The Wild, Wild Web for Prescription Drugs

They say there’s nothing you can’t buy on the Internet. Perhaps. But the real question is whether you should, particularly if the products on offer are sometimes-dangerous prescription drugs.

Among its billions of web pages, the web contains a mini-growth industry in prescription drug sales. That much of this industry has its sights trained on the United States should be no surprise: Americans use prescription drugs heavily and, thanks to the failure of the government to restrict prices or profits (as is done in most developed countries), we pay more for them.

Some consumers have responded to drug company pricing double-standards by hopping a bus and heading north to Canada, but for most people in the United States, this will not be feasible. A trip to your computer terminal, however, puts you instantly in touch with dozens of drug-selling operations, all eager for your business. But can you trust them?

The General Accounting Office (GAO), an investigative branch of Congress, recently conducted a study examining the practices of Internet pharmacy sales. The results should give pause to anyone contemplating succumbing to the allure of the less-expensive products on offer on the web.

The GAO identified 13 drugs of particular interest and filed orders with 90 different pharmacies around the world; in the end, 68 drugs were received. The top-selling drugs like Celebrex, Lipitor and (of course!) Viagra were generally widely available, but drugs requiring patient monitoring to protect patient safety (Accutane, Clozaril) and narcotic pain relievers (e.g., OxyContin, Percocet) were tougher to find.

Of six pharmacies that accepted payments for the drug and that never filled the order, none were located in the United States or Canada. Not one of the 21 drugs obtained from outside the U.S. or Canada (e.g., from Argentina, Costa Rica, Fiji, India, Mexico, Pakistan, Philippines, Spain, Thailand and Turkey) included a product label, and only six contained warning information. Most improperly shipped drugs came from these countries as well: insulin that was not refrigerated, moisture-sensitive drugs that were not sealed, drugs hidden in compact disc cases and drugs labeled as “dye and stain remover wax.”

But the U.S. and Canadian sites were certainly not immune from problems. Sixteen of 18 Canadian drugs did not comply with U.S. regulations in that the packaging or labeling had not been approved by the U.S. Food and Drug Administration (FDA) or the agency had not inspected the manufacturing plant. (These drugs may well have met the requirements of Canadian regulatory authorities; and Canadian labeling is quite similar to that in the United States.) However, all 29 U.S. and all 18 Canadian drugs proved to have the proper amount of the active ingredient, while four of the other foreign drugs did not.

Where the U.S. proved particularly inadequate was in the realm of the requirement for a prescription. Internet pharmacies are usually divided into three groups: 1. those to whom you have to mail a prescription; 2. those that have you fill out a questionnaire online and that, without ever examining you, dispense the drug; and 3. those that don’t even maintain the pretense of a questionnaire and simply provide the drugs. Most states consider the latter two options to constitute an improper practice of medicine but have generally failed to discipline those physicians lending their names to such schemes. Only five of the 29 U.S. sites required a prescription, with the remainder requiring the online questionnaire. Three of the non-Canadian foreign sites required a questionnaire, but the remaining 18 simply mailed the drugs. In contrast, every Canadian pharmacy required a prescription from the patient’s own physician, the most reputable option.

The U.S. government, at least, seems to suspect that illegal activity is rife in this industry. Fourteen of the 68 pharmacies (nine U.S., one Canadian and four other foreign countries) were under investigation by either the U.S. FDA or the Drug Enforcement Administration for allegations of selling controlled substances without a prescription, lack of a doctor-patient relationship, selling adulterated or counterfeit drugs, smuggling, mail fraud, etc.

Given the way the drugs were obtained, it is difficult to make general statements about the reliability of different countries’ Internet sites. The most reliable predictor of web site quality appears to be whether or not it requires a prescription from your own doctor. Ironically, given the current focus on drug importation, the GAO data suggest that, on this measure at least (and assuming you are willing to accept Canadian regulatory standards as equivalent to those in the United States), if you’re going to hop on a virtual Internet bus, it would be best if it were pointed North.