A Web of drugs

Along the Internet’s Main Street -- and its various side streets and alleys -- they are everywhere, promising easy access to the pills that pump you up, chill you out, slim you down and shift your sex life into overdrive. They are, to some Americans, a medicine chest of fun, purveyors of all the stuff that addicts need and the adventurous want to try but are afraid to request from their doctor.

Too shy to ask for Viagra? Worn out your welcome cadging pain-pill prescriptions from local doctors? No problem: There they are, these denizens of the Internet, relentlessly spamming America: “Need Vicodin for pain?” the e-mail enticement asks. “No embarrassing doctor visits! No waiting rooms! Free delivery! Discreet packaging!” Some sites offer a physician to write the prescription. Others waive that formality altogether: Click here and add to shopping cart; we’ll overnight the stuff to you.

These are not the online pharmacies of the nation’s large chain stores or the cyber arms of legitimate retail pharmacies, although it is sometimes hard to recognize the difference. These are the Internet’s “rogue pharmacies,” and they have prompted wonderment from consumers, frustration from state and federal authorities and worry from the medical profession. They have also put a virtual street corner’s worth of addictive and dangerous prescription drugs within reach of anyone, from an addict in Los Angeles to a sheltered teen in a small town in the Midwest with access to a computer.

Who are these pharmacists? Are they legal? Are they safe and is their product what they say it is?

The answers are as fluid and fast-moving as the Internet itself. If you order from them, there is little chance you’ll get caught or punished. These online pharmacies are operating either at the edge of or outside the law, and the resulting unregulated market is rife with violations of privacy as well as medications that are counterfeit, improperly handled, addictive and, in some cases, unsafe for the people who buy them.

In short, this is not your corner pharmacist, and a trip to this store could cost you your money, your privacy or your health.

For Ryan T. Haight of La Mesa, Calif., the cost was even steeper. On Feb. 21, 2001, Haight died at age 18 of an overdose after mixing morphine and two prescription antidepressants with Hydrocodone, a potent and highly addictive painkiller that he bought off the Internet. Haight was 17 and complaining of back and joint pain when he started ordering prescription painkillers from Internet pharmacies, said his father, San Diego eye surgeon Bruce Haight. The high-school senior used the family computer late at night and a debit card his parents had given him to buy baseball cards on EBay. Ryan would intercept the packages when they arrived in the mail from suppliers abroad and from the Web site of a small Oklahoma pharmacy. Ryan grew up with the Internet. In an interview, his father said the teen was a habitue of chat rooms, scoured collectors’ sites for baseball cards and enjoyed downloading music. When Ryan turned to more dangerous pursuits, the elder Haight said his son’s cunning and recklessness was “diabolical,” but he never had to risk arrest or harm on a dangerous street corner. Instead, he could turn to the familiar terrain of the Internet, operating under the screen name “Quiksilver.”

For young people in particular, online pharmacies seem to be especially seductive, says University of Pennsylvania researcher Robert Forman. For this generation, the Internet is a familiar medium where friends hang out, and it feels safe. “Getting drugs off the Internet is as natural as downloading a song,” says Forman. “And in their mind, it may be viewed as no more illegal or likely to be detected.”

Online pharmacies began springing up in the late 1990s, largely to hawk “lifestyle drugs” such as Viagra, the erectile dysfunction medication that quickly achieved blockbuster status after its introduction in 1998. Other drugs that proved popular on the Internet included the baldness treatment Propecia, various diet pills and, after a wave of bioterrorist scares, the potent antibiotic Cipro, a medication prescribed for anthrax infection.

But in the last two years, investigators say, these rogue pharmacies have entered a new phase: selling drugs with wide appeal among abusers -- addictive drugs ranging from Xanax and Soma (anti-anxiety and muscle relaxant medications, respectively) to Percocet, Darvon and OxyContin (all powerful opiate-based painkillers).

*

No doctors needed

In many cases, especially when the drugs originate in foreign countries, no physician is involved at all. But for those cyber pharmacies seeking to convey an air of legitimacy, a physician will review a purchaser’s online questionnaire -- and sometimes conduct a brief telephone interview -- and write out a prescription. While widely recognized by physicians as unethical and unsafe, this medical practice is not uniformly illegal.

Dr. Robert C. Ogle, who signed the prescription that sent 100 Hydrocodone tablets to the then-17-year-old Ryan, was one of these doctors. An osteopath in Rockwall, Texas, Ogle wrote 5,866 prescriptions for Norman, Okla.-based nationpharmacy.com in a seven-month period, earning $249,305.

According to Texas state medical board documents and information provided by the elder Haight, Ogle conducted no exams, ordered no tests and verified no claims made on Internet questionnaires by his “patients,” including Ryan’s claims that he was 22 and that he had chronic back pain. Ogle pleaded guilty earlier this year to one count of conspiracy to distribute a controlled substance and one count of money laundering, and is awaiting sentencing. The Haight family has filed a wrongful-death suit against him, and last month, the Texas State Board of Medical Examiners stripped Ogle of his license to practice medicine.

When online pharmacies became more commonplace in the late 1990s, public health officials began investigating the accessibility of lifestyle and other prescription drugs outside the established doctor-patient routine. Americans essentially were diagnosing themselves, picking out their own medications and choosing their dose. Even with a widely prescribed medication like Viagra, some people experience dangerous drug interactions, negative side effects and missed or delayed diagnoses of underlying diseases, such as diabetes and heart disease.

But the new trade in controlled substances has raised another, more disturbing prospect -- that of a generation hooked on drugs with the ease of logging on to a computer.

“It is a significant public health hazard,” says Dr. Robert N. Thompson, chief executive of the Federation of State Medical Boards. “The market has grown because we have a very entrepreneurial society and there are people willing to behave in an unethical fashion simply for the sake of greed.”

As the Internet drug trade continues to grow, investigators are struggling to understand the methods and the scope of this shadowy market. The Federation, which authoritatively tracks the trade, estimates that 1,200 Internet sites at any given time are selling pharmaceuticals illegally.

*

How they avoid detection

According to the Federation’s investigators, Internet pharmacies tend to pop quickly, spin off dozens of Web sites and, just as suddenly, disappear, only to reappear under a different name to avoid detection. The marketing, record-keeping, storage and distribution operations of these pharmacies can be scattered across many states or countries. A Web site registered in Honduras, for instance, may peddle drugs stockpiled in Nevada, use a prescription-writing doctor licensed in Florida and have payments sent to a post-office box in Oklahoma.

These tactics make cyber pharmacies nearly impossible for investigators to trace. They also put many of these complex interstate transactions beyond the law’s reach, because the regulation and licensing of pharmacies and medical practices rest mainly with the states. Only 30 states have regulations in place that can be used to bar online pharmacies from operating. But they can’t reach across state lines to cripple a whole network, and few states have dedicated much money to enforcement.

And where, meanwhile, do the drugs come from? They are sometimes diverted from legitimate wholesale or retail operations within the United States, often under the pretense that they are for use in hospitals and nursing homes, federal investigators say. But they are just as likely to come from Canada, India, Mexico or Thailand -- in many cases, countries with scant regulation of pharmaceuticals and few resources to halt drug trafficking. Sometimes, the goods are American-made pharmaceuticals shipped abroad and imported back into the United States, but they are sometimes foreign-made copies -- some produced under legitimate licensing agreements and some outright knockoffs, all manufactured under varying degrees of quality control.

Commercial re-importation is illegal, but the U.S. Food and Drug Administration estimates that about 2 million parcels containing prescription drugs enter this country through the mail yearly. Customs and the Postal Service reported that seizures of packages jumped 45% in 1999 alone, and they have grown since. But U.S. officials acknowledge that most pharmaceuticals -- packaged in sandwich bags and tissue paper, hidden in books and teddy bears, and often openly labeled as drugs -- are still getting through.

Unlicensed pharmacies can operate with almost brazen openness, dispensing prescription drugs to just about anyone with Internet access and a credit card. Most of the pharmacies contend on their Web sites that what they are doing is legal. Some offer free samples of anything in their inventory, including narcotics such as Oxycodone. A few promise to reship an order if it is confiscated by authorities.

“It’s an incredible challenge,” says Elizabeth Willis, chief of drug operations in the Drug Enforcement Administration’s Office of Diversion Control.

And the underground market for prescription drugs, already enormous, is growing. The National Clearinghouse for Alcohol and Drug Information estimated in a 2001 report that 4 million Americans ages 12 and older had acknowledged misusing prescription drugs. That accounts for 2% to 4% of the population -- a rate of abuse that has quadrupled since 1980. Prescription drug abuse -- typically of painkillers, sedatives and mood-altering drugs -- accounts for one-third of all illicit drug use in the United States.

The FDA, which regulates the safety and effectiveness of pharmaceuticals in the United States, has relatively few weapons to control the online sale of prescription drugs. With limited legal jurisdiction over the practices of pharmacies and doctors in the United States and none outside the U.S., the FDA has worked mostly through groups such as the National Assn. of Boards of Pharmacy and the Federation of State Medical Boards.

*

FDA lacks muscle

FDA officials have warned consumers on the dangers of pharmacy Web sites without evident documentation, and have offered tips (www.fda.gov/oc/buyonline/default.htm) on how to identify legitimate ones. Beyond that, the FDA can do little more than issue “cyber warning letters” to the operators of online pharmacies, informing them that they may be operating unlawfully. The FDA has sent out nearly 200 such letters.

According to Thomas McGinnis, the FDA’s director of pharmacy affairs, about 70% of those who have received warnings ignore them and continue to operate. The remaining 30% respond to the FDA, he said, often claiming that they believed their activities were legal. But they often disappear afterward, said McGinnis, who suspects many return to business under different names.

The FDA, largely working with state officials, has opened 372 Internet drug-related criminal investigations and has helped prosecute 142 people involved in the online drug trade (securing 106 convictions). But most officials who track the trade acknowledge that that is a drop in the bucket.

However, the move by online pharmacies into sales of narcotics and amphetamines has delivered law-enforcement officials a more potent lever. When the drugs involved are controlled substances -- drugs considered to have clear potential for abuse and addiction -- the DEA can conduct investigations and press criminal prosecutions across state lines. And when foreign governments cooperate, the federal agency can pursue U.S. lawbreakers abroad.

The DEA also works to identify the physicians writing prescriptions for illegal pharmacies -- often a challenging task, says the agency’s Willis. The agency has the authority to pull the physician’s license to prescribe controlled substances. Without such prescription-writing powers, the doctor’s ability to practice would be very limited.

In 2000, California became one of the first states to adopt a law barring physicians from prescribing drugs without first conducting a physical examination. Currently, all but 20 states have similar prohibitions in place, although not all have the force of law. For the San Diego eye surgeon, it is a mystery as to why men and women in his profession would behave so recklessly. “They’re just people in that gray zone who weren’t quite good enough to get a job, or who lost [a job] ... people just desperate to find some line of work,” he surmised.

Such doctors, Haight believes, are helping to transform the Internet from a rich resource of information and entertainment into a very different and dangerous place, especially for young people. Whereas some parents have found themselves looking through their children’s sock drawers when they feared a problem with drug use, today they may also feel compelled to search the computer. “You’ve got to be suspicious, got to do some parenting,” says Haight. “Unfortunately, I found out the hard way.”