Electronic Prescriptions: How Some Internet Pharmacies are Putting Your Health at Risk

Brooke Y. Patterson, Summer Student Intern 2002
Doctor of Pharmacy Candidate 2004,
Purdue University
School of Pharmacy and Pharmacal Sciences

"Order prescription medications from the comfort of your home-without a trip to the doctor's office!"

"Xenical... Phentermine... Propecia... No prior prescription required."

"Our US Physicians will write an FDA-approved prescription for you and the product will be shipped by a US-licensed pharmacist direct to your doorstep."

Welcome to the new age of Internet pharmacies-prescriptions without a physical exam-or even a visit to the doctor's office. As the amount of information on the Internet grows, so does the access to various forms of health care and now self-medication.

The Internet gives consumers and patients access to a large amount of helpful and often accurate health and drug information. It has also opened a doorway to risky online "pharmacies" that sell prescription drugs often at a high cost to the consumer in terms of both their pocketbook and their health.

Many community-based pharmacies such as Walgreens, CVS, and SavOn Drugs, have extended their services online to make it easier to get refills and to provide prescription-filling access to patients who might have trouble getting to a pharmacy. The online pharmacies of these companies fill prescriptions, provide patient information and dispense prescriptions. These pharmacy sites also provide valuable drug interaction information and patient prescription education as a part of their commitment to provide effective care to their patients.

However, a new breed of online pharmacies has appeared on the Internet that provide prescription medicines to patients based solely on an online questionnaire and NOT on a physical exam or office visit with a health professional. Many of the most popular medicines advertised on the Internet if given to the wrong patient could cause birth defects, dangerous blood pressure increases, strokes, and even heart attacks. These pharmacies may be providing strong medications that could lead to serious illness or death if used without the proper screening and monitoring only provided by a personal physician and pharmacist.

A DANGEROUS DOSE
Of the 10 most commonly purchased online drugs, five are drugs used for weight loss. Advertisements for Xenical, Meridia, Bontril, Tenuate and phentermine appear online. You might remember that phentermine was one of the drugs in the dangerous Fen-Phen combination that was removed from the market in 1997. To obtain one of these medications online, all a patient needs to do is answer a few questions and an "online doctor" will prescribe the desired medication. Sounds convenient, but the cost of that convenience could be hazardous to your health.

For example, phentermine is a prescription diet pill that is intended for short-term use in an overall diet plan to lose weight. Under the care and supervision of a physician and a pharmacist, it can be used safely and with minimal side effects. However, there are some important precautions that must be followed before starting this medication.

Phentermine should not be used by people with arteriosclerosis (hardening of the arteries), heart disease, high blood pressure, overactive thyroid, or glaucoma.¹ These are all medical conditions that must be diagnosed by a doctor and that could already exist in an otherwise healthy individual without their knowledge.

Most online pharmacy questionnaires do not ask the patient about these high-risk conditions and without an office visit, there is no way for online pharmacies to monitor for this. For doctors to write such online prescriptions without knowing the patient and their past medical history "is below the acceptable standard of care, " says American Medical Association Past-President and Executive Committee Member Richard Corlin.²

The typical online questionnaire asks an average of 8 to 10 questions covering a patient's general health. Most often, these questions are about a person's weight, height, and age. Very few questions are even about health conditions that might interfere with taking the prescribed drug. Questions that are specific to the medication, like "Do you have high blood pressure?" have only "yes" or "no" answering options. A person may not even know if they have high blood pressure without being diagnosed by an office visit to a doctor. The consequences of someone with unknown high blood pressure obtaining a drug online that is not for use by persons with high blood pressure could be severe and even fatal.

Phentermine is just one example of a growing number of drugs that are being prescribed without a physical exam and without the patient's safety in mind. Viagra, a popular drug to treat erectile dysfunction, is also being heavily prescribed via online pharmacies that only require the consumer to answer an online questionnaire. In fact, online prescribing of this drug, which is not recommended for those with certain heart problems, may have led to one man's death.

A 52-year-old Illinois man with a history of chest pain and a family history of heart disease died of a heart attack during sex after purchasing Viagra from an online pharmacy that only required an online consultation.³ Had he visited his physician to obtain this prescription drug, he would have undergone a physical exam that would have likely found his heart problems. His doctor could have then decided whether his heart problems made it too risky for him to take Viagra. Unfortunately, an online consultation cannot perform the type of test necessary to screen a person for such risk factors.

"Anybody who needs to use Viagra obviously has some medical problems," says Dr. Adolph Hutter, a cardiologist at Massachusetts General Hospital, "and should check with their doctor as to whether it's safe and appropriate."⁴

IS CONVENIENT ALWAYS CHEAPER?
Most online pharmacy websites advertise the convenience of obtaining a prescription drug without a visit to a doctor's office. But how much are consumers really paying for this "convenience"? Most websites charge an initial "consultation fee" that can range anywhere from $50 to $125. This consultation fee is charged on top of often inflated drug prices and shipping charges.

Take for example the drug Ultram, a pain medication. If a doctor prescribed a month's supply of 30 tablets, it would cost a patient about $35. A typical doctors visit (without insurance) will cost $80-100. With the prescription and the visit together, a patient might expect to pay $135.

If a patient were to buy this drug from one of these online pharmacies, they might expect to pay, on average, $80 for an initial "consultation fee"-nothing more than filling out a questionnaire. In addition, the cost of the drug would be close to $150 with another $25 for shipping and handling. Together, this is almost twice what the cost of getting the same medication from a doctor who based his/her prescription on your health history and personal interest would be.

For about $135, a patient gets an office visit with a physician that includes monitoring of vital signs and screening for health conditions. They also get a consultation with their pharmacist where potential drug interactions may be found and monitored. With an online consultation pharmacy, the consumer receives 30 pills in the mail-that's it. No consultation, no monitoring, no screening.

"This practice undermines safeguards of direct medical supervision and physical evaluation performed by a licensed health professional, " says Dr. Jeffrey Shuren, Medical Officer in the FDA Office of Policy, Planning and Legislation. "The Internet makes it easy to bypass this safety net."³

CONCERN FOR YOUR SAFETY
In 1999, the National Association of Boards of Pharmacy (NABP), which represents the official board that license pharmacies in each state, developed the Verified Internet Pharmacy Practice Sites (VIPPS) program.

To be VIPPS-certified, a pharmacy must comply with the laws and regulations of the state it operates in as well as of the states that it offers its services to. In most cases, this means following the rules and regulations of all 50 states. Some of the criteria to determine VIPPS certification includes patient privacy, availability of meaningful consultation with a pharmacist, online security , and quality assurance. To date, only 12 online pharmacies have active VIPPS certification.

Kevin Kincade, NABP Executive Committee Chairman, stated, "VIPPS will be of tremendous benefit to consumers who need to be certain that the prescription medications they receive are from legitimate online pharmacies."³

© 2002 Consumer Health Information Corporation. All rights reserved.

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