Pauline Anderson

May 24, 2017

SAN DIEGO — Chances are good that some of your patients are using the 'Dark Web' to buy opioids, synthetic heroin, or other drugs.

The Dark Web is an underground world of illicit online drug marketing run on a business model akin to Web giants Amazon or eBay.

But not many psychiatrists know about this hidden commerce, and they ought to, Dwight Zach Smith, MD, executive director, New England Psychiatric Consults, Plymouth, Massachusetts, told Medscape Medical News.

"There should be a greater recognition of this because patients could be addicted to substances that doctors know nothing about."

A substance abuse expert, Dr Smith discussed the Dark Web here at the American Psychiatric Association (APA) 2017 Annual Meeting.

Hidden Commerce

Dr Smith first learned about the Dark Web about a year ago when a patient, who was struggling with "horrible" withdrawal symptoms, revealed that he had been buying China White, a fentanyl analogue, over the Internet.

"We as experts don't know anything about China White — we don't know how long it lasts in the body, and we don't know about potential adverse effects like severe withdrawal," said Dr Smith.

His curiosity piqued, Dr Smith investigated the clandestine Web. He learned that in 2015, 15% of illegal drug users in the United States purchased their drugs over the Internet.

Access to the Dark Web is free and easy with a specialized "Tor" browser. That browser "anonymizes" an Internet connection by sending an individual's encrypted signal through multiple routers until the point of origin is lost, said Dr Smith.

A quick tour of the Dark Web reveals a choice of more than 200,000 individual listings for drugs — prescription and nonprescription — as well as weapons and counterfeit products. The sites are filled with promotions, pictures, advertisements, and reviews.

One merchant, based in the Netherlands, was selling a gram of cocaine for about $50.00, shipping included. This merchant claimed to have made 4113 sales of this product. His trust level was rated as high, and many of the comments under his review section were positive.

Drug buyers might not get a break on price when buying drugs over the Internet, but the quality is apparently superior to what you would typically find on the street, said Dr Smith. Buyers pay in bitcoin, an untraceable currency.

Just like other online vendors, Dark Web drug dealers give up a percentage of their sales. Vendors who are based all over the world might make in the neighborhood of $100,000 on average a year, said Dr. Smith.

Stealth Packaging

Purchases are shipped through regular mail using what Dr Smith called a very sophisticated "stealth packaging" system. "They know what customs agents look for, and they are almost always able to circumvent it."

One of the earliest and most successful Dark Net sites was Silk Road. Launched in 2011, within a 2-year period, it processed $1.2 billion worth of sales. About 4000 anonymous vendors sold products to 150,000 customers worldwide.

The site was making an estimated $20,000 daily in commissions from vendors.

Silk Road was shut down in 2013, but it popped back up as Silk Road 2, and it, too, was shut down. It's difficult for authorities to keep up with this Internet commerce, said Dr Smith.

"It's so hard to find the individuals behind it because of the layers of anonymity and the encryption involved."

Profits from Dark Net drug sales continue to soar. Dr. Smith estimates that daily commissions have tripled since 2013. He believes there are now about 50,000 hidden Tor service sites and that transactions generate up to $200 million annually.

While this hidden web hides shady and illicit transactions, there may be times when it serves a useful purpose, said Dr. Smith. "Reporters, political dissidents, and whistle blowers, in some countries and under certain circumstances, might use it for some good."

"Potentially Disturbing"

Commenting on Dr Smith's research for Medscape Medical News, Frances R. Levin, MD, director, Division on Substance Use Disorders and Kennedy-Leavy Professor of Psychiatry at Columbia University Medical Center, New York, said this is "potentially a disturbing problem."  

However, she added, Dr. Smith's research appears to be based on a single case report of a patient buying China White. "It would have been helpful to have more than one case."

She also would have liked more information on the dollar amounts for Dark Web sales. "The reliability of the source needs to be documented."

Dr Levin stressed that "it is incumbent on clinicians" not only to ask patients if they use alcohol, tobacco, and drugs but also if they use synthetic and designer drugs, and to "understand the inherent risks associated with their use."

Dr Smith and Dr Levin have disclosed no relevant financial relationships.

American Psychiatric Association (APA) 2017 Annual Meeting. Abstract P6-012. Presented May 22, 2017

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