Internet Prescriptions: Risky Business for Physicians and Patients Alike

Jay M. Pomerantz, MD

Disclosures

One can easily purchase on the Internet prescription medications, including controlled drugs, without a prescription from a doctor. Not only are there dangers in doing so, but such prescription drugs can be considerably more expensive.

In a recent study commissioned by the National Center on Addiction and Substance Abuse at Columbia University, investigators identified 495 Web sites offering controlled prescription drugs, including opioids, CNS depressants, and stimulants.[1] Of the 495 sites, 338 (68%) were portal sites that act as a conduit to another site that sells the medications, and 157 (32%) were anchor sites from which customers actually purchase the drugs.

Of the 157 anchor Web sites, only 6% indicated on their sites that they required a prescription before selling the drugs. Ninety percent did not require a prescription: 41% indicated that no prescription was needed, while 49% offered an "online consultation," which allows patients to receive their prescription after completing a questionnaire that is reviewed by the site's physicians.

Another study of Internet pharmacies conducted by the General Accounting Office identified 190 Web-based pharmacies selling prescription drugs directly to consumers.[2] Of these, 111 required a prescription from a physician, 54 would provide the prescription after the consumer filled out an online questionnaire, and 25 did not require a prescription at all. Those Internet sellers not requiring a prescription at all may represent rogue or foreign sites, so I will ignore them and hope US consumers do as well. Those Internet pharmacies that require completion of a questionnaire and screening by the sites' own physicians before providing the medications requested are actually more of a threat, since their activities appear to be law-abiding.

The growing number of physicians who engage in Internet prescribing has raised concerns within the profession. Last June, the AMA House of Delegates issued guidelines concerning the safety of prescribing medications to patients via the Internet.[3] These guidelines state that physicians should obtain medical history information and perform a physical examination before prescribing medications online. Physicians who prescribe medication via the Internet should either be licensed in the states where their patients live or meet regulatory requirements of individual state medical boards. Additional AMA-recommended safeguards for physicians who prescribe medications via the Internet include:

  • Having adequate dialogue with patients about treatment options, risks, and benefits.

  • Following up with the patient as appropriate.

  • Maintaining an updated medical record that is readily available to the patient and to his or her health care professionals (subject to the patient's consent).

  • Including the electronic prescription information as part of a patient's medical record.

  • Clearly disclosing physician-identifying information such as name, practice address, and financial interests in any products prescribed.

The FDA is also very clear on the potential dangers inherent in remote prescribing: "Getting a prescription drug by filling out a questionnaire without seeing a doctor poses serious health risks. A questionnaire does not provide sufficient information for a health-care professional to determine if that drug is for you or safe to use, if another treatment is more appropriate, or if you have an underlying medical condition where using that drug may be harmful."[4]

Nonetheless, many online pharmacies offer their own "onboard 24×7 US physicians to write the prescriptions." Prescriptions are listed by brand names and include Viagra, Celebrex, Ultram, Xenical, Tramadol, Adipex, Soma, as well as antidepressants (Prozac, Zoloft, Paxil, Wellbutrin) and tranquilizers (Valium, Xanax). All of these medications are advertised to be available for next-day delivery, with one site indicating that its physicians have approved 99.99% of requests.

The prescribing and selling of antidepressants and tranquilizers, as well as other drugs, over the Internet raises a host of questions and concerns. Without having the person in front of the doctor for an interview and a physical and/or mental examination, how sure can one be of the truthfulness of their answers? Might someone lie about their age, health status, past use, and addiction potential? Also, the use of general medical questionnaires may not be comprehensive enough to uncover important contraindications. For example, without concomitant coverage from an effective mood stabilizer, antidepressants are dangerous for bipolar patients. In my reading of various online questionnaires, there were no questions about a history of manic-depressive disorder or bipolar disorder. There were also no questions about thoughts, feelings, plans, or past attempts of suicide. Often, a prescription alone is not enough; it is only part of a treatment plan, which often includes psychotherapy and may require additional support such as inpatient hospitalization.

The easy availability of tranquilizers, such as diazepam and alprazolam, is even more problematic. These are habit-forming and potentially lethal when used in combination with alcohol or other substances of abuse. While these and other benzodiazepines are useful medications for management of anxiety disorders, careful prescribing is mandatory. The danger of Internet prescribing, without a face-to-face ongoing relationship, is obvious, yet it persists.

Prescription medications obtained through such Internet sites don't come cheap. For example, Pharmacy Discounts, a typical site offering prescriptions from its own doctors, listed fluoxetine at $185 for 30 pills or $413 for 90 pills, and alprazolam at $115 for 30 one-mg pills or $170 for 30 two-mg pills. In contrast, drugstore.com, a more traditional Internet pharmacy not offering its own prescribing doctors, listed fluoxetine at $33.98 for 30 pills and $84.99 for 90 pills. The drugstore.com prices for alprazolam were $7.99 for 30 one-mg pills and $8.99 for 30 two-mg pills. The difference in price is extraordinary, and patients with or without health insurance would be much better off getting a prescription from their own physician.

What complicates the regulation of Internet pharmacies is a jurisdiction issue. The licensing and regulation of pharmacies and physicians traditionally takes place at the state level. However, the Internet easily traverses state and even country boundaries, making standards and enforcement complex and difficult. The Internet also makes identifying pharmacies a problem, since most Internet pharmacies do not identify the states where they are licensed to dispense prescription drugs and use multiple Web sites.

The National Association of Boards of Pharmacy(NABP) does maintain a site (www.nabp.net/vipps/intro.asp) that lists 14 certified online pharmacies that are licensed and follow state regulations. To be certified as a Verified Internet Pharmacy Practice Site (VIPPS), a pharmacy must comply with the licensing and inspection requirements of its home state and each state to which it dispenses pharmaceuticals. In addition, pharmacies displaying the VIPPS seal have demonstrated to NABP compliance with VIPPS criteria, including patients' right to privacy, authentication and security of prescription orders, adherence to a recognized quality assurance policy, and provision of meaningful consultation between patients and pharmacists.

Within the group of Internet pharmacies there are obviously a range of business practices and services offered. It is a situation of "caveat emptor," or "let the buyer beware." Consumers should be encouraged to forego the temptation to bypass their own physicians, especially when dealing with the treatment of depression and/or anxiety. Looking to the Internet for an anonymous prescription is for knaves and fools, old terms that still apply in the time of cyberspace.

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