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Taking the Physician Out of “Physician Shopping”: A Case Series of Clinical Problems Associated With Internet Purchases of Medication

2004; Elsevier BV; Volume: 79; Issue: 8 Linguagem: Inglês

10.4065/79.8.1031

1942-5546

Timothy W. Lineberry, John Bostwick,

Pharmaceutical industry and healthcare

In the United States, psychoactive prescription medications rank second only to marijuana as drugs of abuse (if tobacco and alcohol are discounted). Physician shopping—visiting multiple physicians simply to procure prescriptions—has been a traditional method for acquiring drugs illicitly. As community-based efforts to curtail physician shopping have expanded, drug abusers have turned increasingly to the Internet. Illegal Internet pharmacies, increasing rapidly in number during the past decade and requiring neither prescription nor physician oversight, offer minimal interference to obtaining drugs. With no physician involved, patients cease to be patients. Instead, they become consumers able to buy prescription medications, even controlled substances, from anonymous providers offering no ongoing treatment relationship and taking no responsibility for the drugs dispensed. When complications occur, these consumers become patients, turning back to the traditional medical system to manage overdoses, addictions, and drug adverse effects and interactions. We present a case series illustrating some of the medical problems that resulted from drugs bought on-line illegally. In the United States, psychoactive prescription medications rank second only to marijuana as drugs of abuse (if tobacco and alcohol are discounted). Physician shopping—visiting multiple physicians simply to procure prescriptions—has been a traditional method for acquiring drugs illicitly. As community-based efforts to curtail physician shopping have expanded, drug abusers have turned increasingly to the Internet. Illegal Internet pharmacies, increasing rapidly in number during the past decade and requiring neither prescription nor physician oversight, offer minimal interference to obtaining drugs. With no physician involved, patients cease to be patients. Instead, they become consumers able to buy prescription medications, even controlled substances, from anonymous providers offering no ongoing treatment relationship and taking no responsibility for the drugs dispensed. When complications occur, these consumers become patients, turning back to the traditional medical system to manage overdoses, addictions, and drug adverse effects and interactions. We present a case series illustrating some of the medical problems that resulted from drugs bought on-line illegally. According to the 2002 National Survey on Drug Use and Health,1Substance Abuse and Mental Health Services Administration, Office of Applied Studies Results From the 2002 National Survey on Drug Use and Health: National Findings. US Dept of Health and Human Services, Rockville, Md2003Google Scholar if tobacco and alcohol are discounted, prescription medication ranks second only to marijuana as a source of drug abuse in the United States. Psychoactive medications are most often targeted for abuse, especially opiates intended for pain relief. For several decades, a community-based matrix of physicians, pharmacists, law enforcement entities, state medical boards, and federal regulatory agencies has evolved to attempt to prevent prescription drug abuse. Typically, drug abusers have obtained medication through physician shopping. The physician shopper visits multiple physicians with the singular goal of procuring prescriptions for personal use or sale. Community-level efforts at controlling physician shopping have included careful physician scrutiny during the patient encounter, communication with other providers and pharmacies when physician shopping is suspected, use of triplicate copies and better retention of records of prescriptions for controlled substances, and computer records integrated between pharmacies, hospitals, and managed care organizations. Prescribing guidelines and prescription-pattern monitoring by state medical boards and the federal Drug Enforcement Administration are also elements in this structure. During the past decade, 21 states launched prescription drug–monitoring programs (PMPs)2Office of National Drug Control Policy The President's National Drug Control Strategy.Available at: www.whitehousedrugpolicy.gov/publications/policy/ndcs04/healing_amer.htmlDate: March 2004Google Scholar to collect and analyze data on pharmaceutical prescription and dispensation. Prescription drug–monitoring programs appear to be effective in curtailing physician shopping. According to the 2004 President's National Drug Control Strategy,2Office of National Drug Control Policy The President's National Drug Control Strategy.Available at: www.whitehousedrugpolicy.gov/publications/policy/ndcs04/healing_amer.htmlDate: March 2004Google Scholar the 5 states with the lowest per capita number of prescriptions for OxyContin (Purdue Frederick Company, Norwalk, Conn), an extensively abused schedule II narcotic,3Roche T The potent perils of a miracle drug.Time. 2001; 157: 47PubMed Google Scholar had PMPs. All 5 states with the highest number of prescriptions for OxyContin did not have PMPs. By 2005, the program is expected to expand to 11 more states.4Associated Press Bush policy to target prescription drugs.Available at: www.cnn.com/2004/HEALTH/03/01/bush.drug.policy.ap/Google Scholar However, as these programs have expanded and physician shopping has become more difficult, drug abusers have discovered a new method for obtaining illicit prescription drugs—through the Internet. Anonymous by nature, international by design, and ubiquitous in availability, the Internet has revolutionized communication with its rapid access to information, services, and products. Some on-line pharmacies operate as extensions of legitimate brick-and-mortar businesses, with a verifiable street address and customary prescription requirements.5Fung CH Woo HE Asch SM Controversies and legal issues of prescribing and dispensing medications using the Internet.Mayo Clin Proc. 2004; 79: 188-194Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar However, others established solely to sell drugs exist only in cyberspace. These rogue pharmacies conduct business essentially outside the law and, until now, have been monitored lightly, if at all.6Gaul GM Flaherty MP Google to limit some drug ads: Web giants asked to help discourage illicit online pharmacies.Washington Post. December 1, 2003; : A1Google Scholar Illegal Internet "pharmacies" have taken the physician out of physician shopping. The process of obtaining medications from such establishments is easy and quick. A recent Internet search for tramadol (Ultram, Ortho-McNeil Pharmaceutical, Inc, Raritan, NJ; an uncontrolled synthetic opioid analgesic), using the search engine Google, yielded 2,150,000 associated links.7Google Web site. Tramadol.Available at: www.google.com/search?hl=en&lr=&ie=UTF-8&q=tramadolGoogle Scholar Most advertised links that provide tramadol require no prescription. They pitch free and rapid shipping, free physician consultation, and payment on arrival. Accessing a link leads to a product menu that may or may not include a cursory health questionnaire, offering the illusion of medical oversight. Nothing more than a credit card number is required to initiate the order for door-to-door delivery of drugs. In a recent Mayo Clinic Proceedings article, Fung et al5Fung CH Woo HE Asch SM Controversies and legal issues of prescribing and dispensing medications using the Internet.Mayo Clin Proc. 2004; 79: 188-194Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar outlined legal issues and controversies associated with medication acquisition through the Internet. In the following 4 cases, we focus on clinical problems stemming from purchasing medications through the Internet, particularly those related to patient safety. All clinical examples are real except for certain details changed to obscure identity and protect patient confidentiality. This study was approved by the Mayo Foundation Institutional Review Board. A 35-year-old man presented initially for evaluation of anxiety and depressive symptoms. After institution of paroxetine, his symptoms remitted gradually during the next 2 months. He also described improvement in longstanding marital problems. The patient continued to report doing well at follow-up appointments during the next 5 months, until his son found him unresponsive on the kitchen floor. In a local hospital's intensive care unit (ICU), where severe respiratory depression was treated with tracheal intubation and mechanical ventilation, the patient's amitriptyline blood concentration was sufficient to cause life-threatening QRS complex prolongation. He also developed rhabdomyolysis due to his initial comatose state. Much to his psychiatrist's surprise, the patient admitted, after tracheal extubation, to having attempted suicide by ingesting nearly 4 g of amitriptyline, 20 to 40 times the usual daily dose for depression. Unbeknownst to the psychiatrist and before he sought treatment with him, the patient had found an Internet Web site offering on-line consultation. After an e-mail exchange, a physician recommended antidepressant treatment but gave no specific medication advice. Instead, he offered the patient a menu of choices, from which the patient selected amitriptyline because it was inexpensive. The total cost of prescription and consultation was approximately $100, and 100 tablets of amitriptyline at 100 mg each arrived in the mail 1 week later. Admitted to an inpatient psychiatric unit after a suicide attempt with carbon monoxide, a 37-year-old man described unbearable dysphoria while trying to discontinue use of prescription opiates on his own. He reported that the dysphoria had led to suicidal thoughts. After a decade of sobriety from prescription medications, the patient had begun obtaining drugs through the Internet in conjunction with a separation from his wife. He had developed his own method of acquiring opiates that avoided contact with a cyber physician. The patient would type a narcotic name such as oxycodone into a search engine and deliberately select a link that required no evaluation or prescription. He described the screening questionnaires as brief and easy: "I always marked no to everything." A mail-order purchase was as simple as providing his credit card number. The patient was shocked and excited by how easy it was to obtain opiates through the Internet. A downside was the $1000 lost to Web sites that charged his account but never sent medications. Meanwhile, he continued to see a psychiatrist for depressive symptoms, never revealing his escalating addiction. Unable to reconcile with his wife, the patient also was unable to reachieve sobriety. The patient underwent detoxification from opiates and experienced associated improvement in his depressive symptoms. During hospitalization after his suicide attempt, his family took his computer and his credit cards. A 42-year-old man was transferred to an inpatient psychiatric unit after admission to the ICU because of seizures resulting from excessive ingestion of tramadol. Years earlier, a brief course of tramadol had been prescribed for a burn; however, the patient discovered that he took the drug for more than pain relief. After his pain had resolved, he continued taking tramadol for the euphoria it induced. For 2 years, he easily obtained tramadol through the mail from Internet sites that required no prescription. In response to opiate withdrawal symptoms, the patient escalated use of tramadol to as many as 50 tablets a day, more than 6 times the maximum recommended daily dosage. Despite a history of taking selective serotonergic reuptake inhibitors prescribed by a physician for depression, the patient denied any depressive symptoms except those that accompanied drug withdrawal. He revealed the extent of tramadol abuse only in the aftermath of his seizures. A 29-year-old woman's primary complaint at admission to a psychiatric unit was a desire to discontinue use of the narcotic hydrocodone. She had felt depressed and suicidal while trying to discontinue use of the drug on her own. Her psychiatric history included generalized anxiety disorder, dysthymic disorder, and many unsuccessful antidepressant trials. Although clonazepam (2 mg at bedtime) prescribed by her psychiatrist helped her sleep, the patient worried about its addictive potential and after 2 months abruptly discontinued taking the drug. Four days later, during a withdrawal seizure, she dislocated both shoulders, leading to surgical repair that included hydrocodone for pain control. Initially, she received prescriptions for hydrocodone from a legitimate physician. As use of the drug escalated during the next 2 months, she concealed her growing dependence on opiates from her physicians and purchased hydrocodone through Internet sites that required no prescription. The 4 cases exemplify some of the issues raised by direct medication purchase from on-line pharmacies. This section discusses patient safety and clinical management, offers observations in identifying patients who may be purchasing medications through the Internet, and provides proposed efforts to combat the problem. Life-threatening complications were prominent in 3 of our 4 cases. In case 1, the patient's respiratory depression due to an unsuspected overdose of amitriptyline necessitated admission to the ICU with tracheal intubation and mechanical ventilation. The patient was also at risk for cardiac and renal complications due to QRS complex prolongation and rhabdomyolysis, respectively. In case 2, the patient's severe dysphoria experienced during opiate withdrawal prompted another potentially fatal suicide attempt with carbon monoxide. The patient in case 3 presented with tramadol-induced seizures, a rarely reported adverse effect of excessive intake of tramadol.8Tobias JD Seizure after overdose of tramadol.South Med J. 1997; 90: 826-827Crossref PubMed Scopus (52) Google Scholar Cases 2, 3, and 4 portray Internet-abetted drug dependence. Case 2 shows addictive behavior, with the patient acquiring opiates through the Internet unbeknownst to his psychiatrist, with the goal of intoxication. Without revealing their addictions, the patients in cases 2, 3, and 4 received treatment for depression, anxiety, or both due to symptoms likely attributable to drug abuse rather than to another primary psychiatric condition. Although in case 3 tramadol had been prescribed originally for a burn, the patient used the medication later for the euphoric effect. Likewise, the patient in case 4 became addicted to narcotics prescribed originally for an orthopedic condition. Cases 3 and 4 involve legitimate drug use that blossomed into addiction. Drug-drug interactions, relatively common in the best-managed patients, are even more likely in a system without reliable physician or pharmacist oversight. No federal agency enforces quality control for medications purchased from rogue pharmacies, many of which are internationally based, even though consumers may assume that all prescription medications are safe and that drug manufacturing standards are consistent throughout the world. Awareness of the easy availability of Internet pharmaceuticals is critically important for physicians and the health care system. Prescription drug abuse has been present for years and is common. Deception in the physician-patient relationship, particularly with addictive behavior, is not new. What is novel is the loss of networks of local community checks and balances. The patient is no longer a patient but a consumer, "buying direct" without professional oversight from physician or pharmacist. In the Internet environment, physicians do not write the prescriptions or compare notes with colleagues about the physician-shopping patient who hopes to acquire prescriptions by subterfuge. Consumers do not take their prescriptions to neighborhood drugstores staffed by pharmacists dispensing advice, guaranteeing pharmaceutical quality, monitoring for early refills, checking for prescription alterations, and telephoning physicians they work with regularly to confirm a prescription's accuracy or warn about possible misuse. Collateral history from fellow professionals does not exist because there is no one to call on the telephone. In our case examples, the consumer did not become a patient until grave complications arose. Electronic physician, laboratory, hospital, and pharmacy records may lull the medical treatment team into believing they have a patient's complete medication information. Physicians must remember that, with easy on-line availability, a patient can be taking literally any drug with no records of documentation. In case 1, confusion and uncertainty reigned in the patient's initial emergency management because his medical records contained no evidence of treatment with tricyclic antidepressants. Surviving a potentially fatal overdose and facing incontrovertible laboratory evidence forced him to reveal how he had acquired the drug that led to a suicide attempt. Likewise, in case 3, evidence of tramadol dependence did not emerge until the patient experienced tramadol-induced seizures, a complication to which multiple explanations could have been ascribed in the absence of full disclosure. The patient in case 2 made a near-fatal suicide attempt and was admitted to a psychiatric unit as if experiencing a bona fide mood disorder. Only after admission did the causal link between opiate abuse and depressive symptoms become apparent. The patient in case 4 had been treated for anxiety and depression in the past, but her current symptoms, which mimicked earlier ones, resulted from opiate withdrawal. Having concealed her new-onset addiction from her physician, she admitted to it only when she could see no other option but inpatient detoxification. Overconfidence in integrated information systems, with their easy data availability, may blind physicians to contradictory information in the history and findings on the physical examination, thus delaying appropriate interventions. Forewarned is forearmed for both patients and physicians. Openly discussing with patients the dangers of unsupervised prescriptions is the first step. Besides the possibility that Internet drugs may not be the compounds their suppliers purport them to be, consumers may not become aware of toxicities, drug-drug interactions, and addictive potential until they have occurred. Purchasers may pay a premium for their illegally acquired medications or receive no product at all after providing credit card data. Case 2 illustrates how rogue pharmacies may not even dispense drugs. Rogue pharmacies are interested primarily in maximal profits from drug distribution, not customer service or patient safety. When taking histories, physicians need to ask specifically about Internet medication purchases, as it has become routine to ask about over-the-counter medications, alternative herbal preparations, and dietary supplements. When patients present with treatment-resistant depression or anxiety, suspected drug intoxication, or unusual complications requiring urgent treatment or admission, physicians should suspect Internet drug abuse. For patients whose narrative includes a history of addiction or financial problems, particularly credit card debt, physicians should also be suspicious of medication purchases through the Internet. As programs like PMPs become more widespread and make traditional physician shopping more challenging, more and more substance abusers will probably use Internet pharmacy sites to obtain drugs. Recognizing this concern, the President's National Drug Control Strategy for 20042Office of National Drug Control Policy The President's National Drug Control Strategy.Available at: www.whitehousedrugpolicy.gov/publications/policy/ndcs04/healing_amer.htmlDate: March 2004Google Scholar specifically targets rogue Internet pharmacies, enlisting the support of such businesses as credit card companies, shipping firms, and Internet service providers to alert law enforcement officials to suspicious activities. The Drug Enforcement Administration and the Federal Drug Administration Office of Criminal Investigation will step up investigation and enforcement efforts. The Drug Enforcement Administration will use search engines and database mining to identify problem Internet sites, and both agencies will increase random inspections of courier and mail shipments from abroad. Finally, public service announcements calling attention to the dangers and illegality inherent in direct on-line drug purchases will "pop up" while customers are searching for drugs on-line. Rogue pharmacies can probably never be shut down completely. The borderless nature and sheer volume of such sites require international cooperation if legal enforcement is to have any effect. Reducing demand through substance abuse education is vitally important. Physicians must educate themselves and their patients about the risks posed by easily acquired and unsupervised medication purchases through the Internet. Physicians must also have a high index of suspicion for Internet drug abuse in patients with unusual acute presentations or no plausible explanation for procuring psychoactive medications.