title: Illegal "no prescription" internet access to narrow therapeutic index drugs.
abstract: BACKGROUND
  Narrow therapeutic index (NTI) drugs, because of proximity of therapeutic amounts to toxic amounts, require close professional oversight, particularly when switching formulations. However, safe use may be compromised by unsupervised switching through access to online "no prescription" Web sites.
  
  
  OBJECTIVE
  We assessed no prescription online availability of NTI drugs, using an academically published list (core NTI drugs).
  
  
  METHODS
  Using the Google search term "buy DRUG no prescription," we reviewed the first 5 search result pages for marketing of no prescription NTI drugs. We further assessed if National Association of Boards of Pharmacy (NABP) Not Recommended vendors were marketing NTI drugs. Searches were conducted from November 3, 2012 to January 3, 2013.
  
  
  RESULTS
  For core NTI drugs, we found 13 of 14 NTI drugs (92%) marketed as available without prescription, all from NABP Not Recommended vendors. On the basis of these initial findings, we expanded our core list to 12 additional NTI drugs; 11 of 12 of these drugs (92%) were available from no prescription Web sites. Overall, 24 of 26 NTI drugs (92%) were illegally marketed as available online without the need for a prescription.
  
  
  CONCLUSIONS
  Suspect online NTI drug access from no prescription vendors represents a significant patient safety risk because of potential patient drug switching and risk of counterfeit versions. Further, state health care exchanges with coverage limitations may drive patients to seek formulations online. Food and Drug Administration harmonization with tighter international NTI drug standards should be considered, and aggressive action against suspect online marketers should be a regulatory and public health priority.
authors.affiliation: Institute of Health Law Studies, California Western School of Law, San Diego, CA 92101, USA. baliang@alum.mit.edu
authors.forename: Bryan A
authors.initials: BA
authors.lastname: Liang
authors.forename: Tim K
authors.initials: TK
authors.lastname: Mackey
authors.forename: Kimberly M
authors.initials: KM
authors.lastname: Lovett
mesh_terms: D003132:Commerce / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data; D058110:Counterfeit Drugs / Q000009:adverse effects / Q000600:supply & distribution*; D004335:Drug and Narcotic Control; D006801:Humans; D020407:Internet / Q000331:legislation & jurisprudence*; D055553:Prescription Drugs / Q000009:adverse effects / Q000600:supply & distribution*; D014481:United States; D014486:United States Food and Drug Administration
chemical_list: D058110:Counterfeit Drugs; D055553:Prescription Drugs