E‐drug deals: part of the Wild West world of e‐commerce

THE WILD WEST is a prominent metaphor for the new challenges and opportunities the Internet brings. The adventurous welcome the challenge, the cautious fear the hazards. The Internet has opened up a whole new area of information exchange and free trade. The information exchange makes it difficult for totalitarian regimes to easily control their citizens’ access to information, and Internet share trading makes governments more cautious about their fiscal policies. Free traders welcome the level playing field, for they see restricted markets opening up, and efficiencies based on market forces.1 The Internet cuts out the “middle man”. However, there are downsides, as anyone harassed by SPAM mail will know. Multinationals can more easily extend their sphere of influence, the pornography trade flourishes, as does the trade in music and illicit CDs, which boldly flouts copyright laws. Internet trading of pharmaceuticals challenges the tradition that pharmaceutical drugs should only be prescribed by health professionals and dispensed by pharmacists who have seen the person face-to-face. In June 1999, the American Medical Association formally adopted the position that appropriate medical care can only result from face-to-face consultations.2 Likewise, members of the US Food and Drug Administration are expressing a caveat emptor (“let the buyer beware”) about e-pharmaceuticals, because of problems with the quality of cyberpharmacies and the qualifications of cyberpharmacists.4 To what extent does society get involved in individuals’ free choice, especially in the context of drug use? Is free trade better than social control? Social safeguards are set both to protect the ignorant and to restrain the wilful, although critics will argue that the medical and pharmacy professions are simply protecting their eroding turf. With drugs of dependence, those involved in misuse would prefer to cut out the “middle man”, and make their own deals. In addition, they are quite prepared to use substances of poor quality and uncertain potency. Should the profession try to stop this? And, if so, how? Social controls of the supply of drugs of dependence vary for different drugs. Thus, society is tightening its control over tobacco advertising and distribution, relaxing controls over alcohol, and clamping down on illicit drugs. Decisions for each drug class are decided somewhat arbitrarily — partly they relate to the severity of the perceived problems arising from use of the drug and partly to the feasibility of control measures. The underlying assumption is that society should exercise some control over drug dealers who seek to exploit those vulnerable to drug addiction, but, in each case — whether tobacco, alcohol or illicit drugs — some uneasy compromises are necessary. These compromises change over time, depending in part on ideological and political forces, as well as on the science of drug-related harm. What is the size of the cyberpharmacy problem in relation to addictive drugs? Is the single case of online purchasing of drugs for misuse described by St George and colleagues in this issue of the Journal (page 118)5 an exception, or the start of a new and dangerous trend? We need more data, but we can make some observations. Licit drugs present a far greater problem than illicit drugs. Most drug-related deaths in our society are a result of diseases caused by tobacco. Tobacco accounts for over 80% of drug-related deaths and 79% of years of life lost.6 When the cardioprotective effects of alcohol are factored into the equation, the impact of alcohol is on a par with those of the illicit drugs. Yet, alcohol as a licit drug is freely available in our local supermarkets. Are not tobacco and alcohol a higher priority? The illicit use of licit drugs — prescription opioids and benzodiazepines — is more difficult to study. In particular, the impact of sedatives, including benzodiazepines, is difficult to quantify, as their main impact is their contribution to opiate deaths in polydrug overdoses. How big a problem, compared with other sources, is the cybersourcing of licit drugs for illicit use? As general practitioners have become more aware of the need to restrict benzodiazepine prescribing, a black market has developed. There is also a growing market in black-market prescription opiates, like MS Contin (Mundipharma) and Kapenol (GlaxoSmithKline). Thus, there is a ready market for people keen to buy these drugs. Cyberdrugs will only take off if there is a significant price advantage over that on the black market. Data are hard to obtain, but we suspect that, until it becomes harder for users to obtain benzodiazepines from lax prescribers or on the black market, the purchase of cyberdrugs will be regarded as too slow and too expensive. What should we now do? We need more data, and cases like that described by St George et al help to alert health professionals in the field to this new drug source. The suggestions put forward by St George and colleagues have merit, but, without more data, their alarm may be premature. In the past, drug control on the supply side, especially of illicit drugs, has produced disappointing results.7 In the meantime, we believe more effort is needed to control the damage caused by tobacco, alcohol and opiates.