient relationship. While there are no laws at present that outlaw online pharmacies, various states have enacted legislation, or are in the process of enacting legislation to prohibit a doctor from prescribing drugs to a patient that they have not seen face to face. Some states also require that the doctor that prescribes the drugs be licensed in their state. This alone could hamper the development of cyber-medicine. According to William Hubbard (2004), FDA associate commissioner “The Food and Drug Administration says it is giving states first crack at legal action, though it will step in when states do not act” (FDA, 2004).
The reason that email boxes around the country fill up with offers to supply drugs of all kinds, at reduced prices, without prescriptions, and more is because people buy them as the billions of dollars the drug companies are making each year attest to. The Internet has become the drug store of choice for many.
Categories of Internet Pharmacies
Internet pharmacies are generally acknowledged to be comprised of the following five categories:
Internet pharmacies can be divided up into five different categories, as follows:
Licensed online pharmacies with a no medical affiliation.
Licensed online pharmacies with a medical affiliation
No record online pharmacies (NRP)
International online pharmacies (IOP)
Licensed compounding pharmacies
The licensed online pharmacies with a no medical affiliation are of course Drugstore.com, CVV, and others. They all require a prescription from a licensed doctor that the patient has a doctor patient relationship with. The prescription can be called in by the doctor.
The licensed online pharmacies with a medical affiliation often depend on a broker. The broker collects your medical information, and then assigns your case to one of their networked physicians. Many of these networked physicians are willing to prescribe pain killers as they believe that it is only through the use of these drugs that some people can live a harmonious life.
A Government Accountability Office (GAO) Committee on aging held in June 2004 found that “Unlicensed international pharmacies do not require a prescription, and are generally located off shore.” No prescription pharmacies can be found all over the world. Many of these sites have come under controversy as in some cases all it takes to have that prescription delivered to you by next day air, is to fill out a questionnaire online.
A study conducted by Henkle in 2002 to ascertain how easy it would be to obtain drugs over the Internet found that “37 of the 46″ pharmacy required a prescription from a licensed doctor. The emphasis was on the prescription and not on the doctor. Henkle (2002) in fact notes that some sites offered to recommend a doctor.” Henkle (2002) was able to obtain prescription drugs from nine sites outside the US during the study, without a prescription.
Online pharmacies with a doctor affiliation
There are a number of online pharmacies, with a medical affiliation is that take great pain to differentiate themselves form unlicensed overseas pharmacies. These pharmacies, stress that they are “American based companies that provides consumer’s easy access to FDA approved online prescriptions over the Internet and are quick to point out that “An online consultation can be just as relevant as an in-person consultation.” It is interesting to note that many of these online pharmacies also point out that “While they are committed to making access to online prescriptions easier, they believe that the Internet can not replace the importance of regular doctor visits to fully evaluate your health and any medical conditions.” Many of these online pharmacy sites also makes a wealth of drug information available on its web site that enables the consumer to educate themselves on drugs that may have been prescribed. The Internet has for all intensive purposes is quickly replacing the brick and mortar base physician as a patient’s primary health care provider.
A sales pitch, of course, or is it? Most of the legitimate online pharmacies ensure that they comply with state and federal regulation. The doctors are licensed in all 50 states and their pharmacies are too. These legitimate Internet pharmacies cater to those that are looking for a better price; for some it comes down to making the choice of eating cat food on crackers in order to afford their medications because of the high US drug prices. In other cases patients resort to cyber-medicine to avoid the embarrassment of having to deal with a physician or pharmacy that may be judgmental. Many of these online pharmacies will arrange a consult with a licensed, medical doctor over the phone and will then fill the prescription accordingly.
According to Henkel (2000) “More and more consumers are using the Internet for health reasons” and references a study carried out by a market research firm Cyber Dialogue Inc., “that found that “health concerns are the sixth most common reason people go online” (Henkel 2000).
For many people a trip to the pharmacy is an ordeal. In some cases the local pharmacy may also be located in the closest town which may mean a long drive if one lives in a rural community. Online pharmacies provide a means through which their prescriptions can be delivered conveniently and quickly. Being online also allows the consumer to shop for the best prices, an important factor if one is living on a pension.
The Internet has also created a more aware user. It is not unusual for a consumer to research drugs on the Internet. A consumer may have seen a TV or magazine advertisement advertising a new drug. Ultimately, the Internet also provides the consumer the opportunity to enter into a doctor patient relationship that may in fact be more legitimate than the doctor who makes a physical appearance.
It is interesting to note, as discussed previously, that consumers are becoming dissatisfied with the care and treatment they receive from both brick and mortar physicians and pharmacies. Zanf (2001), references a study by Lang and Fullerton that “Identified four factors related to outpatient pharmacy services: professional communication, physical and emotional comfort, demographics, and location and convenience.” All of which are contributing factors as to why more and more consumers are resorting to cyber-medicine.
The Dark Side
There is also a dark side to the Internet pharmacy, as previously discussed, spam email touting the availability of any prescription drug one could want, without a prescription, is something everyone is familiar with has reached epidemic proportions.
From Ambien, and of course Viagra to more powerful drugs such as Oxycontin, you can have it all. Over night shipping is available in most case, or so these emails proclaim.
In some instances this pharmacy spam originates from unscrupulous individuals who have no intention of delivering the drugs, realizing that very few people, if any, will complain about the non delivery of an illegal drug through the mail.
In other cases the drugs are sent without a prescription from countries where that particular drug may legally be sold without a prescription, or at least the laws are more relaxed. Valium, for example, is sold over-the-counter in Taiwan.
According to Crawford (2004) “Consumers who purchase drugs online thinking that they are they are getting the same drugs as they would from their local brick-and-mortar pharmacy are being misled, and as a result are putting their health, and eventually their lives at risk” Crawford cites examples of Internet pharmacies supplying drugs that were under strength, contaminated and mislabeled (Crawford 2004).
According to Won (2005) Drug-industry executives think the Internet and mail-order operations will be the biggest source of counterfeit drugs over the next five years, according to a report released today by Ernst & Young. According to James G Dickinson (2005):
The federal government in July shut down an alleged illegal Internet pharmacy for selling counterfeit drugs and issued a warning on other counterfeits found to have been sold in Mexican border pharmacies to individual patients from the U.S. The Internet pharmacy had sold more than $7 million in counterfeit Viagra and other prescription drugs over the past five years, according to the San Diego Union-Tribune. The San Diego-based operation required individuals to complete a $35 “doctor consultation” survey before receiving the prescriptions, but the survey was never shown to a health professional to evaluate whether a safety risk existed, the paper says (Dickson, 2005).
In a separate action, the FDA warned Americans about counterfeit versions of Merck’s cholesterol drug Zocor and generic Carisoprodol – used for treating musculoskeletal conditions – that had been imported from Mexico by individual Americans (FDA, 2005).
Over the last year patients suffering from pain, and other conditions that they are reluctant to see a doctor face-to-face, have had the option of consulting a doctor online. The ability to consult with a doctor online, and then to receive drugs as a result has come under much controversy. This has for the most part been as a result of not adequately screening patient’s records, or ordering from unregulated overseas pharmacies.
The Internet – a new way of marketing
Not all Internet pharmacies are illegitimate, however, and there are many pharmacies that provide the consumer with a legitimate prescription by overnight service. My last prescription came by mail. The whole transaction was completed over the Internet. It was a prescription that my doctor had given to me personally, however. As discussed, what constitutes a doctor patient relationship is at the crux of the online pharmacy debate. This of course has implications as to what constitutes a legitimate prescription. What constitutes a legitimate prescription is a hotly debated topic.
As noted, being able to consult a doctor over the phone, and then have one’s prescription filled by an Internet pharmacy is convenient for many people. As the American population ages, more and more people will have trouble getting to the doctors office, not to mention driving to the pharmacy. Clearly safeguards are needed if cyber-medicine is to raise the quality of medical care available to Americans. The online pharmaceutical industry has taken a number of steps to ensure that consumers are protected against unscrupulous online pharmacy operators including the certification of online pharmacies.
According to Henkel (2000) “One way consumers can ensure the quality of an online pharmacy is to look for the Verified Internet Pharmacy Practice Sites (VIPPS) seal.” According to Henkel (2000) any site bearing this seal has gone through a rigorous series of quality checks which are part of the Verified Internet Pharmacy Practice Sites program. Unfortunately as Henkel (2000) notes, “Because VIPPS certification is fairly new and voluntary, only a few sites have been certified so far.” Recognizing the problem of ‘rouge’ pharmacies, SquareTrade, has also implemented a program to protect consumers from ‘rouge’ pharmacies. According to SquareTrade, “The Licensed Pharmacy program verifies that your business is a pharmacy in good standing. Verified pharmacies can display the Licensed Pharmacy Seal on their websites – distinguishing themselves from unverified and rogue pharmacies.”
If these safe guards are not put in place, and legislation is enacted that makes it illegal to obtain a prescription from an online pharmacy based on an online consult, the black market for drugs will continue to thrive. Customs by its own admission only catches approximately 2% of all illicit prescription drugs that enter the US.
Negating the fact that through technology, one could enter into a doctor patient relationship that may be affordable. Security, as some have suggested could be accomplished through the use of video cameras and biometric scanners which would cut down on the number of fraudulent prescriptions written. Measures like these would put the convenience of using an online pharmacy out of the reach of those without the technology. One could also not prevent consumers from using off shore online pharmacies. While the FDA is presently trying very hard to get the Canadian government to enact legislation that would prohibit the export of drugs from Canada by mail it appears that the profit that results from the sale of drugs is causing the legislation to stall. As one Canadian pharmacy owner noted, however “We will just move to the UK.”
Ironically, the Canadian’s are offering to crack down, not because of any concerns relating to the sale of drugs online, but because Canada controls drug prices, making them far cheaper than the same drug in the US. The Canadian authorities are planning on cracking down “arguing that the system was created to help Canadians, not Americans.” The drug industry itself has gone so far as to black list Canadian pharmacies that sell to American customers over the Internet. With all the paranoia relating to terrorism there is a concern that any drug coming in from another country may be contaminated. There are no instances on record of a consumer having received a contaminated drug from Canada (Matthews, 2003).
Even more ironically with all the talk about the dangers of drugs purchased from overseas, some legitimate companies are now being forced to buy from other than US sources because they have been black listed by US drug manufactures (Matthews, 2003). Mathews (2003) goes on to illustrate this by pointing out that “Canadian suppliers, in particular, that have been blacklisted, are now turning to sources in Europe.” Mathews (2003) notes that while for the most part these European sources are legitimate and make a high quality drug. In some cases, however Mathews et al. (2003) note that the pharmacies are having to go ‘farther a field’ to find product.
While there need for controls to be put in place to regulate the practice of both medicine online and Internet pharmacies, we also need to acknowledge that science and technology has furthered the practice of medicine, and that the Internet will further it yet.
The Internet has the potential of expanding medical care to those that may not routinely seek it, or are too infirm to travel to the doctor’s office. While the present trend appears to be to make it illegal for a doctor to prescribe drugs without seeing the patient face-to-face there is also a move to establish rules and regulations that ensure that patients receive quality care over the Internet. Unfortunately medicine and politics have become so intertwined and doctors have inadvertently become unwilling agents in the war against drugs.
One can’t turn back the clock though, and according to Larkin (1999) “At a July 30 US Department of Commerce hearing on the benefits and risks of ‘drugstores on the net’, the question was examined.” The main issue was how to shutdown the online pharmacies run by unscrupulous individuals, while still fostering the legitimate online pharmacy business in order to both promote commerce and still protect the consumer (Larkin, 1999). According to Larkin (1999) “What’s new here is not the practice of pharmacy, but the way we communicate with and inform customers.”
At a January 26th 2004 FDCH Congressional Testimony Jeff Kimmell who is vice President and Chief Pharmacy Officer at drugstore.com, inc. commented, “There is little doubt that as consumers increasingly bear the burden of paying for prescription drugs, they will turn to the Internet for cost- effective alternatives.” As discussed, however, measures need to be taken to ensure that consumers don’t receive counterfeit, tainted or expired drugs.