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Internet pharmacies and online prescription drug sales: A cross-sectional study

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Internet pharmacies and online prescription drug sales: A cross-sectional study

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Psychonaut2002 is a European Union, multi-site research project to investigate the developing relationship between the Internet and drugs with abuse potential. This paper describes the findings of the Scotland research site, which investigated the online availability of prescription drugs. The project used a cross-sectional study to investigate 275 English-language websites, found by searching Google.com and AltaVista.com for ‘prescription drugs’. We found that online pharmacies selling prescription drugs can be classified into four types: (1) legitimate pharmacies; (2) subscription pharmacies; (3) lifestyle pharmacies; and (4) no-prescription pharmacies. The paper considers these findings in relation to what is already known about Internet access. We specifically consider the issues of literacy, Internet access, and credit-card ownership in relation to online pharmacies. We suggest that those from higher socioeconomic groups would be most able to access online pharmacies. However, drug abuse within this population may not be so readily recognized. Efforts to bridge the digital divide may increase access to Internet-sourced drugs amongst those in lower socioeconomic groups. We conclude that stereotypical notions of drug abuse being limited to lower socioeconomic groups may need to change. Increased Internet access may increase the role of the Internet in drug abuse.
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Internet Pharmacies and Online Prescription Drug Sales:
a cross-sectional study
CHRISTOPHER LITTLEJOHN
1
*, ALEX BALDACCHINO
1
,
FABRIZIO SCHIFANO
2
& PAULO DELUCA
2
1
Centre for Addiction Research and Education Scotland, Department of Psychiatry,
University of Dundee, Ninewells Hospital and Medical School, Dundee, UK;
2
Addictive Behaviour Section, Department of Mental Health, St George’s Hospital
Medical School, University of London, Cranmer Terrace, London, UK
ABSTRACT Psychonaut2002 is a European Union, multi-site research project to
investigate the developing relationship between the Internet and drugs with abuse
potential. This paper describes the findings of the Scotland research site, which investi-
gated the online availability of prescription drugs. The project used a cross-sectional study
to investigate 275 English-language websites, found by searching Google.com and
AltaVista.com for ‘prescription drugs’. We found that online pharmacies selling prescrip-
tion drugs can be classified into four types: (1) legitimate pharmacies; (2) subscription
pharmacies; (3) lifestyle pharmacies; and (4) no-prescription pharmacies. The paper
considers these findings in relation to what is already known about Internet access. We
specifically consider the issues of literacy, Internet access, and credit-card ownership in
relation to online pharmacies. We suggest that those from higher socioeconomic groups
would be most able to access online pharmacies. However, drug abuse within this
population may not be so readily recognized. Efforts to bridge the digital divide may
increase access to Internet-sourced drugs amongst those in lower socioeconomic groups.
We conclude that stereotypical notions of drug abuse being limited to lower socioeconomic
groups may need to change. Increased Internet access may increase the role of the Internet
in drug abuse.
Introduction
Traditionally, there are two identifiable illicit drug markets (Schifano et al., 2003).
The ‘street market’ usually provides heroin and crack cocaine, run by hierarchical
organized crime, using mobile phone communications, with all participants
controlled by the threat of actual violence. The ‘free market’ involves the selling
of cannabis and ecstasy amongst small groups of friends. With the advent of the
Internet, there is now the possibility of a third market, the ‘e-commerce market’,
where drugs are sold over the Internet (Schifano et al., 2003).
Drugs: education, prevention and policy ISSN 0968–7637 print/ISSN 1465–3370 online #2005 Taylor & Francis Ltd
http://www.tandf.co.uk/journals
DOI: 10.1080/0968763042000275326
Drugs: education, prevention and policy,
Vol. 12, No. 1, February 2005, 75–80
*Correspondence to: Christopher Littlejohn, Centre for Addiction Research and Education Scotland,
Department of Psychiatry, University of Dundee, Ninewells Hospital and Medical School, Dundee
DD1 9SY, UK. Tel: þ44 (0)1382 632121. Fax: þ44 (0)1382 633923. E-mail: christopher@clittlejohn.fslife.
co.uk
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Psychonaut 2002 is a European Union funded project for searching the Internet
for drug-related websites using a controlled search methodology (Schifano et al.,
2003). The project involves fifteen research centres from eleven European
countries. The web searches were conducted for all drugs (excluding alcohol)
in 2003. The websites found have been entered into a password-protected
database (www.psychonaut2002.org). This paper describes the findings of our
research centre. Our task was to search specifically for prescription drugs.
Following a brief description of the method, we describe our findings, and
then discuss the implications of the uncontrolled availability of prescription
drugs online.
Method
We used Google.com and AltaVista.com to search using the term ‘prescription
drugs’. This generated 1695 results. We visited the first 100 results from both
search engines. We also randomly sampled 5% of the remaining results. In total
we visited 275 websites. We entered data on each website visited into the
Psychonaut database (Table 1).
Table 1. Psychonaut database information
URL of the page
Web page name
URL of the site
Web site name
Organization
Country
How found
How often quoted
Search engine
Ranking
Key word
Date of access
Language
Substances
Type of site
Pro- or anti-drug position
Reasons
Audience
Reference to scientific papers reports, studies
New drugs
How to synthesize/grow
How to use
Warnings or disclaimers
Chat or discussion groups
Links
Sponsors/Ads
Last update
Number of visitors
How old
How to buy
General comments
Do law enforcement need to be informed?
Time spent on line
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Results
Nearly one in three (29.6%) of the websites we visited offered prescription drugs
for sale online. These websites formed four distinct groups:
1. Legitimate pharmacies (Table 2). These websites were the online equivalent of
the high street pharmacies. They would mail medications to patients only as
long as patients produced a valid medical prescription. Many of the sites we
found were Canadian pharmacies marketing lower prices to patients from the
United States. They capitalized on favourable price differences between the
two countries. Generally these online pharmacies stated that they would
not supply controlled prescription drugs, such as opioids, methylphenidate
(Ritalin), or benzodiazepines.
2. Subscription pharmacies (Table 3). These websites promise access to online
pharmacies selling unlimited prescription drugs without prescription, in return
for a subscription fee paid online by credit card. These pharmacies are
described as being located in unregulated areas of the world, such as Mexico
or Asia. These sites do not sell or deliver the drugs themselves.
3. Lifestyle pharmacies (Table 4). These websites offer to supply a limited list of
‘lifestyle’ drugs direct to the patient. Often the website will provide a prescrip-
tion for the drug following an ‘online consultation’. Usually this involves the
patient filling in an online form on the website with their symptoms or
diagnosis, and submitting this along with their order and credit card details.
The website company then mails the drugs directly to the patient. Common
drugs on sale include sildenfil (Viagra) for impotence; finasteride (Propecia) for
male pattern balding; phentermine (Adipex) for obesity; rofecoxib (Vioxx), a
non-steroidal anti-inflammatory analgesic; tramadol, an opioid analgesic; and
antidepressants such as fluoxetine, paroxetine or sertraline. These sites are
commonly interlinked, and clicking to buy a drug on one site can automatically
link to the purchasing screen on another. One reason for this may be that
increasing the number of links to a website increases the prominence it will
receive on search engines such as Google.com. Also, the web designers of these
sites also include unseen keywords (called meta-tags) that search engines use to
index their content. They commonly include controlled prescription drugs in
these metatags, so that their pages appear when searches are run for these
Table 3. Subscription pharmacies
www.1–800prescriptiondrugs.com
www.buyxanaxonline.com/mexican
www.mexican-pharmacy-list.com
www.online-drug-source.com
Table 2. Legitimate pharmacies
http://www.canadadrugs.com/
http://www.prescriptiondrugscanada.com
http://www.rx1.biz
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controlled drugs, even though the websites do not actually offer these drugs
for sale.
4. No-prescription pharmacies (Table 5). While less numerous than the lifestyle
websites, there are online pharmacies that offer to mail controlled drugs
to patients with no prescription. Such sites offer drugs such as opioids,
benzodiazepines, and methylphenidate in return for online, credit-card
payment.
Discussion
Although our search used only a single search term, we still found a large number
of websites offering drugs for sale online. We presume that a more targeted
search, using multiple search terms (e.g. ‘buy opioids’; ‘buy opioids no prescrip-
tion’; ‘buy oxycodone’; ‘buy Ritalin’; etc.) would have resulted in even greater
numbers of websites. However, this form of searching was beyond both our
resources and methodological remit.
Table 4. Lifestyle pharmacies
www.albany-clinic.co.uk/
www.betterpills.com
www.buy-cheap-prescription-drugs-and-viagra-online.com
www.buy-cheap-rx.com
www.cyber-med.com
www.nextdaypharmacy.net
www.onlinemedicine.com
www.pharmacy-one.com
www.planetpillstore.com
www.prescription-drugs.us
www.prescriptiondrugsonline.net
www.prescriptioner.com
www.prescriptionmd.com
www.prescription-online-drugs.com
www.thedrugstoreonline.com
www.usefuldrugs.com
www.vigor-ex.com
www.weight-loss-prescription-drugs.com
Table 5. No-prescription pharmacies
www.abcweightloss.net
www.clicksmeds.com
www.cydrugs.com
www.eprescribe.com
www.e-rx.net
www.getdrugsonline.com
www.medsindialtd.com
www.medprescribe.com
price-rx.com
www.webmedrx.com
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We did not attempt to purchase drugs from any of these websites. This is
a potential limitation, as we are therefore unable to attest to their genuineness.
It is quite possible that some websites would take customers’ money without
delivering what was promised.
When we considered the question of who might use these online pharmacies,
there are at least three prerequisites. These are: (1) literacy; (2) Internet access; and
(3) credit-card ownership.
Literacy
Using the Internet to order drugs requires basic literacy and numeracy skills. The
recent International Adult Literacy Survey tested participants’ literacy and numer-
acy skills, scoring them from level 1 (poor) to level 5 (excellent) (Fawcett, 2003).
Half of the British participants scored level 1 or level 2, ‘which means that they
are basically unable to function in everyday tasks’ (Fawcett, 2003). Given that
socioeconomic deprivation increases the likelihood of scoring such a low level
(Fawcett, 2003), it seems likely that those who have the skills to use the Internet
are also from higher socioeconomic groups.
Internet Access
The British Education Communications and Technology Agency (BECTA) is the
British Government’s lead agency for Information and Communications Tech-
nology (ICT). According to their figures, 30% of British homes overall had access
to the Internet in 2001 (BECTA, 2001). However, this was as high as 53% for social
class AB, and as low as 12% for social class DE. The largest increases in Internet
access has been seen in those with highest incomes. Twice as many in social class
DE have never used a PC compared to those in social class AB. Those in
employment have twice the Internet access as the unemployed. Home owners
are more likely to have Internet access than renters. Only 4% of council tenants
have Internet access.
Credit-card Ownership
According to Datamonitor, there are 8.3 million people in the UK who cannot
obtain ‘High Street’ credit (Palmer & Conaty, 2002). These people are largely from
the poorest socioeconomic sections of society. As a result, low socioeconomic
status is associated with low credit card ownership.
So, Who Uses Internet Prescription Drug Sites?
Those who meet the prerequisites of literacy, Internet access, and credit-card
ownership, are most likely to come from the socioeconomically privileged
sections of society, where high levels of education and employment are likely
to be the rule rather than the exception. Those in this group may be most likely
to comprise that group of ‘expert patient’ who presents in healthcare settings,
‘clutching a sheaf of printouts from the Internet, demanding a particular treat-
ment that is unproved, manifestly unsuitable, astronomically expensive, or all
three’ (Shaw & Baker, 2004). Online health information can make self-diagnosis
Internet and Prescription Drug Abuse 79
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appear dangerously easy. We expect that the online prescribed drug sites are
popular amongst this patient group when their treatment demands are refused.
One possible side-effect of efforts to increase literacy, and equality of access to
the Internet and mainstream financial services, may be to increase access to
Internet-sourced drugs among those in lower socioeconomic groups.
Conclusion
Clinicians are all too familiar with the drug abuse and its associated consequences
in the socioeconomically deprived patient population. Measures to bridge the
‘digital divide’, to bring equal Internet access to those in lower socioeconomic
groups, may well increase the illicit availability of prescription drugs to those with
existing drug abuse. However, the Internet may also be introducing a new
phenomenon: illicit prescription drug abuse amongst the higher socioeconomic
groups. It may not be long before we see patients presenting with the negative
consequences of this use. Yet, would opioid withdrawals be immediately
recognized as such in the well-educated, employed, otherwise ‘respectable’
middle-class patient? Our stereotypical image of the ‘drug abusing patient’ may
need to change.
Acknowledgements
This paper has been supported by grant number SPC 2002 306 (2002–2004) of the
EU’s DG Public Health and Risk Assessment. The conclusion and interpretation of
the findings of this study reflect the authors’ views and the Commission is not
liable for any use that may be made of the information contained in this
publication.
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... This may not always be the case, however. For example, individuals who order medications -often SSFFCs-from no-prescription websites tend to be literate and have relatively high socioeconomic status [50,51]. Although price incentives are often cited as a reason for online medication purchases (94% of which tend to be fake), for some medications, SFM online versions can be more expensive (40-65% higher) than genuine brands [18]. ...
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The 'Digital Divide': a discussion paper
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