When addiction is a click away
Millions already may be hooked on Net-filled prescriptions,
and problem is growing
First of a series
By J. SCOTT ORR
STAR-LEDGER STAFF - WASHINGTON Kelly
Knable, a 34-year-old mother of three from the Richmond, Va., suburb
of Powhatan, didn't have time to be sick.
So when Knable was recovering
from surgery that fused several vertebrae in 1998, her doctor minimized her downtime by placing her on a regimen of prescription
drugs: first a narcotic called Lortab, then a nonnarcotic painkiller called Ultram.
For more than two years, she took two 50-milligram
Ultram tablets three or four times a day, which allowed her to maintain her busy schedule.
Then her doctor moved. Unable to find a new physician
to write her prescriptions, Knable turned to the Internet. By last
spring, she was spending thousands of dollars a month at online pharmacies and popping 30 to 40 Ultram tablets a day.
"That first
time I filled out a form and submitted it and it came back approved, it was like: 'Hey, I got my meds!' I started
taking more and more. It was so easy. I couldn't stop," Knable said
one day this fall, several months after enduring a painful detoxification.
With only a credit card and a computer, Knable had entered a multimillion-dollar shadow market in powerful prescription drugs
that is growing in plain view of federal and state authorities.
A step beyond the gray-market sites that offer lifestyle drugs like Viagra for
sexual dysfunction and Propecia for baldness, this market offers - without any direct contact with a doctor - some of the
most sought-after and addictive drugs available anywhere.
The federal government estimates 46 million Americans older than 12, or nearly
one in five, have abused prescription drugs at least once. But nobody knows how many people are feeding addictions anonymously
through Internet pharmacies.
Whether seeking pleasure or fleeing pain, customers of online pharmacies described themselves in interviews, e-mail
dialogues and Web site postings as functioning grown-ups who struggle to maintain jobs and family responsibilities while secretly
feeding their addictions.
They all said at least part of the reason they use online pharmacies is for the safe, easy access to federally controlled
medications.
Michael Montagne, a professor of social pharmacy at the Massachusetts College of Pharmacy and Health Science, said:
"You've got controlled substances, painkillers, narcotics, OxyContin, tranquilizers like Valium and Xanax, stimulants
like phentermine and Xenical. You name it. It's a very dangerous place.
"These sites are not your typical online pharmacies
selling Viagra," he added.
Like all the experts interviewed, Montagne was careful to make a distinction between legitimate online extensions
of traditional pharmacies such as CVS and Rite Aid that require customers to provide prescriptions from their primary-care
physicians, and questionable sites that provide both doctor referrals and pharmacy services.
"It's doing a disservice to a lot of people.
It's hurting a lot more people than it's helping," said Joseph A. Troncale, a physician and the medical director
at the Caron Foundation, an addiction-treatment facility outside Reading, Pa. "This is really just another facility of
the black market."
Troncale said people seeking drugs, whether to deal with chronic pain or to get high, are resourceful and will find
ways to get what they want.
"The biggest problem that we see with all of the people who use the Internet is it takes away the deterrent
of being caught by police, or by a pharmacist or a physician getting suspicious that he is being scammed for a 'script.'
The Internet makes it more simple, safe and easy for people," he said.
CAUGHT IN APRIL
Knable said she had no problem maintaining an ample
supply of Ultram, delivered to her door in her tidy, middle-class suburb, from a variety of online pharmacies.
She relied on the
Ultram not to get high, she said, but to give her enough energy to keep up with the demands of her business and family.
"Without the
Ultram I just wanted to quit everything and collapse. I knew that if I was tired at 10 p.m., with a couple more Ultram I could
go to midnight or 1 a.m.
"We're very busy people. To me it was: I can't be sick. I can't be down," she said.
The lie she was
living fell apart in April after Knable took her quest for drugs to
a new level, phoning in bogus prescriptions to pharmacies. She was arrested and forced to admit her addiction and seek rehabilitation
at the Coleman Institute in Richmond.
"It was humiliating to face reality and to say: 'Kelly, this is true. You have a major, major problem.'
My husband was very angry. I lied to him, I spent a lot of money. It was a horrible, horrible illness. That's what drove
me. I felt like I was going to die not having them."
Clifford Bernstein, medical director of the Waismann Institute, a Beverly Hills
facility that specializes in rapid detox, said an increasing number of patients tell him online pharmacies were their principle
source for drugs.
"Four years ago my practice was almost all heroin; now it's 70 percent prescription drugs. I attribute that
largely to the ease of obtaining these drugs on the Internet. With the Internet it is easier and, legally, it is safer,"
Bernstein said.
Often addicts who use Internet pharmacies, Bernstein said, are middle-aged professionals who can afford the high
costs of buying drugs online. Many times, they have a prescription from a doctor for painkillers and supplement them by shopping
online.
Bernstein - who, as a pain physician, prescribes narcotics to patients - said patients in pain become dependent on
drugs as the pain subsides. As addiction takes hold, tolerance develops and the drugs are needed for users to function and
to avoid withdrawal.
"Once they are clean, these people do just as well off the drugs as they do on the drugs," Bernstein said.
The
abuse of prescription drugs has increased dramatically in recent years, with marked increases in the abuse of some of the
online pharmacies' best-selling products, such as narcotic painkillers and anxiety drugs like Valium. Hydrocodone, the
active ingredient in Vicodin, Lortab and Lorcet, seems to have seen the biggest jump in usage.
In its annual drug use survey, the federal Substance
Abuse and Mental Health Services Administration found prescription drugs were second in popularity only to marijuana among
substance abusers last year.
In 2002, some 6.2 million Americans - 2.6 percent of the population 12 and over - were nonmedical users of prescription
drugs, meaning they had abused drugs at least once in the month before taking part in the SAMHSA survey.
That figure was
up from 3.8 million in 2000 and 4.8 million in 2001. According to SAMHSA, people admitted to emergency rooms with drug problems
increasingly named narcotic painkillers as the source of their distress. Over the period of 1995 to 2002, those who mentioned
painkillers more than doubled, from 45,254 to 119,185. (The 2002 figure was up 20 percent from the year before.) Mentions
of Valium and similar drugs were up 38 percent over the same seven years, from 76,548 to 105,752.
FOCUS ON BIG VIOLATORS
FOCUS ON BIG VIOLATORS The Drug Enforcement Administration and the Food and Drug Administration are well aware of the hundreds of Web sites
selling prescription drugs, and they do go after big operations from time to time. Still, federal authorities say they lack
the personnel to go after every drug seller in the murky, ever-changing environment of the Internet.
"We simply don't have the manpower to sit
there and surf the Net, looking for these operations," said Terrance Woodworth, deputy DEA director for the office of
diversion control.
"We don't have enough investigators to be determining what physicians or what pharmacies are doing right
or wrong. A person that is a big violator might come under scrutiny. Do we investigate any and every kind of violation? Absolutely
not," Woodworth said.
Woodworth's office, which is responsible for overseeing doctors and pharmacies to prevent prescription drugs
from being diverted to illegal channels, has fewer than 500 investigators. Woodworth said about 50 cases involving Internet
pharmacies are open at any time and those tend to focus on "major operations."
Federal law and laws in all 50 states mandate that
prescriptions for controlled substances be written by doctors "acting in the usual course of professional practice."
In
a memo published in the Federal Register in 2001, the DEA said this requirement means there must be a bona fide doctor-patient
relationship for such prescriptions to be legitimate. "Completing a questionnaire that is then reviewed by a doctor hired
by the Internet pharmacy could not be considered the basis for a doctor-patient relationship," the advisory said.
The American Medical
Association also frowns on doctors writing prescriptions based solely on online questionnaires: "Treatment, including
issuing a prescription, based solely on an online questionnaire or online consultation does not constitute an acceptable standard
of care," the AMA said in its guidelines.
Beyond the domestic sites that contract with doctors and pharmacies to provide
drugs to consumers, there are hundreds, perhaps thousands, of foreign sites that operate in violation of U.S. law by shipping
controlled substances into the country.
"We have shut down a number of domestic sites, but then there has been an
explosion in the foreign sites. The (foreign) local governments are not very aggressive in going after them. . . . It's
not their job, and the drugs are going to America, so they don't really care," said William Hubbard, associate FDA
commissioner for policy and planning.
"So many of these pills are coming in from foreign countries, it is very difficult to distinguish between what
is legitimate and what is not. At Dulles or JFK (international airports) there could be hundreds of these packages a day.
All the customs people are seeing are these little boxes of pills," Hubbard said.
This summer, the FDA and the Bureau of Customs conducted
a series of spot checks at international mail arrival centers in New York, Miami, San Francisco and Carson, Calif. Of 1,153
imported drugs that were checked, all but 134 were illegally shipped.
The drugs, which came from Canada, India, Thailand,
the Philippines and elsewhere, included narcotics and other often-abused drugs, along with counterfeit drugs and substances
that lack FDA approval.
When customs agents find small amounts of controlled substances in international mail, they send the addressee what
is known among online pharmacy users as "a love letter." It states that the importation is in violation of a host
of smuggling laws. The letter contains scary citations of the laws that have been broken, but goes on to say that the government
will merely destroy the drugs unless the customer wants to contest the seizure.
"If you fail to respond to this notice within
the 30-day period, the controlled substances will be forfeited to the United States Government and the case will be considered
closed," the form letter says.
In September, federal and state authorities shut down the Union Family Pharmacy in Dubuque, Iowa, saying it had filled
nearly 5,000 prescription orders in 47 states for the Web site buymeds.com between Aug. 19 and Sept. 1.
Last month, the
DEA shut down a pair of pharmacies in Davie, Fla., that were filling prescriptions based solely on online consultations.
In other cases,
state authorities have used civil complaints to go after online pharmacies. Such a suit, filed by the New Jersey Division
of Consumer Affairs, forced the Pill Box Pharmacy of San Antonio to pay a fine of $30,000 and to agree not to sell or market
drugs to New Jersey consumers.
The Pill Box was also a target of the DEA, which charged that it sold more than 9 million doses of drugs, mostly
hydrocodone and diazepam, over an 18-month period. Five people, including the pharmacy's owner and three doctors, pleaded
guilty in the case and are awaiting sentencing.
In August, a federal investigation into an operation called the Mail Order Pharmacy,
involving a Web site called success123.com, broke up an international drug ring that sold millions of dollars worth of OxyContin
from a basement headquarters outside Knoxville, Tenn.
Four people - businessmen from Colorado and Tennessee, an Oklahoma City nurse and
a woman from Ecuador - pleaded guilty in federal court and were given sentences of between 24 months and 57 months.
Authorities are
hesitant to say what legal actions customers of these sites could face, though few have been charged. In fact, no consumers
were charged in the Mail Order Pharmacy case, even though at least two spent more than $50,000 at the site and 22 others spent
more than $20,000.
In warning against buying drugs from online pharmacies, the FDA notes that consumers could receive bogus products,
wrong doses or no drugs at all. It does not warn, however, that there could be legal consequences.
Of six requests for drugs over the Internet, only one was denied
By J. SCOTT ORR
To test the ease with which
drugs can be obtained online, The Star-Ledger attempted to buy six prescription drugs on the Drug Enforcement Administration's
schedule of controlled substances. Four were narcotic painkillers: morphine; OxyContin; hydrocodone and codeine. The others
were Valium, an anti-anxiety drug, and phentermine, a stimulant diet
pill.
Of the six, only the request for morphine was denied.
The other five drugs were delivered to a rented mailbox, some within days of being
ordered. There was no contact with a doctor other than through an online questionnaire. The Valium came from an address in
Costa Rica; the other four drugs came from domestic addresses in California and Florida.
The codeine, hydrocodone and phentermine came from U.S. mail order pharmacies, with prescriptions ostensibly written
by U.S.-licensed physicians. The OxyContin came from a person named Carlos in San Diego, who demanded payment up front through
Western Union. It took several weeks but, in the end, Carlos delivered.
The drugs were submitted to a pharmaceutical testing
lab. There they were compared with brand- name samples obtained through a traditional pharmacy. All five of the drugs were
at least 98.9 percent as potent as the authentic samples and some, including the OxyContin, were actually stronger.
The Star-Ledger's
prescription for phentermine, a frequently abused diet pill that the
DEA lists as a Schedule IV controlled substance, was requested through the Web site ValuePrescribe.com. The prescription was
written by Ranvir S. Ahlawat, who practices internal medicine in Toms River and was based solely on an online questionnaire.
In
a telephone interview that was cut short by Ahlawat, the doctor said he prescribes about a dozen types of medicines for ValuePrescribe.com
based on medical questionnaires filled out by customers. He said he is paid by ValuePrescibe.com based on the number of questionnaires
he evaluates.
"They pay me based on the consultation, not whether I write the prescription or not," Ahlawat said.
"I review the
medical history form and make a determination if there could be any side effects or contraindications. It depends on the medical
history and the condition the patient has," Ahlawat said.
Ahlawat declined to say how much he is paid or how many prescriptions he has written
for ValuePrescribe.com. He also declined to say what medicines he prescribes based on Internet questionnaires, other than
to say they are listed no higher than Schedule IV by the DEA.
The Star-Ledger's prescription for the codeine - a generic version of Tylenol
4 that includes 60 milligrams of codeine and 300 milligrams of acetaminophen - was written by Carlos Barrera of Miami, a Florida-
licensed physician who did not return dozens of phone calls to his office over several weeks. The pills were ordered through
Buymeds.com
The Star-Ledger's prescription for Vicodin Extra Strength, which includes 7.5 milligrams of hydrocodone with
750 milligrams of acetaminophen, was written by a Felix Rodriguez-Schmidt. No doctor by that name could be located in Florida
or through national physician registries. The pills were ordered through Netpharmrx.com.
The OxyContin was ordered through an outfit called
Mexrxonline.com, which asked that the money be sent through Western Union to San Diego. After some delay, the pills arrived
via U.S. Express Mail in a plain plastic bag with no documentation.
The prescription for Valium was filled with no apparent
doctor involvement by Americanpills.com, which turned out to be located in Costa Rica. It came with a note that began "Dear
Valium Customer" that contained directions on how to use the drug and warning of possible side effects.
The note ended with
a reminder: "You can purchase any of our products without paying for the medical consultation."