title: Health outcomes in patients using no-prescription online pharmacies to purchase prescription drugs.
abstract: BACKGROUND
  Many prescription drugs are freely available for purchase on the Internet without a legitimate prescription from a physician.
  
  
  OBJECTIVE
  This study focused on the motivations for using no-prescription online pharmacies (NPOPs) to purchase prescription drugs rather than using the traditional doctor-patient-pharmacy model. We also studied whether users of NPOP-purchased drugs had poorer health outcomes than those who obtain the same drug through legitimate health care channels.
  
  
  METHODS
  We selected tramadol as a representative drug to address our objective because it is widely prescribed as an unscheduled opioid analgesic and can easily be purchased from NPOPs. Using search engine marketing (SEM), we placed advertisements on search result pages stemming from the keyword "tramadol" and related terms and phrases. Participants, who either used the traditional doctor-patient-pharmacy model to obtain tramadol (traditional users, n = 349) or purchased it on the Web without a prescription from their local doctor (ie, nontraditional users, n = 96), were then asked to complete an online survey.
  
  
  RESULTS
  Respondents in both groups were primarily white, female, and in their mid-forties (nontraditional users) to upper forties (traditional users). Nearly all nontraditional users indicated that their tramadol use was motivated by a need to treat pain (95%, 91/96) that they perceived was not managed appropriately through legitimate health care channels. A majority of nontraditional users (55%, 41/75) indicated they used NPOPs because they did not have access to sufficient doses of tramadol to relieve pain. In addition, 29% (22/75) of nontraditional users indicated that the NPOPs were a far cheaper alternative than seeing a physician, paying for an office visit, and filling a prescription at a local pharmacy, which is often at noninsured rates for those who lack medical insurance (37%, 35/96, of NPOP users). The remainder of participants (16%, 12/96) cited other motivations (eg, anonymity) for using NPOPs. In terms of health outcomes, nontraditional users experienced a significantly (P < .01) greater number and severity of adverse events, including life-threatening seizures: 7% (7/96) of nontraditional users reported seizures, while none of the traditional users reported seizures.
  
  
  CONCLUSIONS
  Although online pharmacies can offer distinct advantages in terms of convenience and cost, users of these "rogue" pharmacies that offer drugs with no prescription or doctor supervision do so at great risk to their health, as evidenced by much higher rates of adverse events. The most logical explanation for these findings is that the lack of physician oversight of dosage schedules, contraindicated conditions, and concomitant medications, were responsible for the increased intensity and frequency of adverse events in the nontraditional users. Although we only examined tramadol, it is logical to postulate that similar results would be observed with dozens of equally accessible prescription drugs. As such, the geometric growth in the use of online pharmacies around the world should prompt intense medical and regulatory discussion about their role in the provision of medical care.
authors.affiliation: School of Medicine, Department of Psychiatry, Washington University in St. Louis, Saint Louis, MO 63110, USA. cicerot@wustl.edu
authors.forename: Theodore J
authors.initials: TJ
authors.lastname: Cicero
authors.forename: Matthew Stephen
authors.initials: MS
authors.lastname: Ellis
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D020407:Internet; D008297:Male; D008875:Middle Aged; D060946:Pharmaceutical Services, Online; D055553:Prescription Drugs
chemical_list: D055553:Prescription Drugs