Internet pharmacies

Abstract

Shopping on the internet has become routine for many people and covers a wide range of products and services. It is therefore unsurprising that, in some countries, medical and pharmaceutical services can also be bought. This has clear advantages in countries such as Australia, where some communities are isolated by huge distances (or other geographical circumstances) but are able to access the internet. However, shopping for psychotropic substances is not quite the same as shopping for toothpaste or televisions. These drugs are subject to strict controls, including the requirement for prescription by a qualified medical practitioner. It is possible to implement systems so that internet shopping for and mail delivery of psychotropic substances conform to regulatory requirements; if this is done, internet pharmacies can be valuable in ensuring an adequate supply of medical provisions to all citizens, wherever they live (US General Accounting Office, 2000). However, these same sales opportunities can easily be exploited by unlicensed internet pharmacies and it is the problems caused by these illicit ‘cyber-pharmacies’ that are now the cause of grave concern.

Firstly, there are concerns about the quality and cost of the drugs they dispense. Because they are unregulated, there are no guarantees of the quality of the pharmaceuticals that they sell, which may be counterfeits, produced anywhere in the world. Figures from the World Health Organization (2000) suggest that developing countries account for around 77% of all reported cases of counterfeit and substandard drugs. Intuitively, it might be expected that internet pharmacies would be cheaper than conventional, licensed premises because they do not incur the traditional overheads of premises and staff. However, investigations carried out in the United States and in a number of European countries reveal that illicit internet pharmacies are more expensive than licensed ones. Moreover, the costs incurred in shopping from them are unlikely to be refunded by national health systems if the drugs are obtained without prescription (International Narcotics Control Board, 2005).

However, the main concern about internet pharmacies is that they make it very easy to obtain prescription-only medicines without a prescription and there is evidence that they are being used in just this way. Investigations in the United States of illicit internet pharmacies show that the proportion of prescription drug sales within their total sale of pharmaceuticals is significantly higher than for the licensed traditional pharmacy. Indeed, some of the sites explicitly advertise that they provide prescription drugs without prescription or that the dispensing pharmacy will issue the prescription when the internet order is placed. These companies act in full awareness of the illegal nature of their trading, and work on the assumption that, owing to the huge amount of internet traffic and of physical shipments, only a fraction of illegal operations will ever be detected.

Some of the sites explicitly advertise that they provide prescription drugs without prescription or that the dispensing pharmacy will issue the prescription when the internet order is placed.

Even more worrying is the fact that the vast majority of sales of prescription drugs ordered over the internet – sometimes more than 95% – relate to internationally controlled psychotropic substances. This information is confirmed by data analysis and case studies undertaken in European and Asian countries, which have also confirmed that most are sold to people without requiring the prescriptions mandatory for psychotropic medicines (International Narcotics Control Board, 2005). Psychotropic substances such as benzodiazepines, central nervous system stimulants, sedative hypnotics, antidepressants and narcotic drugs are subject to very strict levels of international control, as many of them can have fatal consequences if consumed by patients who have not undergone medical examination. In addition to a range of side-effects, many have a high abuse potential and individuals may become unwittingly dependent on them if they take them without medical supervision. For those who are already dependent, it is possible to maintain their supply very easily because they can obtain their drugs by a simple mouse click. Indeed, drug-dependent individuals may see little need to seek professional help if they can obtain their drugs so easily. Measures put in place in various countries to help drug-dependent individuals are undermined by the ready availability of drugs on the internet and this can have far-reaching consequences for public health. Quite simply, psychiatric conditions and the use of psychotropic medication need professional supervision and there are obvious problems associated with self-medication by those with mental health problems.

The vast majority of sales of prescription drugs ordered over the internet – sometimes more than 95% – relate to internationally controlled psychotropic substances

A specific issue of grave concern is the impact on young people. As the vast majority of internet pharmacies despatch drugs without requiring a valid prescription or, in cases of online doctor consultations, without verifying personal details of the ‘patient’, there are no checks on the age of their customers. In countries such as the United States, illicit commerce over the internet has been identified as one of the major sources for the misuse of prescription medications among children and adolescents.

It is difficult to gauge the true scale of the internet pharmacy market but several billion doses of medicine are sold in this way. Systematic searches on the internet and evidence collected and analysed by regulatory and law-enforcement authorities indicate that the illicit sale of psychotropic drugs through the internet is a serious global problem, with total profits estimated to be billions of US dollars (International Narcotics Control Board, 2005). At present, most of the customers are in industrialised countries, where there is generally readier internet access. However, the scope of the market is clearly global because ordering over the internet with shipment by mail is, at present, unrestricted, as long as technical access is available. Therefore, there is an immediate risk of expansion to all parts of the world, with consequent exposure of the most vulnerable – individuals and countries – to unrestricted access to psychotropic and narcotic drugs without professional and regulatory supervision.

The solutions will have to be multifaceted, covering monitoring programmes, physician training and public education. Psychiatrists can and should play an important role in all these aspects.

It should be apparent to all that there is an urgent need to develop strategies to tackle these problems. The solutions will have to be multifaceted, covering monitoring programmes, physician training and public education. Psychiatrists can and should play an important role in all these aspects. The pharmaceutical industry, medical community and governments need to work in partnership and look for new initiatives and technologies to identify, investigate and prosecute illicit internet pharmacies.

Consumers need to be made aware that obtaining prescription-only medicines without prescription is illegal and that it can be medically dangerous. Equally, the judiciary will have to accord more importance and adequate penalties to illicit sales of pharmaceuticals, and especially of controlled drugs. However, it should be emphasised that enforcing existing laws in all countries would make a significant contribution to preventing the diversion of psychotropic drugs, and the competent authorities in all countries should therefore seek to identify and rectify weaknesses in their national regulatory systems as well as in their reporting and inspection procedures.

However, global problems usually require global action and the problems associated with internet pharmacies are no exception. Drugs can be ordered from anywhere in the world and shipped to anywhere in the world. Therefore, effective action requires close international cooperation and, above all, the political will of all governments to accord importance to the matter. Specifically, the anonymity conferred by the internet sets new challenges for those investigating the diversion of psychotropic drugs as well as for those responsible for its prevention. However, significant synergies could be achieved in concerted international effort through a wide range of regional and international organisations, such as Interpol, the World Customs Organization, the World Health Organization, the Universal Postal Union and the internet service providers, in addition to the medical and pharmaceutical establishments.

Thanks to Mr Koli Kouame, Ms Carmen Selva-Bartolome and Ms Gisela Wieser-Herbeck for their contribution to this article.

The United Nations International Narcotics Control Board brought the problem of illicit internet pharmacies to attention as early as the 1990s, and it has sought preventive measures. At its 50th session, in 1997, the World Health Assembly adopted a resolution requiring its member states to take action against the uncontrolled sale of pharmaceutical products on the internet. In July 2004, the United Nations Economic and Social Council urged member states to require companies within their national borders to supply internationally controlled psychotropic drugs via the internet only to persons who have met all the medical and legal requirements. It also encouraged the competent authorities to increase public awareness of the risks inherent in obtaining drugs in this way, particularly in relation to the uncertain quality of the products and the disadvantages of having no accompanying medical supervision (International Narcotics Control Board, 1997; United Nations Economic and Social Council, 2004).

The internet is revolutionising lives in the 21st century just as electricity and the telephone changed lives in the last century. As with many innovations, its advantages are accompanied by challenges, and this is undoubtedly true in relation to internet pharmacy. Well regulated, it has the potential to contribute to health service delivery; unregulated, it will be a major hazard to individual and public health. Committing a crime in an electronic environment – ‘cyber crime’ – is easy. Few resources are required and there is generally little danger of prosecution, because these crimes are notoriously difficult to detect and investigate, often across several jurisdictions. International cooperation is essential to prevent the internet turning into a World Wide Web of psychotropic drug trafficking and crime. Regulatory bodies must restructure themselves into operational and functional networks at a global level if they are to succeed in destroying organisations that are trafficking psychotropics. Professionals and the public should be vigilant about the mental health consequences of illicit pharmacy on the population in general and on those with mental health problems in particular.