Proscribing Online Prescribing

Why isn't a digital doctor's note enough?

Everyone who has an email account gets perhaps a score or more spams every day offering great online deals for prescriptions for Viagra, Xenical, Zyrtec, and a host of other medicines. Online purchasers obtain a prescription generally by filling out an electronic questionnaire about their symptoms which is reviewed by doctors hired by the online pharmacies.

The Washington Post today is running a front page article about the efforts by state medical boards to stop one such doctor, Miles J. Jones, from prescribing for online customers. Jones, who lives in Kansas City, Missouri, has written more than 35,000 prescriptions for the online service netdr.com. His medical license has been suspended in 13 states for online prescribing. The American Medical Association is considering a resolution against online prescribing. Of course, Jones is far from alone.

First a bit of history. How did doctors get prescribing power anyway? Doctors became drug gatekeepers as a result of Federal efforts to control the sale of opiates in the early 20th century. One milestone in this evolving process is the Harrison Narcotic Act of 1914, which established that large quantities of opiates must be prescribed by doctors. On the face of it, it doesn't seem unreasonable that doctors should be the gatekeepers to medicines since they are, after all, trained in properly diagnosing and treating diseases.

Not so fast. The fact is that many of us can and do diagnose ourselves. If we have heartburn, we go to the grocery store and load up on Tagamet, Pepcid or Prilosec. But not so long ago those three drugs were available by prescription only and we could get access to them by only means of an expensive visit to the doctor. Of course, there is the benefit that the doctor could rule out the remote possibility that our heartburn was the result of stomach cancer. However, the chances of having heartburn from stomach cancer are not lower and the drugs are no safer than they were before they were approved for over-the-counter (OTC) sales. If they are safe now for purchase OTC, then they were just as safe when only doctors could prescribe them.

Similarly, a guy is pretty good at diagnosing when he is experiencing "erectile dysfunction" and when he's not. Of course, his condition might be caused by high blood pressure or a tumor, and since he can obtain Viagra over the internet that might cause him to delay visiting his urologist, but why shouldn't he be allowed to run that risk? Besides what medicines do most people want to buy over the internet anyway? Chiefly "lifestyle" drugs that firm their erections, help them lose weight, control allergies or keep their hair. I suspect in the fullness of time, that most of these drugs will one day be deemed safe enough to be offered over the counter.

Of course, even Jones is a still a gatekeeper, albeit a somewhat less bothersome one. There are other ways to arrange for dispensing at least some medicines. For example, when I lived in Central America, one could simply go to a pharmacist, describe one's symptoms and he or she would dispense whatever medicines he or she thought appropriate. On a recent trip to the British Virgin Islands, one could find OTC pain relievers containing mixtures of aspirin and codeine or Tylenol and codeine, neither of which can be obtained without a prescription in the U.S. There may be problems with this relatively easy access to medicines in other countries, but they are not immediately apparent.

It is very likely that some people have indeed been hurt by purchasing medicines online. They failed to go to the doctor when they had a life-threatening problem or they experienced rare side effects. But it is far from evident that there are hordes of people dying from drugs prescribed online.

"[I]f someone can show me in a scientific study that what I am doing is dangerous, I will stop tomorrow. That's the way to convince me," says Jones in The Washington Post.

In fact, an article in the Journal of Medical Internet Research looking at the costs and benefits of online prescribing notes, "FDA evidence for the alleged risks of online prescribing to date merely consists of a few anecdotal cases… This scarcity of reports of adverse events is surprising, given that millions of pills are prescribed on the Web each year." Perhaps not so surprising, if the drugs are in fact generally as safe as medications already available over the counter. Perhaps that should be the standard—that drugs can be prescribed online if they are no more harmful than current over-the-counter medications. Of course that raises another question—if they are no more harmful, why do we need any doctor's, even an online doctor's, permission to use them in the first place? But that's an issue for another time.