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WHAT SHOULD BE DONE AND WHAT ARE WE DOING TO STOP ON SUPERVISED MEDICINE USE AND BETTER PROTECT OUR PATIENTS?

The patients can buy prescription medications without a prescription from up to 85% of our main pharmacies. These figures coming from independent and nonprofit research suggest that there is a potential for serious misuse of medications by Internet drug purchasers. What should be done and what are we doing to stop on supervised medicine use and better protect our patients? You are listening to ReachMD XM160, The Channel For Medical Professionals. Welcome to Focus On Pharmacy. I am your host, Charles Turck, PharmD. Our guest is Susan Foster, Vice President and Director of Policy Research and Analysis At The National Center On Addiction and Substance Abuse (CASA) at Columbia University. Ms. Foster oversaw the preparation of one of the center’s most recent reports, You Have Got Drugs about illegal drug commerce from the Internet.

DR. CHARLES TURCK:

Welcome Ms. Foster.

MS. FOSTER:

Thanks so much.

DR. CHARLES TURCK:

We are discussing the availability of prescription medications on the Internet. If you would, Ms. Foster, just give a little background about the report that you have tried?

MS. FOSTER:

Well, it is here for the last 5 years. We have been monitoring online access to control prescription drugs without a prescription and this July we released the fifth in our series looking at how easy it is to go online, order, control prescription drugs without a prescription and receive them. We found out that in fact, the Internet seems to be a <_____>candy store for acquiring prescription drugs online. This study grew out of a larger encore we did about several years ago looking at the larger issue of the diversion and abuse of controlled prescription drugs in the United States.

DR. CHARLES TURCK:

Let us call them, legitimate and rogue pharmacy just to distinguish. How exactly do rogue pharmacies online technically violate the law?

MS. FOSTER:

To comply with the law they have to actually comply with the Federal Controlled Substances Act and that act says that it is unlawful for any one knowingly or intentionally to possess the controlled substance unless it was obtained pursuant to a valid prescription from a practitioner who is operating the course of his or her regular professional practice. So, the Drug Enforcement Administration with the full support of medical and pharmacy practice groups has interpreted acting in the course of professional practice to main4 things:

1. That the patient has a medical compliant.

2. That the physician takes a medical history.

3. The physician performed a physical exam.

4. That there is a logically connection between the complaint, the history, the exam, and the drug prescribed and simply offering a drug online does not comply with that standard of interpretation of the law.

DR. CHARLES TURCK:

So, some websites nowadays offer what they call online consultations. Do those constitute a legitimate doctor patient relationship in the eyes of the law even if the consultation is conducted by a physician via the Internet?

MS. FOSTER:

There are only a few examples where that could be considered legitimate. For example, in remote rural areas where there is a physician practice that is an online Internet based where you have healthcare professionals in a rural area and then the physician is actually supervising the patient's medical complaint, the history, the exam, and then prescribing as a result of that, but that is operating in accordance with all other standards of medical practice. When it comes to these online consultations through rogue pharmacies none of that is occurring. You are usually simply filling out a simple form asking you basic information about yourself and then what kind of drug you wanted, why, and then you receiving that drug with regard to virtually anything else on the form. An example is included when we first started this work. We did it in concert with an investigative firm here in the city called Beau Dietl & Associates. They actually ordered the drug and they would enter into these websites the name of a child and put in the age and the height and weight of a child and then request a heavy duty pain reliever and indicate that the pain was may be a 9 on a scale of 1 to 10 and actually receive the drug as a result. Those practices are not used much because the DEA <_____> , so other than anecdote we do not really know, but we are aware that those online consultations that operate in that way are considered illegal.

DR. CHARLES TURCK:

So say, we have a 13-year-old child. Based on past experience, you found that it actually is possible for somebody to truthfully report their age and still get a medication without a prescription technically?

MS. FOSTER:

Beau Dietl & Associates found that out, yeah.

DR. CHARLES TURCK:

Which drug classes containing controlled substances are most commonly offered by Internet sites?

MS. FOSTER:

All research looked at pain relievers, central nervous system depressants, and stimulant drugs. What we found is that the most frequently offered class of drugs are the benzodiazepines, usually the anti-anxiety and central nervous system depressants followed by the pain relievers. Those are the 2 sets of largest offerings, and then in line next you find the stimulants.

DR. CHARLES TURCK:

Do rogue online pharmacies ever take steps toward tricking consumers and to thinking that they are purchasing medications from a legitimate website?

MS. FOSTER:

Our sense is that yes they do and they operate in a variety of ways:

1. They may have a more legitimate firm front for them and then when you get the controlled drug purchase you switch to another site which you or may not know. So, there might be some collision between sites. So, you might have one that is approved through some process such as pharmacy checker or something like that, which tries to identify legitimate sites for the Internet search engines. We found that even with that kind of a checking device, you usually get ads for rogue pharmacy. So, that is one way they do it and another way they do is to create logos that appear legitimate. So, they might have the Food and Drug Administration or the US Department of Health and Human Services logo or they might make up a logo by something like approved by the American Drug Administration, which does not seem to exist. Anything to make a consumer appear or think that this is a more legitimate site. Now, there are some sites that just clearly do not make any effort to disguise what they are doing. They will advertise things like, you know, we are happy to ship this in a brown paper bag to you or we are happy if you buy it now, you will get double the number of Vicodin or something like that. So, it is really depending on the network operating the site how blatant they are.

If you are just joining us, you are listening to Focus on Pharmacy on ReachMD XM160. I am your host, Dr. Charles Turck. Our guest is Susan Foster, Vice President and Director of Policy Research And Analysis At The National Center On Addiction and Substance Abuse at Columbia University. Ms. Foster directed the preparation of the center’s most recent, You Have Got Drugs, a report and spurious drug sales on the web. We are discussing some more unsavory aspects of Internet drug commerce.

DR. CHARLES TURCK:

Ms. Foster, you have mentioned just a little bit earlier about purchasers or potential purchasers being directed from one website to another without even necessarily knowing that they are going to different websites. Are we struck by how the morphing nature of the Internet and going from website to website is one of the aspects that probably makes it difficult to keep track of these websites between years?

MS. FOSTER:

Another issue is the persistence of these anchor sites or the sale sites. When we first started looking at this in 2004, we tried to keep track of how many of those same sites are still in operation in each year and by the time we did this report this year, only 2% of those original sites were still operating. So, they often change their names or their URLs just to avoid detection. I think it is interesting to know that there is some effort under way by the financial institutions to try to limit the use of their brand, to pay for these drugs. It used to be when we first looked at this with the click of a mouse and a credit card you could get what you wanted. For this time, the 4 financial institutions that was Mastercard, Visa, American Express and Paypal collaborated with us and we gave them a sample of the sites we found that advertise their brand, which is another way that they try to make themselves look legitimate, but when these financial institutions attempted to process a purchase with their cards, a very small percentage of them actually even attempted to make the payment transaction. So, that we hope is good news that the financial institutions or at least these 4 are having some success in limiting use of their cards. At the same time, we see an increasing use of things like e-checks and regular bank checks, cash on delivery seems to be back in fashion and other payment mechanisms like Western Union as ways to buy the drugs.

DR. CHARLES TURCK:

How are the search engines been playing long enough efforts to tamp down illicit drug commerce.

MS. FOSTER:

Well, the Internet search engines, really the top 3 that account for most of the Internet searches are Yahoo, Google, and MSN live search. They report that they use an organization called pharmacy checker, which is a company to attempts to identify legitimate versus illegitimate pharmacies and then screens ads for those pharmacies that they deem to be legitimate. Unfortunately, many, many rogue sites get through that process. In our own work, we were able to identify ads that had gotten through their checking process, but will for rogue sites. So, our organization in the National Center of Addiction and Substance Abuse, our president Joseph Califano, has written to the heads of the Internet search engines asking them to take strong action to try to limit the use of their search engines to aid in this process.

DR. CHARLES TURCK:

So, we are talking about the role that organizations or companies have played in keeping non-prescribed medications out of the hands of consumers or at least the increasing role that they have played over the last couple of years. How about actions taken by the government in either the executive or legislative branch?

MS. FOSTER:

Well, the DEA and the FBI report continuing their law enforcement activities to attempt to crack down on rogue sites. There has been some effort on the part of the Office of National Drug Control Policy, the DEA, and the Food and Drug Administration to put more public service announcements that automatically appear during Internet searches. We recommend that those should be broadened and expanded. We also know that this year the Senate Judiciary Committee <_____> sessions have introduced legislation to try and control

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