AMA warns doctors on dangers of Web pill pushing

Physicians who prescribe Viagra to patients without a face-to-face consultation draw fire from the AMA.

By Gary Baldwin, AMNews staff. July 19, 1999. - Additional information.
AMNews Annual Meeting '99 coverage - AMA's Annual Meeting site.

Chicago -- With little debate, the AMA took a strong stand during its Annual Meeting on the controversial practice of online prescribing. It called on state medical societies, government regulators and licensing boards to investigate doctors who dispense pills to patients without examining them.

"It's inappropriate and it puts patients at great risk," said AMA Trustee Donald J. Palmisano, MD.

Online prescription services already have caused trouble for some physicians. One, whose license was temporarily suspended by the Illinois Dept. of Professional Regulation, paid a $1,000 fine for prescribing Viagra over the Internet to patients he had not examined in person. After he agreed to stop, the state reinstated his license and placed him on probation for two years.

The department justified the fine because the physician was "engaging in unprofessional conduct by prescribing Viagra without first examining or personally interviewing patients," according to the IDPR disciplinary summary.

Doctors in Washington and Wisconsin have faced similar allegations. Licensing boards in at least 10 states are investigating Internet prescribing.

The AMA urged state medical societies to take "necessary action against physicians who fail to meet the local standards of medical care when issuing [online] prescriptions."

Noting that no state laws directly address the issue of online prescribing, the AMA said it would assist the Federation of State Medical Boards in developing them. But in the absence of state law, local medical boards should take action against doctors who are prescribing drugs for patients they don't know, Dr. Palmisano said.

Viagra sites just the beginning

Although Viagra is the most popular online offering, many other drugs are also available to consumers with Internet access, according to the AMA Board of Trustees report adopted by the House of Delegates. They include Propecia, Proscar and Claritin.

The Viagra Web sites boast such provocative and compelling names as "doctorasap.com" and "get-it-on.com." Patients pay the cost of the drugs and "consultation fees" that range from $35 to $85. The AMA board report lists 14 sites likely involved in sight-unseen online prescribing.

"Typically, a Web site will advertise the advantages of obtaining Viagra via the Internet, require the purchaser to acknowledge a liability waiver, select a quantity of Viagra to be purchased and ask the purchaser to fill out a short questionnaire," the report notes.

One online prescribing site's questionnaire confused the terms "hypotension" and "hypertension," Dr. Palmisano said. Worse, another site revealed patients' answers.

The entire transaction can be conducted online, with the customer paying by charge card, even arranging for overnight delivery. Nothing prevents consumers from lying on the questionnaire to obtain the drug.

"Clearly, there essentially is no medical assessment at all, and there is no follow-up to determine whether the medication has been effective or if there are side effects," the report says.

The report directs the AMA to work with the FSMB, the National Assn. of Boards of Pharmacy and the Food and Drug Administration to curtail inappropriate online prescribing.

But the report is not a blanket condemnation of Internet prescribing. "Care must be taken to protect and even enhance legitimate electronic prescribing and dispensing practices," it says.

Legitimate uses

During testimony, a handful of pro-Internet physicians argued for a proactive online policy, charging that the board report was shortsighted. The final policy acknowledged this criticism, stating that the AMA "support[s] the use of the Internet to prescribe medications with appropriate safeguards to ensure that the standards for high-quality medical care are fulfilled."

Recognizing the growing use of the Internet in health care, the report considers online transmission of prescriptions, order refills and electronic consults appropriate if the physician and patient have a preexisting relationship.

"A patient may inform his or her physician via telephone or e-mail of a flare-up in a seasonal allergy, a documented problem, and the physician may then electronically transmit a prescription for an antihistamine to the pharmacy without an additional office visit," the report says. "The key here is that the physician and patient have an ongoing relationship, the patient routinely uses this physician, and history and physical information are already in the medical record."

The AMA is not alone in its effort to curb the Viagra sites. Pfizer, manufacturer of Viagra, has asked the Federal Trade Commission to crack down on the Internet sites, the report says.

The AMA is working with the NABP, which represents state pharmaceutical licensing authorities, to develop a seal of approval program for Internet pharmacy sites. Launched in February, the voluntary program would verify that the pharmacy sites are appropriately licensed and run.

The program's charge hints at the difficulty of controlling online prescribing. NABP says it seeks to "assure the integrity, legitimacy and authenticity of the prescription drug order and to prevent prescriptions from being submitted, honored and filled by multiple pharmacies."

In related actions, the AMA house referred to the Board of Trustees a plan to develop guidelines for patient-physician e-mail communications. The guidelines would address such issues as appending copies of e-mail correspondence to a patient's chart.

The house also instructed the AMA to lobby the Drug Enforcement Administration to permit encrypted electronic prescriptions for schedule II controlled substances. These prescriptions now may be transmitted via fax to pharmacies if the pharmacist has seen the original, signed prescription.

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One Internet prescription drug provider, the Net Doctor Group (http://www.net-dr.com/), which describes itself as "the pioneer in providing cutting-edge medicine through Internet technology," tells consumers that a physical exam is not necessary to receive a Viagra prescription. Here is the site's rationale:

"We are often asked: Isn't a physical exam needed to determine if I would benefit from Viagra? If you have had a physical exam recently and consider yourself healthy, you do not necessarily require another physical exam in order for it to be professionally determined that you may benefit from Viagra. Thousands of psychiatrists and general practitioners throughout the United States are prescribing Viagra following a review of the patient's medical history alone, without a physical exam.

"The contraindicated drugs and other medical factors which would prohibit a physician from prescribing Viagra are discoverable through a review of the patient's medical history. There is no reason to suggest that an in-person review of this history is any more relevant than an online consultation."

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