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The tragic death of 18-year-old Ryan Haight highlighted the ethical, public health, and youth patient safety concerns posed by illicit online nonmedical use of prescription drugs (NUPM) sourcing, leading to a federal law in an effort to address this concern. Yet despite the tragedy and resulting law, the NUPM epidemic in the United States has continued to escalate and represents a dangerous and growing trend among youth and adolescents. A critical point of access associated with youth NUPM is the Internet. Internet use among this vulnerable patient group is ubiquitous and includes new, emerging, and rapidly developing technologies—particularly social media networking (eg, Facebook and Twitter). These unregulated technologies may pose a potential risk for enabling youth NUPM behavior. In order to address limitations of current regulations and promote online safety, we advocate for legislative reform to specifically address NUPM promotion via social media and other new online platforms. Using more comprehensive and modernized federal legislation that anticipates future online developments is critical in substantively addressing youth NUPM behavior occurring through the Internet.
On February 12, 2001, Ryan Haight, an 18-year-old honors student and varsity athlete from California, USA, died from an overdose of the opioid prescription drug Vicodin (hydrocodone/acetaminophen) bought from an online pharmacy without a prescription [
However, the effectiveness of the RHA on NUPM online sourcing and regulation of online pharmacies has not been well established or studied. Consequently, the problem of illicit online sourcing of controlled substances and other medications without a prescription has yet to be adequately resolved [
In order to inform policy efforts to address youth NUPM and current regulatory limitations, we explore the potential public health and patient safety implications of promotion of youth-based NUPM in social media. To do so, we first review current national trends in youth NUPM behavior and Internet and social media utilization. We then examine the use of social media by illicit online pharmacies in promoting NUPM and analyze current policy instruments, including the RHA. We then recommend policy solutions and advocate for additional research to better inform the public and ensure safe Internet access to prevent youth NUPM.
Since Ryan Haight’s death, prescription drug abuse among youth has become part of a larger national trend of morbidity and mortality associated with drug overdose, diversion, and polydrug abuse [
Crucially, a key high-risk group for NUPM is youth (children and adolescents, aged 12-17). Estimated prevalence of NUPM among this age group is high, with the CDC reporting in 2011 that 20.7% of high school students had engaged in NUPM (OxyContin, Percocet, Vicodin, Adderall, Ritalin or Xanax) [
Youth narcotic and controlled substance NUPM, which includes commonly abused pain medications such as OxyContin and Vicodin, is perhaps the most deeply concerning risk to youth health development and has even been associated with illicit heroin drug abuse [
Traditional methods of drug diversion, including person-to-person purchasing, trading, loaning, sharing, stealing and theft, family member and friend access, street drug purchases, prescription forgeries and fraud, and “doctor/prescription shopping”, have traditionally enabled NUPM [
Although these programs may provide controls to stem diversion of high-risk prescription drugs to youth populations [
Exacerbating risks of NUPM access is unregulated content on the Internet, the use of which is now ubiquitous among both youth and adults. Indeed, survey data from the Pew Research Center’s Internet and American Life Project (Pew Internet) indicate that some 72% of US adult Internet users search for health and medical information online and that more than one third engage in health care self-diagnosing [
As might be expected, Internet use by the youth demographic is almost universal. Pew Internet reports that an estimated 95% of teens (ages 12-17) [
Although this population group has widespread adoption of the Internet and social media, they may not engage in safe online behavior. For example, at least 44% of teens admitted they lie about their age to access websites or to set up an online account [
Within this already vulnerable population, there is also a disproportionate income effect. Teens from lowest-income families are twice as likely (23% vs 11%) to seek health information online compared to teens from higher income households [
Youth online behavior trends indicate that this population is adopting digital technology for consumption of health information and may be engaged in risky online behavior, which can increase risk for Internet-enabled NUPM [
Importantly, any online pharmacy purportedly marketing the sale of a prescription medication without the need of a prescription is both violating applicable US laws and regulations, as well as promoting NUPM behavior given that adequate controls to ensure patient safety are lacking. This promotion of NUPM is often facilitated by false and misleading marketing used in online direct-to-consumer advertising (DTCA) [
Despite its illegality, the spectrum of drugs available for online NUPM sourcing is virtually unlimited [
Collectively, these studies illustrate that illicit online sourcing represents a potential risk factor for youth NUPM. Illicit NUPM promotion through Internet pharmacies engenders a completely unregulated system of parallel access for youth. This can lead to self-prescribing of virtually any medicine, resulting in drug abuse and dependence, as well as use of drug forms that are of questionable quality, authenticity, and safety, all without medical or parental oversight [
Recognition and needed research on the convergence of social media and youth NUPM is highly uneven. Despite growing evidence of online sourcing risks, a recent systematic review of NUPM behavior among adolescents failed to mention online information seeking/sourcing or social media usage as a specific risk factor [
Some studies have also attempted to assess this area of risk. Previous research has identified increasing use of popular social media platforms by illicit “no prescription” online pharmacies marketing the sale of several high-risk drug products [
Another published study examined the use of Twitter to discuss Adderall NUPM behavior among college students [
Though an evidence base supporting the association between social media and NUPM is beginning to emerge, there is an urgent need for additional research specifically examining in detail NUPM-related risk factors enabled by social media. This should be pursued in conjunction with policy analysis to determine if current law and legislation can effectively regulate this digital medium to ensure youth and patient safety.
More than 10 years after Ryan Haight’s unintentional death, youth online-enabled NUPM access remains relatively unabated despite legislative and law enforcement efforts. Global action (such as Interpol’s Operation Pangea) have led to the closure of some illicit online pharmacies [
The specific mechanisms of the RHA to stem controlled substance online NUPM focus on registration, licensure, disclosure, and reporting requirements for online pharmacies offering controlled substances as well as requiring valid prescriptions for dispensing (including at least one in-person examination) [
Additional gaps in the RHA in effectively dealing with the illicit online sale of controlled substances have also been reported. This includes websites “unlocking” hidden content that provides access to controlled substances and using affiliate networks and portal sites to avoid law enforcement detection [
Further highlighting the limitations of the RHA in effectively regulating controlled substance NUPM, a 2011 report by online monitoring company LegitScript, published a sample list of 1000 illicit online pharmacies actively offering the sale of controlled substances without a valid prescription (including over half with domain name or server presence in the United States)—an activity in direct violation of the RHA [
Associated risks of NUPM to patient safety and public health are high, but in no group is the risk greater than in youth and adolescents. The physical, mental health, and emotional harms from youth NUPM can have lasting impacts for this vulnerable population [
Reform should begin with examining amendment and modernization of the RHA to improve its scope, effectiveness, and enforceability over illicit online NUPM promotion of prescription controlled substance drugs where it is actively occurring. First, the RHA does not specifically address other nonInternet pharmacy actors that actively facilitate this illicit trade. These Internet service intermediaries are clearly enabling NUPM behavior and sourcing and may also profit from this illicit activity through generation of revenue from search engine marketing/optimization, ad revenue, and processing, membership, and referral fees [
These enabling risk factors require RHA amendment to expand its scope and enforcement powers to address new forms of digital communication and media that promote online NUPM. This could be accomplished by amending the RHA to include a new definition of “Enabling 3rd Party Intermediaries” to capture additional and relevant online mediums promoting NUPM and illicit access points. Through amending the RHA to include this provision, this term can encompass online digital technologies, including nonpharmacy websites, Internet service providers (ISPs), Web applications, mobile-based platforms/games, payment processors, affiliate sites, membership forums, and, specifically, social media sites. Further, it can focus on high-risk and clearly illegal online promotion activities that advertise sourcing without a prescription, facilitate NUPM sourcing (through direct links to online pharmacies, online ads, etc), or fail to monitor and remove direct marketing associated with NUPM promotion often in direct violation with their own legal terms of conditions and use (including key social media platforms) [
Indeed, despite potential facilitation of illicit sourcing, third-party sites have remained largely unregulated and have for the most part escaped enforcement efforts [
In addition, in order to provide consumers with important and necessary information on safe online sourcing of controlled substances, the RHA should also be amended to require the DEA to publish a publicly available list of online pharmacies that have successfully modified their DEA registration to allow online sale of controlled substances as statutorily required under the Act [
Past failed legislative efforts to more dynamically regulate online pharmacies may provide important lessons for future potential solutions. In 2012, two US congressional bills, the House’s Stop Online Piracy Act and the Senate’s Protect IP Act, included provisions to regulate domestic and foreign online pharmacy websites, and associated search engines, payment processors, and other ISPs, that facilitate illicit online drug e-commerce [
In retrospect, it seems clear that important public health considerations to protect consumers online need to be positioned in their own unique legislation that solely addresses issues of patient safety and does not concurrently address commercial or intellectual property rights. Hence, an amendment of the RHA may provide for such a policy forum, as controlled substance NUPM among youth and adolescents continues to represent a national public health crisis that existing law has arguably failed to adequately address and the subject is sufficiently narrow in scope compared to general anticounterfeiting legislation. Though legislative action may face challenges, amendment of the RHA could modernize the Act to respond to emerging digital technologies, provide additional tools to the DEA in pursuing enforcement, and address regulatory gaps currently being exploited by illicit online pharmacies
Last, there is a need for better cooperation and tangible action by stakeholders currently advocating for action against illicit online pharmacies. The Center for Safe Internet Pharmacies (CSIP), a nonprofit organization with goals of combating illegal online pharmacies through education, enforcement, and information dissemination, was formed in 2011 and is a partnership between numerous private sector entities actively involved in e-commerce [
Included in CSIP membership as a strategic partner and board member is the world’s largest social media platform, Facebook [
The frenetic pace of technology change through new forms of digital sources has quickly made existing legislative approaches to maintain online drug safety antiquated. This is reflected in today’s “Ryan Haight”, who is not only frequently on the Internet but is also a common if not daily user of popular social media sites such as Facebook, a platform already linked to NUPM promotion [
Hence, it is crucial that particularly youth, who are already at high risk of NUPM and are the most active demographic on the Internet, be provided a safe online environment to make rational and informed choices not to engage in dangerous health behavior. Unfortunately, the present environment presents significant challenges for this important decision-making process and attempts at prevention. Hence, domestic and international approaches addressing NUPM must be modernized to meet the needs of a new digital youth generation and prevent the unnecessary death of the next Ryan Haight.
Attention Deficit Hyperactivity Disorder
US Centers for Disease Control and Prevention
Center for Safe Internet Pharmacies
US Drug Enforcement Agency
direct-to-consumer advertising
US Food and Drug Administration
Internet Service Providers
National Association of Boards of Pharmacy
nonmedical use of prescription medicines
Prescription Drug Monitoring Programs
Pew Research Center’s Internet and American Life Project
Ryan Haight Online Pharmacy Consumer Protection Act
Verified Internet Pharmacy Practice Sites
TKM is the 2011-2012 Carl L Alsberg, MD, Fellow of the Partnership for Safe Medicines and the Rita L Atkinson Fellow and gratefully acknowledges their support. Dr Strathdee is supported through a NIDA MERIT Award (R37 DA019829).
Timothy K Mackey (TKM) and Bryan A Liang (BAL) received no extramural support from any organization for the submitted work. TKM is the 2011-2013 Carl L Alsberg MD Fellow of the Partnership for Safe Medicines (PSM), which supports his general research activities. BAL is a voluntary board member and Vice President of PSM and receives no compensation for any PSM activities. PSM is not connected with the submitted work. BAL also serves as a member of the US Agency for Healthcare Research and Quality, Healthcare Safety and Quality Research Study Section, and the National Patient Safety Foundation Research Program Committee, both of which consider grant proposals addressing medication safety. TKM and BAL report no other relationships or activities that could appear to have influenced the submitted work. Steffanie A. Strathdee reports no conflicts of interest associated with this manuscript.