The lure of illegal pharmacies is low cost and convenience. Many illegitimate pharmacies will send patients prescription drugs without a prescription. Pharmacy Web sites located in other countries typically sell their drugs for much less than U.S. pharmacies as well. Many foreign pharmacies that cater to the U.S. market are located in Canada. Clifford Krauss reported in "Internet Drug Exporters Feel Pressure in Canada" (New York Times, December 11, 2004) that the 270 online Canadian pharmacies made more than $800 million from U.S. customers in 2003. While many of the Canadian pharmacies follow the same strict standards as American pharmacies, it is illegal for individuals in the United States to buy pharmaceuticals from foreign countries.
Illegitimate online pharmacies have generated a great deal of concern among health-care professionals and government lawmakers in the United States. One problem is that state medical boards, who typically oversee brick- and-mortar operations, have difficulty monitoring pharmaceutical Web sites. While some of these pharmacies follow many of the same standards as legitimate operations, others disregard them altogether. In addition to providing drugs without a prescription, many send patients drugs without warnings or dosage information. Such a practice is exceedingly dangerous. Accutane, an acne treatment medication, has been known to cause severe birth defects and mental problems in select patients. If a
TABLE 8.5
| Prescription drugs ordered and received from Internet pharmacies, 2004 | |||
| Drug ordered | Orders placed1 | Drug samples received2 | Drug samples obtained without a prescription provided by the patient |
| Note: The samples were shipped by FedEx (24), UPS (3), the U.S. Postal Service (39), and other couriers (2). | |||
| 1Does not include attempted orders that were not accepted. We did not reach our goal of placing 10 orders for each drug because we could not always locate 10 sources from which we could purchase the drugs in a manner consistent with our methodology's protocols. | |||
| 2We did not receive a drug sample for every order placed. Reasons included the drug being out of stock, a requirement that physicians prescribing certain drugs be part of a registry, and pharmacy requests for follow-up information we could not provide. In several instances, we could not determine why an order placed was not received. | |||
| 3Includes one sample we could not link to an order we placed. | |||
| 4Although we placed orders for Vicodin, we did not receive any samples of the brand name version of the drug; all nine samples received were of the generic equivalent hydrocodone. | |||
| SOURCE: "Table 2. Prescription Drugs Ordered and Received from Internet Pharmacies," in Internet Pharmacies: Some Pose Safety Risk to Consumer, United States General Accounting Office, June 2002, http://www.gao.gov/new.items/d04820.pdf (accessed December 11, 2004) | |||
| Accutane | 10 | 63 | 3 |
| Celebrex | 10 | 9 | 7 |
| Clozaril | 9 | 0 | 0 |
| Combivir | 6 | 5 | 1 |
| Crixivan | 6 | 6 | 2 |
| Epogen | 1 | 1 | 0 |
| Humulin N | 7 | 4 | 3 |
| Lipitor | 10 | 9 | 6 |
| OxyContin | 1 | 1 | 1 |
| Percocet | 0 | 0 | 0 |
| Viagra | 10 | 9 | 7 |
| Vicodin/hydrocodone | 10 | 93,4 | 9 |
| Zoloft | 10 | 9 | 6 |
| Total | 90 | 68 | 85 |
pregnant woman were to receive an unlabeled bottle of Accutane and did not know of the warnings, the results could be disastrous. Another concern is that many of these sites have been known to deal in counterfeit drugs with diluted ingredients or no ingredients at all. Counterfeit heart medication or even cholesterol medication could result in a patient's death. When federal and state agencies become aware of one of these illegitimate pharmacies in the United States, they attempt to shut it down. However, government regulators can do very little about controlling pharmacies outside of U.S. borders.
In the first six months of 2004 the United States General Accounting Office (GAO) conducted a study of Internet pharmacies. The investigators placed up to ten orders for each of thirteen different drugs from online pharmacies located in the United States, Canada, and other foreign countries, including Argentina, Costa Rica, Fiji, India, Mexico, Pakistan, and Turkey. (See Table 8.5.) When the GAO received the drugs they forwarded them to drug manufacturers for chemical verification. The results were reported in Internet Pharmacies: Some Pose Safety Risks for Consumers, which was published in June 2004 by the GAO. As Table 8.6 shows, all the Canadian Internet pharmacies required prescriptions from a patient's physician.
TABLE 8.6
| Prescription requirements of domestic and non-U.S. Internet pharmacies, 2004 | |||
| Prescription requirement | U.S. Internet pharmacies | Canadian Internet pharmacies | Other foreign Internet pharmacies |
| SOURCE: "Table 3. Prescription Requirements of Pharmacies from which We Obtained Samples," in Internet Pharmacies: Some Pose Safety Risk to Consumer, United States General Accounting Office, June 2002, http://www.gao.gov/new.items/d04820.pdf (accessed December 11, 2004) | |||
| Prescription from patient's physician must be provided | 5 | 18 | 0 |
| Web site provides prescription based on questionnaire | 24 | 0 | 3 |
| No prescription required | 0 | 0 | 18 |
Only five U.S. Internet pharmacies followed this convention. The other twenty-four sent out prescriptions based on questionnaires that inquired about a patient's history—a practice condemned by the Food and Drug Administration (FDA), the American Medical Association (AMA), and many state medical boards. Most of the foreign Internet pharmacies outside of Canada did not even require a questionnaire.
Some of the sites, particularly in Canada and the United States, followed every rule that brick-and-mortar pharmacies did in the United States. In one case, a U.S. pharmacy refused to send the investigators a prescription for Accutane since the doctor who wrote the prescription was not on an official list of doctors qualified to do so. Table 8.7 lists some of the problems encountered with the sixty-eight online pharmacies that did send drug samples to the GAO investigators. For the most part, the samples that were sent from U.S. online pharmacies had only a few problems, including improper labeling. Many Canadian pharmacies sent versions of popular U.S. drugs that were not licensed for sale in the United States. Much like generic medications, these drugs have the same medicinal ingredients as their U.S. equivalents and pose no additional threat to those taking them.
Drugs sent from foreign countries other than Canada were riddled with problems. Five foreign pharmacies took the investigators' money and sent them no drugs. Of the drugs received from these other foreign countries, none of them had an instruction label and only six out of twenty-one had warning labels. Some of these drugs, particularly narcotics, were packaged in strange ways to disguise the contents of the package. The supposed shipment of Oxy-Contin arrived in a used CD case wrapped in brown packing tape. Several of the foreign drugs were counterfeit as well, including the OxyContin, which did not contain any of the actual drug. When the GAO investigators attempted to track down the origin of the foreign packages, they came up with some bizarre locations. A sample of Lipitor from Argentina was apparently shipped from a shopping
TABLE 8.7
| Problems observed among prescription drug samples obtained from online sources, 2004 | |||||||
| Pharmacy location | No pharmacy label with instructions for use 23 samples) | No warning information (21 samples) | Improperly shipped or dispensed (4 samples) | Unconventional packaging (6 samples) | Damaged packaging (5 samples) | Not approved for U.S. market (35 samples) | Counterfeit or otherwise not comparable to product ordered (4 samples) |
| Notes: Drug names indicated are those that General Accounting Office (GAO) ordered. The samples we received were not the brand name drugs we ordered in all instances. Drug samples do not add to 68 because some samples exhibited more than one problem. | |||||||
| SOURCE: "Table 4. Problems Observed Among Prescription Drug Samples Received," in Internet Pharmacies: Some Pose Safety Risk to Consumer, United States General Accounting Office, June 2002, http://www.gao.gov/new.items/d04820.pdf (accessed December 11, 2004) | |||||||
| Canadian | Celebrex (2) | Accutane (3) | |||||
| Zoloft (2) | Combivir (3) | ||||||
| Crixivan (3) | |||||||
| Humulin N (1) | |||||||
| Lipitor (2) | |||||||
| Viagra (1) | |||||||
| Zoloft (3) | |||||||
| Other foreign | Accutane (3) | Accutane (2) | Humulin N (3) | Accutane (1) | Accutane (2) | Accutane (2) | Accutane (1) |
| Celebrex (3) | Celebrex (3) | Celebrex (1) | Celebrex (1) | Celebrex (3) | OxyContin (1) | ||
| Combivir (1) | Crixivan (2) | Crixivan (2) | Crixivan (1) | Combivir (1) | Viagra (2) | ||
| Crixivan (2) | Lipitor (3) | OxyContin (1) | Lipitor (1) | Crixivan (1) | |||
| Humulin N (3) | OxyContin (1) | Viagra (1) | Humulin N (3) | ||||
| Lipitor (3) | Viagra (2) | Lipitor (3) | |||||
| OxyContin (1) | Zoloft (2) | OxyContin (1) | |||||
| Viagra (2) | Viagra (2) | ||||||
| Zoloft (3) | Zoloft (3) | ||||||
| U.S. | Celebrex (1) | Lipitor (1) | Crixivan (1) | ||||
| Zoloft (1) | Zoloft (1) | ||||||
mall in Buenos Aires. An order of Humulin N and Zoloft were traced to private residences in Lahore, Pakistan.
Who Is Ordering Online Medications?
Though the number of people purchasing drugs online has grown since the turn of the century, the overall percentage of Americans buying pharmaceuticals on the Internet was still fairly low as of mid-2004. According to Susannah Fox in Prescription Drugs Online (Washington, DC: Pew Internet & American Life Project, October 2004), only 5% of American adults (ten million people) had bought prescription drugs online for themselves or others by spring 2004, compared with the 64% (129 million people) of American adults who took prescription drugs on a regular basis or lived with someone who did. Predictably, most people who bought online drugs said that convenience and savings were the two biggest reasons they bought drugs online. Roughly 75% of people who made an online drug purchase bought a drug for a chronic medical condition such as high blood pressure. The rest said they went online to purchase a drug for other purposes such as weight loss or sexual performance.
The vast majority of people surveyed in the Pew/Internet report who bought online drugs said they had a prescription from a doctor. Almost all of these people received their prescription drug from an online pharmacy based in the United States. Only a few people replied that they found their online pharmacy by responding to a spam e-mail advertisement. In the end, most people who went online for their drugs were happy with their experience. Roughly 90% of those who purchased online pharmaceuticals said they planned to do it again. The biggest complaint people had was that their packages were lost in the mail. Given these positive experiences, one would expect that more people would fill their prescriptions online. Even with all the reputable online pharmacy Web sites, a full 62% of Americans surveyed still believed that purchasing prescription drugs online was more dangerous than buying them at a local pharmacy. Only 20% felt online purchases were as safe.
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