Editorial for July 26, 1999

Police Web prescribing

At the recent AMA Annual Meeting, delegates set a sensible standard for prescribing drugs over the Internet: Do so only with safeguards in place to ensure the quality of care being provided. When that doesn't happen, the AMA pointedly added, authorities should take action against the physicians involved as well as to stop sites from illegally providing prescription drugs.

There is plenty of work to be done to implement those recommendations. A significant number of Internet sites -- estimates place the figure into the hundreds, based both in this country and abroad -- are improperly dispensing prescription medicine.

It is common knowledge among the Internet-literate that to avoid the embarrassment or scrutiny of a visit to the doctor's office -- presumably why the erectile dysfunction drug Viagra is such a popular Internet offering, along with obesity and baldness meds -- anyone can simply type the names of those drugs into a Web browser. In a few seconds a list of links will appear to sites touting no-hassle prescriptions and quick delivery.

Once at the site, the process typically involves nothing more than a click of the mouse to acknowledge a liability waiver, then on to a brief questionnaire. That the questions be answered honestly or even be understood is blatantly optional -- the replies won't be verified. All that's left is to provide a credit card number for payment.

The problem lies in what's missing. No serious history-taking, medical exam or tests to make a proper diagnosis, no counseling, no follow-up, no semblance of a true patient-doctor relationship.

Many of the sites are offshore and have even less physician participation than the limited medical involvement offered by sites based in this country. The offshore sites also illegally promote and dispense drugs not yet approved for use here, but which (at least in small quantities) often pass through customs inspections.

Sites based in the United States operate in a gray area of conflicting jurisdictions, out-of-date statutes and blurred distinctions about location and licensure. That the issues of physician ethics and standards of care are more obvious in Web prescribing has already provided the basis for some states to sanction doctors who prescribe without a reasonable patient exam. Other states and the federal government are just beginning to look at the problem.

At the meeting, delegates also directed the AMA to work with the Federation of State Medical Boards and others to support or develop model state legislation on the limits of Internet prescribing. And AMA will also support the National Assn. of Boards of Pharmacy "Verified Internet Pharmacy Practice Sites" seal of approval program. It is important to note that legitimate Internet pharmacies, essentially cyber-age versions of mail order pharmacies, are getting an undeserved black eye from sites that improperly prescribe.

Also tarnished is the Internet's potential as a useful tool for physicians and patients. An AMA report that accompanied the recommendations cited acceptable uses such as transmission of prescriptions and refill orders (imagine, no more wisecracks about the doctor's handwriting) and situations where consults between physicians and established patients could result in a new prescription. But all that is in the context of what rogue prescribing sites lack -- a legitimate patient-physician relationship. It's time to more aggressively police Internet prescribing before the problem gets even worse.

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