Thanks to Online Pharmacies, Addiction Can Be Just a Click Away

 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 non-narcotic 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.

Concerns from federal regulators, the National Association of Boards of Pharmacy and legitimate online pharmacies persuaded Google, the Internet's largest search engine, to agree this week to stop accepting advertising from rogue online pharmacies. Google joins the Internet's other major search engines -- Yahoo, MSN Search and AOL Search -- in refusing to display the ads that pop up when Internet surfers search for words associated with prescription drugs.

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 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.

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. ... "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, Calif., facility that specializes in rapid detox, said an increasing number of patients tell him online pharmacies were their principal 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.

Addicts who use Internet pharmacies are often middle-aged professionals who can afford the high costs of buying drugs online, Bernstein said.

Bernstein -- who, as a pain physician, prescribes narcotics to patients -- said patients 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.

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. "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 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.

ORDERING ONLINE

To test the ease with which drugs can be obtained online, orders were placed for 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 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 prescription for phentermine, a frequently abused diet pill that the DEA lists as a Schedule IV (moderately dangerous) 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, N.J., 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," 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 he prescribes only drugs listed as Schedule IV or Schedule V (least dangerous) by the DEA.

The 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 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."