Not a day goes by when our email inboxes do not fill with advertisements for prescription drugs. Many of these emails promise to deliver drugs of all classes by overnight courier without a prescription. While there are legitimate online pharmacies, and the practice of telemedicine or cyber-medicine is gaining acceptance, this change in the way medicine is being practiced is rocking the foundations of the medical establishment. Being able to consult a doctor online, and obtain prescription drugs delivered to your doorstep by UPS has broad social and legal implications. The Internet facilitates making drugs available to those who may not be able to afford to pay US prices, are embarrassed to see a doctor face-to-face, or are suffering from pain, the treatment of which puts most doctors in direct conflict with the ‘war on drugs’ but on the other hand there is the question whether these pharmacies make drugs available to recreational drug users without the oversight of a licensed medical practitioner.
The Need for Alternatives
Medical care in the US has reached a point where it is expensive and impersonal which has caused the consumer to become generally unsatisfied with the medical establishment as a whole. Examples include the huge differences between the cost of drugs in the US and Canada, long wait times in US pharmacies, and poor service in general. Perhaps realizing this, US customs appears to tolerate the millions of Americans that visit Canada every year to buy their medications, as for the most part, these ‘drug buyers’ are elderly American’s that can’t afford the high cost of filling their prescriptions in the US.
Rather than to travel to Canada or Mexico millions of Americans are now turning to the Internet for both their medical needs. Telemedicine (or cyber medicine) provides consumers with the ability to both consult with a doctor online and order drugs over the Internet at discounted prices. This has resulted in consumers turning to online pharmacies for their medical needs, and in particular pharmacies with a relationships with a physician, which allow the consumer to completely bypass the traditional brick and mortar pharmacies, with the added benefit of having their physician act as an intermediary between the consumer and the pharmacy. According to Johnson (2005) this is as a result of consumers becoming very dissatisfied when it comes to dealing with both brick and mortar pharmacies and medical practitioners. As Johnson, notes, “Consumers are more likely to know the name of their hairdresser than their pharmacist.” When Johnson (2005) rated the various professions within the health care system, he found that pharmacists had the lowest interaction with their patients than did any other group. Today, as a result of this “consumers are buying 25.5 percent of their prescriptions online, opposed to 13.5 percent of which are picked up at a brick and mortar pharmacy” (Johnson 2005).
Drugs and Society
What has brought so much attention to online pharmacies is that it is possible to obtain just about any drug without a prescription online. Many of these prescriptions are for legitimate purposes purchased through an online pharmacy because the buyer is too embarrassed to visit the doctor or for other reasons including the unavailability of FDA approved drugs to the consumer. These drugs may include steroids that due to their misuse and being classed as a classed a category three drugs, are seldom prescribed by physicians. These drugs have a useful purpose to those suffering from any wasting disease such as AIDS, they also play a role in ant-aging (FDA, 2004).
The Doctor Patient Relationship
Today a visit to a doctor is generally brief, much of the triage it is done by a nurse or a nurse practitioner with the doctor only dropping in for a few minutes, if at all. In many cases the patient is seen by a nurse practitioner. One of the arguments against telemedicine or perhaps a better term is cyber-medicine, is that the doctor does not have a physical relationship with the patients and thus is in no position to make a diagnosis, and thus can not legally prescribe drugs.
Ironically when one compares the work up that one has to go through to consult with an online physicians and compares this to a face-to-face visit with a brick and mortar doctor, one finds that the online physician, in many cases, has a better understanding of the patient’s medical condition than does the doctor who meets face-to-face with the patient. In most cases before an on-line a doctor prescribes any type of medication they insist on a full blood workup they may also require that one has additional tests performed, for example.
The AMA, the federal government, and various states claim, however, that it is illegal for a doctor to prescribe drugs without a valid doctor-patient relationship. While there are no laws at present that outlaw online pharmacies, various states have enacted legislation, or are in the process of enacting legislation to prohibit a doctor from prescribing drugs to a patient that they have not seen face to face. Some states also require that the doctor that prescribes the drugs be licensed in their state. This alone could hamper the development of cyber-medicine. According to William Hubbard (2004), FDA associate commissioner “The Food and Drug Administration says it is giving states first crack at legal action, though it will step in when states do not act” (FDA, 2004).
The reason that email boxes around the country fill up with offers to supply drugs of all kinds, at reduced prices, without prescriptions, and more is because people buy them as the billions of dollars the drug companies are making each year attest to. The Internet has become the drug store of choice for many.
Categories of Internet Pharmacies
Internet pharmacies are generally acknowledged to be comprised of the following five categories:
Internet pharmacies can be divided up into five different categories, as follows:
Licensed online pharmacies with a no medical affiliation.
Licensed online pharmacies with a medical affiliation
No record online pharmacies (NRP)
International online pharmacies (IOP)
Licensed compounding pharmacies
The licensed online pharmacies with a no medical affiliation are of course Drugstore.com, CVV, and others. They all require a prescription from a licensed doctor that the patient has a doctor patient relationship with. The prescription can be called in by the doctor.
The licensed online pharmacies with a medical affiliation often depend on a broker. The broker collects your medical information, and then assigns your case to one of their networked physicians. Many of these networked physicians are willing to prescribe pain killers as they believe that it is only through the use of these drugs that some people can live a harmonious life.
A Government Accountability Office (GAO) Committee on aging held in June 2004 found that “Unlicensed international pharmacies do not require a prescription, and are generally located off shore.” No prescription pharmacies can be found all over the world. Many of these sites have come under controversy as in some cases all it takes to have that prescription delivered to you by next day air, is to fill out a questionnaire online.
A study conducted by Henkle in 2002 to ascertain how easy it would be to obtain drugs over the Internet found that “37 of the 46″ pharmacy required a prescription from a licensed doctor. The emphasis was on the prescription and not on the doctor. Henkle (2002) in fact notes that some sites offered to recommend a doctor.” Henkle (2002) was able to obtain prescription drugs from nine sites outside the US during the study, without a prescription.
Online pharmacies with a doctor affiliation
There are a number of online pharmacies, with a medical affiliation is that take great pain to differentiate themselves form unlicensed overseas pharmacies. These pharmacies, stress that they are “American based companies that provides consumer’s easy access to FDA approved online prescriptions over the Internet and are quick to point out that “An online consultation can be just as relevant as an in-person consultation.” It is interesting to note that many of these online pharmacies also point out that “While they are committed to making access to online prescriptions easier, they believe that the Internet can not replace the importance of regular doctor visits to fully evaluate your health and any medical conditions.” Many of these online pharmacy sites also makes a wealth of drug information available on its web site that enables the consumer to educate themselves on drugs that may have been prescribed. The Internet has for all intensive purposes is quickly replacing the brick and mortar base physician as a patient’s primary health care provider.
A sales pitch, of course, or is it? Most of the legitimate online pharmacies ensure that they comply with state and federal regulation. The doctors are licensed in all 50 states and their pharmacies are too. These legitimate Internet pharmacies cater to those that are looking for a better price; for some it comes down to making the choice of eating cat food on crackers in order to afford their medications because of the high US drug prices. In other cases patients resort to cyber-medicine to avoid the embarrassment of having to deal with a physician or pharmacy that may be judgmental. Many of these online pharmacies will arrange a consult with a licensed, medical doctor over the phone and will then fill the prescription accordingly.