Availability of buprenorphine on the Internet for purchase without a prescription

Abstract

Background

Use of illicit buprenorphine is increasingly recognized, but it is unknown if the Internet currently represents an accessible source.

Methods

A series of Internet searches were conducted. Twenty searches were performed on two different search engines. The first 100 results of each search were classified into categories based on content. All Internet pharmacies were searched for buprenorphine preparations and if available, sites were examined to determine if a prescription was required for purchase, for the cost of buprenorphine, the geographical origin of the pharmacy, and evidence of validation by an online pharmacy verification service.

Results

Of the 2,000 links examined, 1422 were unique. Six percent of links were to illicit commercial sites, 2% were to legitimate commercial sites, and 2% were to illicit portal sites, which contained links to many illicit commercial sites. Twenty pharmacies offering buprenorphine for purchase without a prescription were identified. The monthly cost of a typical starting dose of 2 mg buprenorphine daily ranged between $232 and $1,163 USD. No pharmacies were listed by online pharmacy verification services.

Conclusion

Twenty online pharmacies advertising buprenorphine formulations for sale without a prescription were identified. Prices varied widely between illicit pharmacies but were uniformly more expensive than legitimate pharmacies. Illicitly obtained buprenorphine formulations appear to be relatively inaccessible and at high cost on the Internet.

1. INTRODUCTION

Illicit use of buprenorphine is increasingly recognized worldwide (Yokell et al., 2011). Obtaining buprenorphine from friends or buying it on the streets is commonly reported (Bazazi et al., 2011; Daniulaityte et al., 2012; Monte et al., 2009). However, it is unclear whether the Internet represents a potential source of buprenorphine. Previous research has documented that prescription opioids other than buprenorphine are available illicitly through the Internet (Forman, 2003, 2006; United States General Accounting Office, 2004), but studies examining buprenorphine’s availability through the Internet are few. We are also unaware of any studies documenting the availability of the buprenorphine/naloxone co-formulation, thought to have lower abuse potential. To address this, we conducted an Internet-based prevalence survey to estimate the number of Internet pharmacies that offered buprenorphine for purchase without a prescription.

2. METHODS

To examine the availability of buprenorphine on the Internet for purchase without a prescription we first conducted a series of searches using terms and methods previously described. We then classified websites into different categories based on the content of the websites. Finally, we examined cost of buprenorphine and geographic origin of websites.

2.1. Search strategy

Our search strategy was developed using previously described methods (Forman, 2003, 2006; Lott and Kovarik, 2010; Mahe et al., 2009; Mainous, III et al., 2009; Memmel et al., 2006; Schepis et al., 2008). Five separate searches were performed using the terms “no prescription buprenorphine,” “no prescription Suboxone,” “no prescription Subutex,” “no prescription Temgesic,” and “no prescription Buprenex” as well as an additional five searches replacing the words “no prescription” with “purchase without a prescription” (i.e., “purchase Suboxone without a prescription”). All ten searches were conducted separately using the Google (www.google.com) and Microsoft Bing (www.bing.com) search engines, totaling 20 searches. Google and Microsoft Bing were selected for these searches as together they are estimated to power over 90% of Internet searches performed in the United States (comScore Inc. 2011).

2.2. Classification of websites

In December 2011, the first 100 websites listed for each of the 20 searches, totaling 2000 websites, were examined and duplicate links were removed. The websites were then categorized as follows: (a) “illicit commercial” if prescription medications, including but not limited to buprenorphine, could be directly or indirectly purchased from that website without a prescription; (b) “illicit portal site” if the website was comprised of links to illicit commercial sites; (c) “legitimate commercial” if the website represented a licensed pharmacy requiring a prescription; (d) “informational” if the link only provided treatment-related information regarding buprenorphine; (e) “Internet forum” if the website was an online forum or message board for informal discussion on buprenorphine treatment or addiction or (f) “unrelated” if the website did not fit in one of the above categories (e.g., websites with broken links or in which the search terms did not appear). Advertised links were not considered, as their placement is paid for and not reflective of actual rank on the search engine. The illicit commercial, illicit portal sites and legitimate commercial sites were then examined six months after the initial searches (June 2012), to assess stability of the websites.

2.3. Illicit pharmacies

The prices of buprenorphine from illicit commercial sites and legitimate commercial sites were then compared by calculating the cost of a 30-day supply of 2 mg of buprenorphine, a potential starting dose for opioid dependence (Center for Substance Abuse Treatment, 2004). Prices are reported in USD and an exchange rate calculator was used if necessary (xe.com). To determine if purchase without a prescription was possible we proceeded with checkout, stopping only before payment information was required. All Internet pharmacies were examined for certifications by organizations such as the National Association of Boards of Pharmacy in the United States (the Verified Internet Pharmacy Practice Sites program) and the Canadian International Pharmacy Association (Liang and Mackey, 2009). Additionally, the illicit commercial sites were examined for claims of geographic origin and these were compared to registration information found using a WHOIS query, a standard Internet procedure for determining the registered owners of a domain name.

3. RESULTS

Of the 2000 search results, 578 (29%) were duplicate links. Of the 1422 unique links, the majority of sites were unrelated (48%), informational (29%) or internet fora (13%). Six percent of links were illicit commercial sites and 2% were illicit portal sites. Of the links to illicit commercial sites, 79% were still operational six months after the original search. Among the links to illicit portal sites, 74% were still operational after six months. All of the illicit commercial sites and portal sites that were deactivated between the original search and the reevaluation six months later offered other prescription medications but not buprenorphine for sale without a prescription.

Links to illicit commercial websites that remained operational led to 42 unique online illicit pharmacies, 14 (33%) of which sold buprenorphine. Examination of portal sites led to another 28 illicit pharmacies, six (21%) of which advertised buprenorphine for sale without a prescription. Of the links leading to legitimate commercial websites, there were 12 unique pharmacies identified, only two (17%) of which sold buprenorphine with a prescription, one in the Unites States and one in the United Kingdom. In summary, we found 20 illicit commercial pharmacies and two legitimate commercial pharmacies that advertised buprenorphine formulations for sale.

In all illicit commercial pharmacies identified, we were able to proceed with the purchase to the point of inquiry regarding payment information without any mention of requiring a valid prescription. No illicit commercial pharmacies were registered with online pharmacy verification programs. The illicit commercial pharmacies only sold buprenorphine in a 0.2 mg sublingual tablet formulation and the price for a 30-day supply of 2 mg of buprenorphine per day, the recommended starting dose, was calculated (Center for Substance Abuse Treatment, 2004). This dose required a total of 300 tablets monthly and the cost from these sites ranged from $232 to $1,163 USD. From the legitimate commercial site in the United States, a 30-day supply of 2 mg of buprenorphine per day was $105, and a 30-day supply of 2/0.5 mg of buprenorphine/naloxone was $135. The United Kingdom site offered a 30-day supply of 2 mg of buprenorphine for $62, and 2/0.5 mg of buprenorphine/naloxone for $58.

Among the 20 illicit commercial pharmacies, only one made a specific claim of geographic origin (United Kingdom). A WHOIS query confirmed that this domain was registered to an individual in the United Kingdom. All other pharmacies reported vague geographic origins (e.g., “overseas” or “international”) and those sites were subscribed to domain name privacy services which mask the country of registration.

4. DISCUSSION

In this Internet-based prevalence study, we found only twenty online pharmacies that advertised buprenorphine formulations for sale without a prescription. However, links to these sites only made up a small percentage of all search results. Illicit pharmacies only offered buprenorphine in a 0.2 mg tablet, originally used to treat pain rather than opioid dependence. Prices varied widely between the illicit pharmacies but the cost of medication was uniformly higher than with legitimate pharmacies. However, given that purchasing buprenorphine without a prescription avoids the cost of a physician visit, buprenorphine obtained this way may represent a net savings to patients. Nonetheless, while buprenorphine may be available over the Internet, it appears to be relatively inaccessible, at a potentially high cost, and in nonstandard pill sizes.

The quality and completeness of information on the illicit pharmacy websites was uniformly poor. In only one case was there an identified individual pharmacist contact. While pharmacies often employed imagery of medical professionals (e.g., persons in white coats recommending products), no website was registered with an online pharmacy verification program. In addition, all but one website was subscribed to a domain name privacy service, designed to obfuscate the owner and country of registration of the domain name. It was therefore impossible to determine the country of origin of most illicit pharmacies. Given these factors, there are clearly grave concerns about the purity and safety of the medication advertised.

In the US between 2006 and 2010, emergency department visits related to prescription opioids increased nearly 80%, and use of prescription opioids obtained illicitly is thought to be a contributing factor (Substance Abuse and Mental Health Services Administration (SAMHSA), 2012). Previous work has clearly demonstrated that the Internet is a potential source of illicit opioids (Forman et al., 2006; United States General Accounting Office, 2004). In previous studies, few illicit pharmacies selling buprenorphine were found, relative to the number of pharmacies selling other opioids (Forman et al., 2006). Despite recent reports of increasing use of illicit buprenorphine, the current study demonstrates that there is a relative scarcity of Internet pharmacies offering buprenorphine for purchase without a prescription.

This study has several important limitations. Our search strategy may not have identified all illicit commercial pharmacies. Several Internet fora we encountered mentioned members-only websites or pharmacies located in the so-called “darknet,” largely outside the reach of law enforcement (Goldberg, 2012). These may represent more reliable and less expensive sources of buprenorphine for members. We examined one hundred links for each Internet search performed in the current study, as in previous research, but the number of links a typical user would examine is unknown. In addition, as we did not actually purchase buprenorphine from the illicit pharmacies identified, we could not determine whether the product would be delivered as advertised and whether it would be suitable for human consumption. Despite this, successful delivery seems reasonably possible as a similar study revealed that 10 of 11 (91%) online orders placed for oxycodone and hydrocodone without a prescription were received (United States General Accounting Office, 2004).

In sum, despite recent increases in the use of illicit buprenorphine, an Internet search of 2000 links only yielded twenty illicit pharmacies offering buprenorphine for sale over the Internet without a prescription. These pharmacies were of questionable quality, high cost, and almost all were protected by services designed to obfuscate the country of origin. Illicit pharmacies that advertise buprenorphine do not appear to be a readily accessible, affordable, or reliable source of the drug.