E-drug: prescribing on the internet
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BMJ 1999;319:213 ( 24 July )
News
American Medical Association moves to regulate prescribing on the
internet
Douglas Carnall , BMJ
Prescribing drugs on the internet by relying solely on the completion
by the patient of an on-line questionnaire "falls well below a minimum
standard of medical care," according to an interim report issued last
week by the Board of Trustees of the American Medical Association, and
action should be taken against doctors who fail to meet this standard.
At least 10 state legislatures are investigating doctors who have
prescribed in this way, among them the Washington Medical Quality
Assurance Commission, which has initiated a licensure action against a
Seattle doctor reportedly earning $5000 (�3125) a month from on-line
sales of sildenafil (Viagra).
The report estimated that at least 400 "instant prescription" websites
exist, which usually require the buyer to acknowledge a liability
waiver, select a quantity of the drug to be purchased, and complete a
short on-line questionnaire.
Among them is Direct Response Marketing, based in the Channel Islands
(www.direct-responsemarketing.co.uk), which is typical in offering
sildenafil for impotence, orlistat (Xenical) for weight loss,
finasteride (Propecia) for hair loss, and bupropion (Zyban) as an aid
to stopping smoking. Its managing director, Tom O'Brien, is not
medically qualifiedhe started out in the mail order drugs business 11
years ago selling minoxidil through press advertising but has no
qualms about the ethics of his business. "Our business is to sell
lifestyle treatments to people who have proven their intelligence by
accessing the internet and owning a credit card. We pay two
independent doctors on a percentage deal to assess the web forms." He
added: "We have regular inspections by the medical authorities here on
Jersey, and they are quite happy with our procedures."
The American Medical Association's board maintains that the terms used
in such questionnaires are often beyond the technical comprehension of
a lay person and that no mechanism exists to ensure that the questions
have been answered correctly or to confirm the history by physical
examination. But the board recognises that the Food and Drug
Administration has limited powers to influence overseas businesses,
accepting that "such sites potentially render the whole concept of
prescription only drugs meaningless in the United States."
The board recognises that, despite potential dangers, there are
potential benefits of the internet for prescribing and dispensing
drugs. In the board's view, legitimate uses include transmission of
prescriptions to a pharmacy at the conclusion of a traditional face to
face consultation and the ordering of repeat prescriptions for chronic
conditions.
Insistence on the importance of physical examination between doctor
and patient is one of the keystones of the report, but it does
recognise that this might sometimes be unnecessary.
The report urged state medical boards and societies to investigate
local doctors who breach its guidelines, and it stated that efforts
will continue to develop model legislation to regulate internet
prescribing. The board also has plans to develop a programme of
"verified internet pharmacy practice sites" in association with the
National Association of Boards of Pharmacy.
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