Review of Research Literature

The Internet and Drug Availability

With more than 200 million internet users in the United States and about 117 million individuals going online every week [1] the internet is a vital medium for communication, entertainment, and commerce. The Pew Internet & American Life Project reported in 2005 that 87% of 12–17 year old teenagers, and 73% of all adult Americans use the internet [2]. Just like television, radio and print media, the internet provides the public with information, entertainment, and advertisements. The internet differs from all other media, however, in at least one important way: it enables customers from around the world to shop with relative anonymity in a global marketplace. 

About half of all adult Americans take a prescription medication regularly, and one in four have used the internet to learn about prescription medications. The majority of Americans have greater confidence in their local pharmacy than internet-based pharmacies, and only about 4% report having purchased medications online [3].

In addition to being a valuable source of information, communication, and recreation, the internet also is being used to disseminate drug-related information and sell controlled substances without prescriptions. Drug information websites can emphasize the benefits of drug use and provide information on how to manufacture, acquire and use drugs such as marijuana, ecstasy and GHB. According to Gordon, Forman, and Siatkowski, it is possible that use of the internet to acquire drugs may be more prevalent among individuals who are non-dependent, particularly so called “recreational drug users” and substance abusers [4].

A wide range of controlled substances are offered for sale online including stimulants, steroids, sedatives, hallucinogens and marijuana [5]. No prescription websites (NPWs) are online pharmacies that supply consumers with controlled substances without a valid prescription. There are two general categories of NPWs: Retail NPWs directly offer to sell opioid medications without prescription while Portal NPWs provide multiple links to Retail NPWs. Gordon, Forman, and Siatkowski found that the majority of the NPWs identified in monitoring studies conducted since 2003 were classified as Portals. 

While legitimate online pharmacies require a valid prescription from the consumer’s physician, there are hundreds of NPWs that sell prescription medications based solely on an online questionnaire, a telephone interview, or a simple online order without any interaction with a physician or other licensed healthcare professional. To assess the relative availability of NPWs versus websites that offered addiction health information (e.g. WebMD), during the first two weeks of August 2004, Gordon, Forman, and Siatkowski conducted 27 Google searches using a wide variety of opioid search terms. Two search terms—no prescription Vicodin, and no prescription hydrocodone –yielded 80-90% NPWs and no links to addiction health information websites. On the other hand several opioid medications including Fentanyl, Duragesic, buprenorphine, and Subutex – with and without the no prescription prefix—yielded a majority of addiction health information websites and few or no NPWs.

Beyond qualitative examinations of typical NPWs, there has been no systematic study of the content of current Retail NPWs. Forman and Block [6] looked at fifty NPWs by examining links within the top three portal NPWs identified during a search in June 2005. During the coding process, any website found to be a legitimate retailer that only sold medication to customers with a doctor’s prescription was eliminated from consideration and replaced by the next linked website until a total of fifty NPWs were reached. Nearly all (92%) of the NPWs contained an implied legitimacy or credibility claim of some kind. Over 80% of NPWs contained a medical legitimacy claim (82%). Fewer NPWs displayed a retailer legitimacy claim (24%). 88% of NPWs accept payment via one of the major credit cards and over half (52%) mention delivery through a reputable carrier like FedEx or DHL. This provides reassurance that working with credit card and shipping companies are viable mechanisms for identifying ownership of NPWs and potentially suspending their credit card contracts. Approximately half (52%) of NPWs require some kind of online questionnaire to be filled out by the patient; a much smaller percentage offer a telephone consultation, either for free (8%) or fee (20%). 

The fluidity and semi-reality of cyberspace is ideally suited to illicit drug transactions, creating a complex challenge for law enforcement, policy makers and the general public [7]. Businesses wishing to circumvent the U.S. Controlled Substances Act may do so by establishing multiple websites, in multiple countries, under multiple online identities. For example, an NPW can be physically located on a computer in Uzbekistan; registered to a business address in Mexico; ship its drugs from Pakistan; deposit payments to a Cayman Island bank – while the owner resides in Miami. Importantly, all links in this online enterprise can be quickly dismantled and resurrected under a new set of virtual identities.

The Global Marketplace and the Controlled Substances Act 

The benefits of the internet apply equally to everyone, including individuals who commit unlawful acts such as software piracy, virus releases, identity theft, espionage, the sale of child pornography, illegal weapons, and controlled substances. Online stores can be hosted and registered anywhere in the world, advertising, selling, and delivering products internationally with relative anonymity and convenience – and with little regard for the laws of other countries. The United States Controlled Substances Act (CSA) prohibits the sale of Schedule I drugs such as marijuana, heroin, psilocybin, crack cocaine, and ecstasy and regulates access to Schedule II-V drugs including analgesics, sedatives, stimulants and steroids by requiring a valid prescription from an appropriately licensed healthcare professional [8]. Many countries have drug policies that differ from those of the United States, or have similar laws but less enforcement.

Individuals wishing to sell drugs such as opioid medications to customers in the United States can do so through NPWs registered and operated outside the U.S. Such websites can be identified through internet searches using terms such as Vicodin or no prescription. Internet search engines such as Google enable customers of any age to purchase opioids from an international network of online pharmacies. In 2004, the National Center on Addiction and Substance Abuse (CASA) [9] identified 147 anchor web sites that offered sales of Schedules II–IV controlled prescription drugs without a prescription during a one-week investigation and only 10 websites that required prescription verification. In a 2006 update to this study, CASA [10] reported that the number of anchor sites selling Schedule II–IV controlled prescription drugs had grown to 165, while the number of sites requiring prescriptions had increased to only 20. Forman [11] published data indicating that the majority of links obtained in a Google search using the term “no prescription codeine” yielded websites offering to sell prescription opiates without a prescription. In a later report, Forman [12] noted that this availability remained consistent over a one-year period, and that websites offering to sell steroids, sedatives, stimulants, ketamine, coca leaves, marijuana, and a wide range of other controlled substances were readily available. In December 2003, Google issued a press statement announcing it would no longer accept advertisements from unlicensed, “rogue” pharmacies though they would continue ranking and including NPWs in search results [13, 14].

Because it is illegal to purchase prescription opioids and other controlled substances without prescription, there is limited data on the actual delivery rate of NPWs. However, the U.S. General Accounting Office (GAO) conducted an investigation in which they attempted to purchase prescription drugs without a prescription. In total, the GAO investigators placed 90 orders for prescription drugs without prescription; of these orders 45 (50%) were filled. The GAO purchased a wide range of prescription medications, including 11 purchases of opioids. Of the 11 attempted purchases of opioid medications (including hydrocodone and oxycodone), 10 (94%) were delivered [15].

 On July 30, 1999, U.S. Deputy Attorney General Ivan Fong testified before the Subcommittee on Oversight and Investigations, Commerce Committee, United States House of Representatives, that “…online pharmacies allow consumers to purchase prescription drugs without any pretense of a prescription” and that these websites introduce “potential risks to public health and safety” [16]. A week later the White House issued Executive Order 13133 [17] creating the “Working Group on Unlawful Conduct on the Internet” leading to the publication of “The Electronic Frontier” [18]. The Drug Enforcement Administration (DEA) subsequently published guidance [19] which specified four conditions under which legal prescriptions can be issued over the internet: a) A patient presents a medical complaint; b) A medical history is obtained; c) A physical examination is performed; and d) Some logical connection exists between the medical complaint, the medical history, the physical examination, and the drug prescribed. Prescriptions based on telephone interviews or online questionnaires are not considered valid. In support of these guidelines, the American Medical Association subsequently issued guidance for physicians on internet prescribing that largely parallels the DEA’s position [20].

Enforcement

Since 2001, the sale of controlled substances over the internet has been cited in U.S. Justice Department reports [21, 22, 23] and has led to criminal investigations for non-prescription drugs such as ecstasy, gamma hydroxyl butyrate (GHB) and methamphetamines, [24, 25, 26, 27] and the illicit sale of prescription drugs online [28, 29, 30, 31, 32]. Similarly, the U.S. Food and Drug Administration (FDA) has provided testimony [33], and reports [34, 35, 36, 37] on the risks of online prescription practices and, in conjunction with U.S. Customs, the FDA participated in an investigation of illicit prescription drug sales originating overseas [38]. On March 1, 2004, the White House Office of National Drug Control Policy (ONDCP) issued the 2004 National Drug Control Strategy Update [39] which for the first time described plans to monitor illicit internet drug offers. Concurrent with the issuance of this strategy update, ONDCP issued a press release [40] entitled “U.S. Drug Prevention, Treatment, Enforcement Agencies Take on ‘Doctor Shoppers,’ ‘Pill Mills’” and a fact sheet entitled “Reducing Prescription Drug Abuse” [41] both of which announce initiatives to stop illicit online prescription drug sales. Subsequently in 2005 and 2006 updates to the national drug control strategy, the ONDCP announced that the focus of its efforts in halting prescription drug abuse would be in preventing the diversion of prescription drug through support of state-level Prescription Drug Monitoring Programs [42, 43].

The issue of the abuse of prescription drugs and their sale over the internet has also come under increasing scrutiny from the United Nations International Narcotics Control Board (INCB). In recent years, the INCB’s annual reports have continually noted the importance of multinational efforts for stopping the diversion of prescription drugs via the internet [44, 45]. In response, in late 2004 and early 2005, the INCB convened two meetings of experts to discuss possible solutions for the international challenge of shutting down illegal internet pharmacies [46, 47]. Later in 2005, the United Nations Commission on Narcotic Drugs passed a resolution calling for international cooperation between member nations in order to end illegal internet drug sales [48]. In one of its strongest warnings to date on the subject, the INCB’s most recent 2006 annual report cautioned that the abuse and trafficking of prescription drugs will soon surpass illicit drug abuse [49]. Moreover, the report states that the illegal sale of prescription drugs via the internet continues “unabated,” and it recommends specific actions to be undertaken both by member country governments and by the United Nations Office on Drugs and Crime in order to halt these sales [50].

Forman and Block identified four potential “choke points” for NPW enforcement efforts: a) search engines that list NPWs when searches are conducted; b) credit card companies with which NPWs and their customers have accounts; c) package delivery companies; and d) internet service providers (ISP) where NPWs files are hosted [6].

Popular Media

Because public awareness about the availability of opioid medications without a prescription is increased by media reports, it is instructive to consider media coverage of NPWs. Beginning in the fall of 2003, the popular press began describing—and publicizing—the illicit sale of prescription drugs over the internet. The earliest press report on NPWs that we found was published on October 18, 2003, in the New York Times [51] in an article describing a joint DEA/FDA taskforce targeting “rogue online pharmacies” that sold prescription drugs without a prescription. Two days later the Washington Post [52] released a five-part series detailing the results of a one-year investigation into the availability of prescription drugs without a prescription. A month after the Washington Post series, USA Today [53] reported on the “uncontrolled sale of controlled substances” over the internet and then, in December 2003, news coverage about NPWs became widespread with the Los Angeles Times [54], Philadelphia Daily News [55], Boston Herald [56], Miami Herald [57], Denver Post [58], San Jose Mercury News [59], and the Chicago Tribune [60] all publishing stories about the online availability of controlled substances without a prescription. Additional media coverage has been given to police investigations of operators of large internet pharmacies [61, 62, 63, 64]. Since then, the Partnership for a Drug-Free America launched an aggressive media campaign against the abuse of prescription drugs in spring of 2006 [65].

Adolescent Abuse of Prescription Drugs

In its 18th annual national study of teen substance use, the Partnership for a Drug-Free America reported in 2006 that almost one in five adolescents (19%) has abused prescription medications, including Oxycontin and Vicodin [66]. This proportion is equal or higher than adolescent abuse of cocaine/crack, ecstasy, methamphetamine, LSD, and heroin. Thirty-seven percent of adolescents said they have close friends who have abused prescription painkillers such as Vicodin, OxyContin, and Tylox, while 29% report the same about Ritalin and Adderall. According to the study, almost half of all teens believe that getting high from prescription medications is “much safer” than street drugs, and 3 out of 10 teens see nothing wrong with abusing prescription medicines once in a while, and they believe that prescription drugs are not addictive.

Monitoring the Future, another national annual survey of teen drug use conducted by researchers at the University of Michigan, has also recorded high levels of prescription drug abuse [67]. In 2006, survey results indicated that the annual prevalence rates of Oxycontin use among 8th and 10th graders reached 2.6 percent and 3.8 percent, respectively. These are the highest observed levels to date. In contrast, the 2005 rates for 8th and 10th graders were 1.8 percent and 3.2 percent, respectively. Vicodin usage also has a high prevalence rate, and its annual prevalence among 8th, 10th, and 12th graders was 3 percent, 7 percent, and 9.7 percent, respectively. This marked an increase from the rates of 2.6 percent, 5.9 percent and 9.5 percent for 8th, 10th and 12th graders, respectively, in 2005.

Finally, the National Survey on Drug Use and Health continues to report high levels of abuse of psychotherapeutic drugs [68]. Though slight decreases were reported in the usage of prescription-type psychotherapeutics in comparison to 2004, current usage levels still remain well above levels first reported in 2002 when the survey was significantly revised. In 2005, 12 percent of youths ages 12–17 said they had tried psychotherapeutics for non-medical use at least once in their lifetime, including 1.1 percent reporting using Oxycontin, 3.0 percent using tranquilizers, 4.6 percent using Vicodin, Lortab or Lorcet, 1.7 percent using hydrocodone, and 1.8 percent using codeine. Previously from 2003–2004, lifetime use of Oxycontin had risen from 1.0 to 1.2 percent, lifetime use of Vicodin, Lortab or Lorcet had risen from 4.5 to 5.1 percent, lifetime use of hydrocodone had risen from 1.6 to 1.7 percent, and codeine lifetime use had remained constant at 2.1 percent [69].

Research on Internet Prescription Opioids

In contrast with the many reports in the law enforcement literature and popular press, there are few publications in the public health or medical literature concerning the availability of prescription opioids over the internet. In a Medline search conducted on June 28, 2004 using combinations of terms including “online,” “opioids,” “internet,” and “narcotics” only one publication addressing the availability of prescription opioids over the internet was found: the principal investigator’s (Forman 2003) preliminary research report. Since then the author collaborated in the production of several research articles on the sale of prescription drugs over the internet [70, 71]. This, and other searches conducted using Medline and PsychINFO, identified general articles about online pharmacy prescribing practices [72, 73, 74, 75, 76, 77], the internet as a source of drug information [78, 79, 80, 81, 82, 83, 84, 85], and the online sale of sexual performance enhancement drugs [86, 87, 88], but no articles were found about websites selling prescription opioids without a prescription. These reviews did find an article in a Swedish language journal describing the online sale of hallucinogenic mushrooms [89], a case report about a patient who became dependent on opium poppies that were purchased online [90], and a case report about a patient who overdosed on diet pills (phentermine) obtained online [91].

The European Union funded a project called the Psychonaut 2002 Project which searched the Internet for drug-related websites using a controlled search methodology (psychonaut2002.org). Its primary aim was to collect and analyze the information available on these websites, and to develop an Early Warning System for professionals providing information and suggestions concerning the emerging drug markets, new drugs and new trends in drug use. This was a multi-site research project involving 15 centers from nine European countries and analyzed more than 4.000 sites in 8 languages. Investigators in this project have published multiple articles about the availability of controlled substances on the internet [92, 93,94, 95, 96, 97, 98] report having one manuscript under review [99], and have presented their findings at two international scientific conferences [100, 101].

In addition, there is an overall lack of information about who is using the internet to obtain NPOs. In the study conducted by Gordon, Forman, and Siatkowski, one hundred adult drug dependent inpatients in a private, residential treatment program participated in a semi-structured interview from 2003 to 2004 regarding how they obtained their drugs. Twenty-nine percent reported knowledge of the internet as a source of drugs and 11% reported they had used the internet either to buy drugs or locate a drug dealer. Among the respondents who knew the internet was a drug source, reasons given for not using it were: it was too expensive; the desired drug could not be obtained (e.g. cocaine); and fear of being identified by authorities or other family members using the same computer. The results of this preliminary study suggest that the internet is becoming an increasingly important source of controlled substances for some addicted individuals.