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Three years ago, Mary Ellen Mellor got the kind of phone call every parent dreads. It was her husband, calling from a hospital. "I'm in the emergency room," he said. "Keith has had an overdose." Mellor's stepson, then 15, had been found in his mother's house, conscious but in a stupor, and unable to walk. "Something was terribly wrong, and my husband was frantic because he didn't know what was behind Keith's symptoms," says Mellor, a 46-year-old emergency-room nurse who lives in Berwyn, Pennsylvania.
The cause of Keith's condition also stumped the hospital staff until the dazed teen blurted out the address of an Internet site. After going online, a nurse found a solicitation to buy dextromethorphan (DXM), a party drug that produces a euphoric feeling. In small doses, the powder is safe and is even used in over-the-counter cough suppressants. But Keith had ordered DXM from his home computer, paying with a money order from a convenience store. Along with three friends, he had mixed the drug with milk and guzzled it down. His friends merely got buzzed; Keith, who had more DXM in his drink, suffered a nonlethal overdose.
Keith, now 18, got off easy. After being given intravenous fluids for several hours, he was released from the hospital, and recovered fully in a few days. Had he taken more of the drug, he might not have been so lucky. Taken in large amounts, DXM can cause hallucinations, paranoia and psychotic reactions. It makes the pulse race or weaken, and the lips and fingernails turn blue. There have been at least two cases of DXM-related deaths.
In pure form, DXM is not available by prescription or over-the-counter. Like most mothers, Mellor had no idea that it could be purchased over the Internet. "I thought I was a pretty smart parent," she says. "I know what marijuana smells like. I know what people act like when they're on cocaine. You educate yourself about these things, then all of a sudden there's something new. But your kids already know about it, and they know how to easily get it."
Unfortunately, DXM is not the only drug that children -- or anyone else -- can easily get via the Web. "You can order any drug that's manufactured anywhere in the world -- from anabolic steroids to medicines used for people with terminal illnesses," says Carmen Catizone, M.S., R.Ph., executive director of the National Association of Boards of Pharmacy (NABP). Prozac to combat depression, Xenical for weight loss, even Androcur for advanced prostate cancer: All of these medicines are available on the Internet to anyone with access to a credit card or money order, without ever seeing a doctor. In fact, Ladies' Home Journal had no problem ordering and receiving five popular prescription drugs for people who don't even exist. We invented two fictional customers, Miranda Jones and Brad Pando, and created e-mail accounts for them. We then ordered drugs such as Viagra, which can be fatal to someone with a heart condition; Accutane, which can cause serious birth defects; and DXM with ease. What's more, some of the drugs we received looked questionable. For example, our Prozac order, which came from a Panamanian company, arrived crushed and flattened, with its tamper-proof seals broken and taped over.
Not all drug-selling Web sites are problematic. There are about 20 legitimate Internet pharmacies -- including planetRx.com, drugstore.com, clickpharmacy.com and familymeds.com-that require you to mail or fax a written prescription from your physician. (To find out if your online pharmacy is certified by the NABP, go to www.nabp.org/vipps/consumer/listall.asp.) But medical professionals and law-enforcement officials are becoming alarmed over the proliferation of what they call "rogue" sites, which do not require customers to see a doctor. Experts estimate there are about 400 of these pharmacies, and many operate out of Indonesia, New Zealand, Costa Rica and other foreign countries beyond the control of U.S. authorities. And their business seems to be booming: In 1999, seizures of mailed pharmaceuticals by the U.S. Customs Service jumped 450 percent over the year before, an increase the agency attributes to online sales. Unfortunately, experts believe the 9,725 shipments seized in 1999 are only the tiniest fraction of the amount coming into the U.S.
Most of the rogue Web sites offer lifestyle drugs like Prozac and Propecia (for hair loss). Some require customers to fill out a "consultation form," a quick medical history and survey of symptoms that might be reviewed by a physician for a fee of $35 to $85. But these forms are often already filled out with the "correct" answers. For example, at one Viagra Web site based in the Turks and Caicos Islands, the questionnaire indicates that the customer does not have any of two dozen medical conditions, including coronary artery disease and congestive heart disease, which can make taking Viagra fatal. The customer needs only to fill in some basic information on height and weight, plus a mailing address and credit-card number.
The head of one Internet pharmacy says using the Web is an innovative way to practice medicine. "We're trying to be cutting-edge," says Tania Malik, CEO of the Virtual Medical Group, in Morrisville, North Carolina, which was the company behind the sites from which we ordered Xenical and Viagra. "We're augmenting traditional medicine, and only for conditions that can be treated appropriately through the Internet." The American Medical Association (AMA) has warned consumers against using online pharmacies that don't require doctor visits for a prescription drug. Still, Malik argues that her company offers customers special advantages, like the anonymity of consulting with a physician from home. "You also can have a private conversation with your pharmacist, rather than standing in line at Eckerd's and having someone call out, 'Whose birth control pills?'" she says.
But it can be dangerous -- even life-threatening-for a doctor to prescribe medication without performing a physical exam. "Let's take Viagra," says James R. Winn, M.D., executive vice president of the Federation of State Medical Boards. "Erectile dysfunction is not a disease; it's a symptom. It may occur because of multiple problems, including depression, diabetes, vascular problems or a pituitary tumor. It's the physician's responsibility to sort that out, and to determine the treatment." If a patient orders Viagra online, he might never see a doctor, and might never learn if he suffers from a serious underlying condition.
Malik says that her doctors are licensed practitioners who are fully capable of evaluating the extensive online consultation forms from patients. LHJ's experience suggests otherwise. When our fictional Brad Pando complained of painful side effects from taking Viagra, Internet physician, Renee Giometti, M.D., admitted that she had prescribed twice her usual starting dosage. Even after she advised Pando to stop taking Viagra, we received an e-mail message from 1stonlinepharmacy.com offering to refill his prescription. And when Miranda Jones complained of common side effects from taking the diet drug Xenical, Giometti suggested that writing the original prescription might not have been the best idea. "My suggestion to you is to follow a low-fat, healthy diet rich in protein, fruits and vegetables, watch your portions and exercise," the physician wrote in an e-mail. "This would be a much healthier way for your body to lose weight than to take medication that is making you uncomfortable." When later contacted by LHJ, Giometti refused to comment.
Even if it were possible for a doctor to carefully prescribe medicines online, many Internet physicians don't exercise that care. In Kalamazoo, Michigan, TV station WWMT News 3 launched an investigation of online pharmacies, and was able to order ten 100 mg tablets of Viagra for a patient named Tom. The only problem: Tom was a house cat. In the online questionnaire, the station indicated that Tom stood 6 inches tall, weighed 15 pounds, and was neutered. WWMT also received Viagra for a reporter's dead grandfather and for a station employee who reported that he had heart trouble and took nitrate medicines. Viagra is potentially fatal when taken in combination with nitrates.
And last spring, ExpressToday.com physician Darryl Joseph Mohr was reprimanded and fined by the Arizona Board of Medical Examiners after prescribing Viagra to a federal agent without conducting a physical exam. During an interview with the board, Mohr admitted that he doesn't always look at the applications of the hundreds of Viagra customers each week that are "clean" -- free of contraindications like heart disease. "Because of the extensiveness of the questionnaire and the protocol, I don't feel it's necessary for every clean patient to be seen or reviewed by me," said Mohr.
Believe it or not, that's more scrutiny than some companies offer. We ordered the acne drug Accutane from MedsMex.com, which doesn't even require customers to fill out a medical questionnaire. With just a few mouse clicks and a credit-card number, a Web surfer can purchase dozens of medicines from the Mexican company. And when we purchased DXM from JLF Poisonous Non-Consumables in Columbus, Indiana, our order arrived in a plastic bag with a lengthy disclaimer warning us not to "eat, drink, inject, inhale, insert, absorb, snuff, snort, smoke or ingest in any way." Since we couldn't be sure what we really received, we had the powder tested by S. William Zito, a professor of pharmaceutical sciences at St. John's University, in New York City, and a former scientific adviser to the FDA. His lab results showed that we had, in fact, bought the real thing. "This is very pure," says Zito. JLF claims that its products are intended to be used as incense or potpourri, in arts and crafts projects, and for religious ritual and scientific research, but Zito says that's absurd. "I can't imagine any possible way DXM would be used for artwork," says Zito. "It should only be in the hands of experts conducting scientific research -- not teens or anyone surfing the Internet." While company owner Mark Niemoeller acknowledges that kids use DXM to get high, he says that it's parents' responsibility to supervise their kids.
Compared with JLF or MedsMex.com, the companies that require customers to fill out health questionnaires might seem safer. But even when a doctor does review these forms, the physician has no way to tell if a patient is lying about her weight or other vital statistics. When LHJ ordered Xenical, we were originally denied the diet drug because the weight we entered was too low. No problem; we simply changed the weight and our order was approved. (Tania Malik, whose company filled our order, says that the site should not have permitted us to make the change.)
Let's say you've ordered the right medicine for your condition. You've taken the drug before. Your physician approves. Is it still dangerous to order from a rogue Web site? Absolutely, say authorities. First, there's no assurance that the medicine you receive will be the real thing, although Zito confirmed that the four prescription medications we received were authentic. "People who buy these drugs from overseas pharmacies are playing Russian roulette," says Kevin Bell, a spokesman for the U.S. Customs Service. "They may receive the wrong drugs, or even counterfeit drugs." There's also a chance that your credit card number might not be safe since some sites don't provide secure servers for transmitting financial information.
Ordering from rogue sites is dangerous -- but is it illegal? While experts disagree about whether a consumer is breaking the law by ordering nonaddictive drugs like Viagra, it's unlikely that the government will be looking to prosecute the buyer. Instead, state authorities are trying to crack down on the sellers. It's a frustrating process. Kansas, for example, carried out a sting operation against six Web sites, with the help of a 16-year-old boy who ordered prescription medicines using his real age. "We were unpleasantly surprised to find he was able to order Viagra and Xenical," says Kansas state Attorney General Carla Stovall. "Both drugs were delivered." The state filed lawsuits against the six companies, but Stovall admits that her actions have barely made a dent in the illegal pharmaceutical trade. "All we can do is stop these sites from operating in Kansas," says Stovall. "I can't stop them in Missouri or Colorado or North Dakota. By the time Missouri looks at them, they may have changed their name."
The federal government is starting to help with enforcement. Last summer, for example, the Federal Trade Commission (FTC) settled a lawsuit against a group of online pharmacies accused of false advertising. One of the companies, Focus Medical Group, billed itself as a "full-service clinic with a full-time staff dealing with the treatment of sexual dysfunction" that dispensed drugs like Viagra. In fact, according to the FTC, there was no clinic, and the firm's "network" of physicians consisted of one doctor.
The U.S. Customs Service is also trying to stop illegal pharmaceuticals from entering the country. But the rogue pharmacies are savvy at getting their goods past authorities. "Sometimes they'll be shipped in a brown-paper wrapper with something like Joe's Gift Shop as a return address," says Tom McGinnis, director of pharmacy affairs at the FDA. American officials have had little success at closing down foreign companies, since the U.S. government has no jurisdiction overseas.What's being done
Last year, Congress considered the Internet Pharmacy Consumer Protection Act, which would require online pharmacies to disclose their addresses and phone numbers, along with a list of states where they are licensed to do business. The measure would also allow states to win nationwide injunctions against illegal Web sites. Unfortunately, the congressional session ended without its passage.
Supporters are hoping that the current congressional session will be different -- and they warn that the consequences could be dire if legislation does not pass this year. "Rogue sites are reinventing back-alley drug dealing," says former Pennsylvania Representative Ron Klink, one of the bill's original sponsors who lost his seat when he ran unsuccessfully for the Senate last year. "If we allow this wild, wild west of drug sales to continue, we might as well throw the whole regulatory system out the window."--Barry Yeoman