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Therefore, pharmacists need to be aware of indicators that an online pharmacy Web site is unsafe in order to counsel patients. Unsafe sites 5 :. Offer to dispense prescription-only medications without a valid order from a licensed prescriber. Conversely, a trustworthy online pharmacy site requires a valid prescription from a licensed health care professional prior to dispensing, contains appropriate contact information for the site, provides online usa to a licensed pharmacist, and is licensed by the state board of pharmacy where the Web site is located.

The criteria may be broken up into various categories and are summarized in Table 1. Although several laws exist to regulate online pharmacies, oversight and enforcement are poor.

Pharmacists should be aware of the far-reaching nature of this problem and direct patients to legitimate online pharmacies that have the NABP VIPPS seal of approval in order to promote ordering of safe medications through the Internet. Hosp Pharm. Published online Sep Author information Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Unsafe sites 5 : Do not provide contact information including a phone number.

Offer prices for medications that are dramatically lower than competitors. Do not protect the personal health information of the patient. Category Criteria Licensure and policy maintenance Provide NABP with the necessary documents to ensure that the pharmacy is licensed to operate in all applicable jurisdictions.

Provide NABP with documentation that all individuals affiliated with the site are appropriately licensed. Develop and enforce a comprehensive policy and procedure document. Comply with all applicable statutes and regulations. Prescriptions Develop and enforce policies and procedures that ensure the integrity, legitimacy, and authority of the prescription drug order.

Prevent drug orders from being submitted and filled by multiple pharmacies. Prevent medications from being prescribed or dispensed based upon telephonic or online medical consultations that do not result from a pre-existing prescriber-patient relationship. Patient information Develop and enforce policies and procedures that ensure reasonable verification online pharmacies no prescription the identity of the patient, prescriber, and caregiver if applicable.

Obtain and maintain patient medication profiles. Conduct a prospective drug use review prior to medication dispensing. Ensure patient confidentiality and protect patient-specific information when such information is transmitted over the Internet.

Communication Develop and enforce policies and procedures that require pharmacists to offer consultative services online pharmacy patients. Develop a system regarding reporting of adverse drug reactions and errors.

Develop a mechanism for contacting patients regarding delays in delivering a prescription medication as well as drug recalls. Develop a mechanism for educating patients regarding disposal of expired, damaged, or unusable medications.

Storage and shipment Develop a system for shipping controlled substances safely and securely. Unlike controlled substances with the potential for abuse, there are no current laws regulating the sale of these other potentially dangerous prescription medications through NPOPs. The main arguments against taking the easiest step, which would be to simply eliminate all online pharmacies, is that they are difficult to close down [ 4 ] and that with appropriate controls they can provide consumers advantages in both cost and accessibility [ 1 - 520 ].

In fact, one study demonstrated the efficacy of utilizing online pharmacies no prescription accredited online pharmacy to prescribe Viagra. Patients who used the online pharmacy showed similar numbers of side effects and similar treatment efficacy compared to those receiving Viagra through a local pharmacy.

They also provided a more complete medical history [ 21 ]. To manage the increased use of online pharmacies, however, more regulations are online pharmacies no prescription proposed, including the Online Pharmacy Safety Act and the online pharmacies no prescription of state-run online pharmacy programs [ 2223 online pharmacies no prescription.

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 [ 24 ].

Unfortunately, this accreditation is limited to domestic online pharmacies and, as it only approves online pharmacies that require a valid prescription [ 24 ], it does not address the larger issue of people seeking medications through NPOPs outside of a typical doctor-patient-pharmacy relationship.

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 [ 725 - 31 ]. This lack of oversight generates a number of safety concerns for NPOP consumers in distribution, information, and medication-related issues. Distribution issues include damaged packaging that exposes pills to light and moisture, shipments that do not meet manufacturer specifications such as temperature-controlled or insulated packagingand the ability of the consumer to reorder as many pills as desired [ 8 - 1032 - 33 ].

The lack of proper labeling or safety information is common with NPOP-purchased medications and provides consumers with little to no information on dosage scheduling, dosage administration, or potential side effects [ 932 - 36 ]. Finally, the medications themselves could be expired, counterfeit, or cut with other substances.

Even genuine drugs purchased from NPOPs could lead to a number of adverse events, including death, if the user is unaware of dangerous drug combinations or contraindicated medical conditions [ 353237 ]. 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 price drug 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 online pharmacies no prescription 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 [ 38 ] and it is one of the most commonly offered authentic drugs from NPOPs with few restrictions on refills or quantity of tablets offered [ 810 ].

Tramadol has a demonstrated abuse profile [ 39 - 41 ], but its rate of abuse is not as high as other opioids hence its noncontrolled status in the Controlled Substances Act. Like all drugs, there is also the potential for adverse side effects that can pose serious health risks. For example, tramadol not only has the potential to produce many of the same adverse events as other opioids eg, constipation and dependence [ 39 ]but also carries a serious risk of potentially fatal grand mal seizures, which are exacerbated by contraindicated medications and medical conditions [ 42 - 44 ].

In a prior report, we documented the ease of obtaining tramadol over the Internet, the authenticity of which was certified by a chemical analysis [ 8 ]. The purchase required the completion of a brief questionnaire that served as online pharmacies no prescription medical examination.

Subsequently, a virtual prescription was generated and filled by a pharmacy in Canada. The tramadol was received within 24 hours, and numerous phone calls and emails were received almost immediately to refill the prescription some offers included up to pills in a single order and have continued on a monthly basis for over three years thus far.

It has been widely documented that recruiting and administering surveys over the Internet is an acceptable and beneficial research methodology [ 45 - 46 ]. While these methods provide quick access to thousands of people, they are not easily used to attract a targeted audience. To circumvent this problem, we developed a recruitment program online pharmacies no prescription directly targeted a population of tramadol users with access to the Internet. Thus, our advertisement only appeared to Internet users who had an interest in tramadol or tramadol-related topics, making our target population more likely to include potential participants ie, users of tramadol.

When users clicked the ad, they were automatically directed to an online consent form and the subsequent survey hosted on an institutional website. Subjects were screened to be 18 years of age, users of tramadol in the past 30 days for any reason, and United States residents. 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.

Restricting Internet Access to Prescription Drugs | Prevention [email protected]

A total of tramadol users qualified for and completed this study. Of onljne participants, indicated that they received tramadol solely through a valid prescription from their local doctor and filled it at a local pharmacy.

As shown online pharmacies no prescription Table 1both traditional and nontraditional users were primarily white and female. Traditional users were significantly older than nontraditional users.

Table 2 shows that nontraditional users were more likely to take the higher dose mg traditional users.

My Canadian Pharmacy: Overview, Key Principles and Offers

Nontraditional users were also considerably more likely to use tramadol more frequently online pharmacies no prescription or more times per week. All traditional users used tramadol for its indicated purpose ie, to treat painwith only 2. Nontraditional users experienced a much more severe adverse event profile than traditional users Figure 2.

Both pharmaceis had high rates of suddenly stopping their use of tramadol, but nontraditional users were significantly more likely to cease use abruptly traditional users: Upon cessation, nontraditional users experienced more severe withdrawal symptoms than traditional users see Figure onlinf.

If an illegitimate pharmacy offers prescription medications at a deep Additionally, in those online pharmacies where no physician is. Objective: This study focused on the motivations for using no-prescription online pharmacies (NPOPs) to purchase prescription drugs rather.

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.

While the precise mechanisms are unknown, seizures are more prevalent in people who take online pharmacies no prescription doses of tramadol [ 4252 ], have predisposing medical conditions eg, history of head injuries [ 53 ], or take contraindicated medications eg, tricyclic antidepressants [ 54 - 55 ]. Physicians are trained to recognize such predisposing factors, but nontraditional users are likely to be unaware of these potential complications, leading to poor health outcomes.

Moreover, we found that nontraditional users experienced much more intense opioid withdrawal symptoms when they stopped taking tramadol. The most logical explanation for these findings is that the lack of physician oversight in monitoring dosage schedules, contraindicated conditions, and concomitant medications was online pharmacies no prescription for the increased intensity and frequency of adverse events in nontraditional users.

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.

There are several possible interpretations of the latter motivation. Second, the physician denied the patient additional tramadol because the doctor incorrectly believed the pain was managed drugs online 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.

Regulation of Internet Pharmacies: A Continuing Challenge - PMC

This should not be surprising given the well-documented regional, social, and economic phqrmacies in access to medical care in the United States [ 56 - 59 ]. It is also possible that some NPOP users, while initially using tramadol for therapeutic purposes, had predisposing factors that led to the development of tramadol online pharmacies no prescription or abuse. This euphorigenic use, a health outcome itself, would have led to higher dosages and increased phaarmacies of use, playing a role in the higher rates of adverse events.

In a physician-patient relationship, however, a doctor may have recognized predisposing factors for misuse and not prescribed an opioid analgesic or, if already prescribed, recognized the signs of abuse and misuse and switched from tramadol to a less addictive drug.

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 prescgiption 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 online pharmacies no prescription being discussed to control the use of online pharmacies, some of which ban the use of those located outside of the United States [ 2223 ], but phxrmacies following two factors need to be considered.

First, the passage of online pharmacy regulations that promote verification programs [ 24 ], licensure and location disclosures [ 3 ], standardized criteria for Internet-based prescriptions [ 60 - 61 ], and a more thorough analysis of the advantages and disadvantages of online health care services eg, the ability of online pharmacies to detect interactions between medications instantly [ 5 ] may help integrate online pharmacies into health care utilization models.

U.S. Food and Drug Administration

The reality, however, is that regulating these legitimate online pharmacies is likely to have no effect on those using NPOPs. These users have already turned their back on typical medical channels and seem to be able to quickly adapt to any change in access to online pharmacies no prescription pharmacies eg, shift of NPOPs to foreign countriesand no amount of regulatory oversight would likely change their drug-purchasing behaviors.

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 [ 2162 ].

Because online pharmacies no prescription aggressive marketing and pricing strategies, as well as the recent shift in patients becoming more involved in their own health care decisions, people using online pharmacies are in danger of unconsciously transforming from patients to consumers, and then back to patients again when they suffer from adverse effects from the use of the drug [ 1363 - 64 ]. Patients should be aware of the real possibility that while offshore pharmacies may be cheaper and easier to use, the medications received may not be what was advertised.

For this reason, recent US Food and Drug Administration FDA and WHO reports have advocated global drug safety, including international cooperation regarding the regulation of online pharmacies [ 1131 ].

Such an effort is badly needed because if one country attempts to ban online pharmacies, most users will simply try a website from another country. Clearly, in addition to regulatory activity, educational efforts are needed to ensure that patients and physicians understand the positive and negative aspects of online pharmacies. Perhaps most importantly, more research is needed to better understand the motivations of people who, despite the availability of legitimate online pharmacies, continue to seek medications using NPOPs.

Inherent in this study are all online pharmacies no prescription 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 online pharmacies no prescription 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 buy cialis 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.

This study was financed with institutional funds and was approved by the Institutional Review Board at Washington University in St. Edited by G Eysenbach; submitted Skip to Main Content Skip to Footer. Article Authors Cited by 18 Tweetations 10 Metrics. Original Paper. Louis Online pharmacies no prescription Box S. Euclid Ave. Table 1. Demographics and health information for traditional and nontraditional users.

Table 2. Tramadol use among traditional and nontraditional users. Quality of global e-pharmacies: can we safeguard consumers? Eur J Clin Pharmacol Dec;58 9 Controversies and legal issues of prescribing and dispensing medications using the Internet.

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Mayo Clin Proc Feb;79 2 Online pharmacies: safety and regulatory considerations. Int J Health Serv ;37 2

“No prescription” websites are online venders that sell prescription drugs (particularly opioids and other controlled drugs) without a valid prescription. Offer to dispense prescription-only medications without a valid order from a licensed prescriber. Deliver medications that are of unknown quality or origin or.

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