Buying Drugs Online: Prescription for Controversy

For people looking to fill in the gaps left by an overburdened managed-health-care system, the Internet can be a valuable resource. But the sudden proliferation of Web sites touting miracle cures, diagnosing diseases and even prescribing and shipping drugs has health-care professionals and government agencies concerned.

"In just two days of surfing the Net, we found over 800 sites making blatant cure and treatment claims for serious diseases such as cancer, heart disease and AIDS," says Rich Cleland, senior staff attorney for the U.S. Federal Trade Commission (FTC). "And I'm afraid that's just the tip of the iceberg and the number is growing."

While the FTC will investigate sites making dubious claims, Cleland admits the agency doesn't have the resources to go after all offenders. "We can't carefully analyze every site on the Internet," he says. "There are just too many. We have to depend upon consumers and the industry to do their part as well."

And with health sites among the biggest draws online, with nearly 25 million patients using the Web to find medical information, mostly about specific illnesses and treatments, a new concern plaguing both the FTC and the U.S. Food and Drug Administration (FDA) is the flourishing online drug market. While sites like CVS/pharmacy and Drugstore.com simply act as online pharmacies filling prescriptions sent by patients or their doctors, other sites like ConfiMed.com are filling prescriptions written by cyberdoctors who have never examined the patients--raising both ethical and legal questions. Still other sites sell drugs with no physician-patient contact at all.

"Some sites will just plain sell you a drug with no doctor involvement, just as if you might buy a television set over the Internet, and that's illegal," says William Hubbard, senior associate commissioner for policy at the FDA. "And some sites purport to do some sort of medical screening by asking you questions and supposedly have a physician at the other end looking over your answers and then writing you a prescription."

Hubbard contends that may be illegal too. "Traditionally, the FDA, the medical profession and the states consider a valid prescription to be one that's written by a physician who has examined the patient. So the question is whether a patient can have a true medical relationship with a physician by answering a few questions over the Internet. Generally, the answer is going to be no."

Lifestyle Drugs in Demand

That doesn't seem to bother the thousands taking advantage of sites offering medical cyberconsultations, or those looking to obtain easy prescriptions for three new lifestyle-changing medications: Viagra, for erectile dysfunction; Propecia, for male baldness; and Xenical, for obesity. These drugs are proving to be so popular on the Web that in just one year, ConfiMed.com sold more than 10,000 prescriptions of Viagra and has recently launched another Web site called EatThin.com, which sells Xenical.

All anyone interested in these drugs has to do is answer a health-history questionnaire, which is reviewed by an anonymous online doctor; pay a one-time consultation fee, ranging from $30 for Xenical to $75 for Viagra; and submit a credit card number. If the prescription is approved, the drugs are charged to the card and sent by express mail, usually within 24 hours.

What if someone lies about his health status on the questionnaire? "If people want to lie and cheat and be untruthful to get something, they can generally get it," acknowledges Eric Thom, senior vice president of ConfiMed.com, based in Seattle. "We try to put in as many checks as we can in the questions we ask, but even if a fellow went to the doctor's office and filled out a questionnaire, he could still lie about his medical problems."

Maybe so, but Nancy Dickey, M.D., former president of the American Medical Association, says that virtual prescribing bypasses safety mechanisms built into the offline health-care relationship. "Prescribing for a patient implies that either I know the patient or we've had a doctor-patient interaction, so that I know what the diagnosis is and have selected an appropriate drug for that diagnosis. It also means I know what the potential complications of that drug are and have either talked to the patient or examined the patient to be sure he or she is not at particular risk for complications."

For men with heart disease, complications stemming from drugs like Viagra can be especially serious--sometimes even fatal. Since it was introduced in March 1998, over 100 men have died after taking the drug. "When we talk about instituting medical treatment based on your answering a list of questions, then you are missing the opportunity to question the doctor, and you're missing the doctor's opportunity to be sure that your examination fits with your description of what's going on," says Dr. Dickey.

And physical examinations will often detect the underlying causes for problems like erectile dysfunction, such as heart disease and diabetes. "There has been a tremendous increase in the early diagnosis of diabetes and cardiovascular disease in men because they come into their doctor's office to talk about their erectile problems," says Dr. Dickey. "And while the appropriate evaluation may demonstrate that they might benefit from Viagra, it will also show in the long run they will benefit from having their diabetes or cardiovascular disease treated."

Government Weighs In

Now Congress is considering legislation to regulate the practice of online prescribing, and state and federal agencies are stepping up their efforts to enforce existing laws related to online drug sales. Recently, Pfizer, the maker of Viagra, filed with the FTC a complaint asking it to take action against sites dispensing Viagra with prescriptions obtained from answering online questionnaires. State licensing boards in Arizona, Colorado, Connecticut, Illinois, Nevada, New Jersey, Ohio, Texas, Washington and Wyoming have started investigating physicians who prescribe drugs online without examining the patient. And some states are taking aggressive steps against online pharmacies: Kansas has filed a court order preventing ConfiMed.com from doing business there, and Missouri has filed an injunction preventing ThePillbox.com, a Texas-based company from shipping drugs into the state.

But perhaps even worse than having a cyberdoctor prescribe medication is not having a doctor at all. "What these Internet sites are doing is using a questionnaire and the ruse that they have a physician actually review the medical histories," says Carmen Catizone, executive director of the National Association of Boards of Pharmacy. "And we've found in some instances doctors aren't reviewing them at all. In one case the physician reviewing Viagra prescriptions was actually a retired veterinarian licensed to practice in Mexico."

Compounding the danger is a burgeoning black market fueled mostly by foreign companies selling everything from infertility drugs to antidepressants. "The foreign-based sites are the most dangerous," says Catizone. "If a doctor is not licensed in the U.S. or the site is not based in the U.S., that's a major problem because there's nothing we can do to them."

The FDA's Hubbard agrees. "Buying drugs directly off the Internet is taking a risk both with your pocketbook and with your health," he says. "If it's not a legitimate site, it might just take your money and run. Or if it does send you the drug, you might get a placebo, you might get a super- or subpotent version of the real thing. There is a great risk there."