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Many prescription drugs are freely available for purchase on the Internet without a legitimate prescription from a physician.
This study focused on the motivations for using no-prescription online pharmacies (NPOPs) to purchase prescription drugs rather than using the traditional doctor-patient-pharmacy model. We also studied whether users of NPOP-purchased drugs had poorer health outcomes than those who obtain the same drug through legitimate health care channels.
We selected tramadol as a representative drug to address our objective because it is widely prescribed as an unscheduled opioid analgesic and can easily be purchased from NPOPs. Using search engine marketing (SEM), we placed advertisements on search result pages stemming from the keyword “tramadol” and related terms and phrases. Participants, who either used the traditional doctor-patient-pharmacy model to obtain tramadol (traditional users, n=349) or purchased it on the Web without a prescription from their local doctor (ie, nontraditional users, n=96), were then asked to complete an online survey.
Respondents in both groups were primarily white, female, and in their mid-forties (nontraditional users) to upper forties (traditional users). Nearly all nontraditional users indicated that their tramadol use was motivated by a need to treat pain (95%, 91/96) that they perceived was not managed appropriately through legitimate health care channels. A majority of nontraditional users (55%, 41/75) indicated they used NPOPs because they did not have access to sufficient doses of tramadol to relieve pain. In addition, 29% (22/75) of nontraditional users indicated that the NPOPs were a far cheaper alternative than seeing a physician, paying for an office visit, and filling a prescription at a local pharmacy, which is often at noninsured rates for those who lack medical insurance (37%, 35/96, of NPOP users). The remainder of participants (16%, 12/96) cited other motivations (eg, anonymity) for using NPOPs. In terms of health outcomes, nontraditional users experienced a significantly (
Although online pharmacies can offer distinct advantages in terms of convenience and cost, users of these “rogue” pharmacies that offer drugs with no prescription or doctor supervision do so at great risk to their health, as evidenced by much higher rates of adverse events. The most logical explanation for these findings is that the lack of physician oversight of dosage schedules, contraindicated conditions, and concomitant medications, were responsible for the increased intensity and frequency of adverse events in the nontraditional users. Although we only examined tramadol, it is logical to postulate that similar results would be observed with dozens of equally accessible prescription drugs. As such, the geometric growth in the use of online pharmacies around the world should prompt intense medical and regulatory discussion about their role in the provision of medical care.
The Internet has evolved into a source of consumer products that were historically only available in “brick-and-mortar” establishments. Recently, there has been growth in the use of the Internet in medical practice, most prominently in the use of online pharmacies to fill physicians’ prescriptions and mail the drug directly to the patient. These pharmacies serve as an important resource for patients, particularly for those who have limited mobility or accessibility needs [
Initially, as the number of no-prescription online pharmacies (NPOPs) [
While controlled substances may not be readily accessible from domestic NPOPs [
In a major effort to steer consumers toward legitimate online pharmacies that are safe to use and away from rogue online pharmacies that pose a potential threat to consumer safety, the National Association of Boards of Pharmacy developed the Verified Internet Pharmacy Practice Sites (VIPPS) program to accredit online pharmacies based on a number of qualifying criteria [
It should be stressed that no matter what legislative controls are adopted, there is a simple way to bypass these restrictions: move the NPOPs offshore, which is rapidly occurring with little government control [
While the recent focus, appropriately, has been placed on the regulation of online pharmacies, there is very little systematic research outside of case reports on two potentially more important basic issues: (1) why consumers use online pharmacies in the place of legitimate medical channels; and (2) with such a variety of safety concerns, why consumers of drugs purchased from NPOPs have worse health outcomes than those who obtain the same the drugs through legitimate healthcare channels. The study described in this paper was designed to address these issues.
Since most online pharmacies offer dozens of drugs for purchase, we needed to narrow the focus to users of a single representative target drug. Tramadol was selected as the representative drug for this study because it is extensively prescribed (the third most frequently used analgesic [
It has been widely documented that recruiting and administering surveys over the Internet is an acceptable and beneficial research methodology [
Since this study represents a preliminary approach into this area of research, no standardized instruments could address all points of inquiry. As such, we developed a descriptive tool centered on our representative drug, in which questions about dosage schedules, adverse events, etc, were specifically related to tramadol. While we developed this descriptive tool to meet the objectives of this pilot study, we hope that the results can provide a basis for a more standardized instrument that can be used to investigate the same objectives for any number of drugs purchased from NPOPs in future studies. Other than demographics, the survey covered a broad variety of topics related specifically to tramadol, including the following: dosage schedule, intended use, comorbidity, legitimate and illegitimate drug use, and adverse events. Participants who listed NPOPs as a source of tramadol were presented with a subset of questions to determine the underlying factors behind their use of online pharmacies.
A total of 445 tramadol users qualified for and completed this study. Of these participants, 349 indicated that they received tramadol solely through a valid prescription from their local doctor and filled it at a local pharmacy. These participants are referred to as “traditional users.” The other 96 participants are referred to as “nontraditional users.” This group obtained tramadol from an online pharmacy without a valid prescription from their doctor, and included those who were provided a prescription online by a “virtual” physician. We analyzed data using IBM SPSS Statistics Version 20. We used chi-square and logistical regression analyses to test for significant differences between traditional and nontraditional users at a
As shown in
Demographics and health information for traditional and nontraditional users.
Traditional users | Nontraditional users |
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(n=349) | (n=96) | ||||||
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Female | 67.0 | 57 | .08 | |||
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Caucasian | 80.2 | 91 | .02 | |||
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African American | 8.6 | 3 | .07 | |||
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Hispanic | 4.6 | 4 | .86 | |||
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Other | 6.6 | 2 | .09 | |||
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47.2 (0.7) | 38.5 (1.2) | <.001 | ||||
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Private | 36.8 | 35 | .71 | |||
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Dependent | 10.4 | 4 | .06 | |||
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Medicare/Medicaid | 25.2 | 13 | .009 | |||
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Military | 5.5 | 1 | .07 | |||
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Other | 5.8 | 11 | .11 | |||
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None | 16.2 | 37 | <.001 |
We asked nontraditional users what their primary reason was for using online pharmacies in place of other sources (
Motivations for using online pharmacies as a source of tramadol reported by nontraditional users (N=96). The values given are the percent of respondents who endorsed a motivation listed or specified a motivation that was not listed (in quotation marks).
Tramadol use among traditional and nontraditional users.
Traditional users | Nontraditional users |
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(n=349) | (n=96) | |||
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25 mg | 4.9 | 5 | .91 |
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50 mg | 83.7 | 73 | .02 |
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100 mg | 6.2 | 19 | <.001 |
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150 mg | 5.2 | 3 | .39 |
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1-2 times/week | 38.2 | 26 | .03 |
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3-4 times/week | 49.5 | 29 | <.001 |
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5 or more times/week | 12.2 | 45 | <.001 |
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Only to treat pain | 97.7 | 63 | <.001 |
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Both to treat pain and to get high | 2.3 | 32 | <.001 |
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Only to get high | 0.0 | 5 | <.001 |
Percent of traditional and nontraditional users who experienced each adverse event while taking tramadol. Asterisks denote a significant difference (
Both groups had high rates of suddenly stopping their use of tramadol, but nontraditional users were significantly more likely to cease use abruptly (traditional users: 41.9%, n=144/344; nontraditional users: 66%, n=61/92;
Percent of traditional and nontraditional users who experienced each withdrawal symptom as a result of the abrupt cessation of tramadol. Asterisks denote a significant difference (
Our data indicate that those who eschew the typical doctor-patient relationship to obtain tramadol through NPOPs do so primarily for reasons related to cost and accessibility and, most importantly, expose themselves to great health risks. We found that nontraditional users who used NPOPs had much higher rates of all recorded adverse events, particularly life-threatening seizures, than traditional users who obtained a prescription for tramadol from their physician. Seizures are quite rare in normal pain patients being treated with tramadol, observed at a rate of less than 1% [
Nearly all nontraditional users in our study indicated that their tramadol use was motivated, at least in part, by a need to treat a health condition (eg, pain) that was not otherwise managed through legitimate health care channels. It was this perception of their unmet medical need (ie, inadequate pain management) that drove them to use NPOPs. This finding raises an important question: Why were normal medical channels shunned in favor of an online pharmacy? There appear to be three distinct motivations for using online pharmacies: (1) inability to pay the costs associated with obtaining a legitimate prescription; (2) limited access to a doctor who would prescribe tramadol or prescribe it at doses sufficient to fully relieve pain; and (3) unwillingness, not inability, to use legitimate medical channels.
With regard to economic motivations, 37% (n=35/95 of NPOP users lacked medical insurance coverage and NPOPs are a less expensive alternative to seeing a physician, paying for an office visit, and filling a prescription at a local pharmacy at noninsured rates. Furthermore, many respondents indicated “no other way to get tramadol” as their main reason for using an NPOP, which suggests there were barriers to accessing a physician, such as cost or the patient’s distance from a medical facility. By far the most commonly reported motivation for using an NPOP was an issue of accessibility: the absence of a physician who was willing to prescribe tramadol either at all or at levels sufficient to meet a patient’s perceived need. There are several possible interpretations of the latter motivation. First, the patient had an unrealistic expectation for “total” pain relief and the physician believed that other drugs would be a suitable alternative to tramadol in providing tolerable pain relief. Second, the physician denied the patient additional tramadol because the doctor incorrectly believed the pain was managed to the extent possible (ie, inadequate pain management). Third, the physician was reluctant to prescribe opioid analgesics, even a weak one such as tramadol, at sufficient levels to adequately relieve pain due to the inherent fear of iatrogenic dependence. At this time, it is unclear which of these was the strongest motivation to use NPOPs, but lack of access to appropriate medical treatment appears to be a major factor. This should not be surprising given the well-documented regional, social, and economic differences in access to medical care in the United States [
While most of the foregoing discussion focused on pain management, 32% (n=31/96) of our population indicated they used an NPOP to buy tramadol for both its euphorigenic and analgesic properties. However, only 5% (n=5/96) reported the Internet as their primary source for tramadol as a drug of abuse. This agrees with a number of studies that show the Internet is not often used as a source of opiates among habitual drug abusers (<5% claim to have obtained their drugs from the Internet [
Although we used tramadol as a prototype in these studies, there is no reason to believe that different results would be observed with dozens of equally accessible prescription drugs obtained through NPOPs that are used without the oversight of a physician. The dangers of overdose and other adverse events with these medications, especially when little to no information about contraindicated medications and medical conditions is included with purchase, have the potential to be more clinically significant with other medications than those we observed with tramadol. As such, the geometric growth in the use of online pharmacies around the world, both legitimate and illegitimate, should prompt intense medical and regulatory discussion about their role, if any, in the provision of medical care.
Currently there are several bills and regulations being discussed to control the use of online pharmacies, some of which ban the use of those located outside of the United States [
Second, so long as a licensed doctor provides a prescription and the pharmacy verifies the legitimacy of the prescription, it would be inappropriate, perhaps unethical, to ban a patient from shopping around to find the most economical and convenient means of filling their prescriptions. Whether this doctor-patient relationship needs to be on a physical basis merits further discussion. Research has shown that email and virtual consultations are just as good, if not better, at capturing patient information necessary for health care decisions [
Inherent in this study are all of the limitations typical of epidemiological and survey research, most notably generalizability and veracity of information gathered. With regard to the latter, most studies indicate that the results obtained from self-administered surveys are comparable to those elicited by trained interviewers. In our study, there were no right or wrong answers. There was no incentive or need to lie about any information because respondents were paid for their participation regardless of their answers. In terms of a biased sample, it is true that our subjects might have greater economic status and certainly more computer literacy than the average person, but these users would most likely to be exposed to advertisements touting online pharmacies.
Our data suggest that online pharmacies may have a role in supplying prescribed medications because they are convenient and may charge less than traditional brick-and-mortar pharmacies. However, from a public health perspective, the potential benefits of online medical care need to be balanced against the use of unregulated pharmacies that could sell counterfeit or adulterated drugs and the dangers inherent in self-medication without any physician supervision.
US Food and Drug Administration
no-prescription online pharmacy
search engine marketing
Verified Internet Pharmacy Practice Sites
World Health Organization
This study was financed with institutional funds and was approved by the Institutional Review Board at Washington University in St. Louis.
None declared.