The provision of health-related services through the Internet is fast becoming a reality. Online pharmacies are an extension of this service.1 There have been reservations about privacy as well as the quality of the information available from these health sites, but we have recently become aware of a more disconcerting issue: obtaining potentially addictive prescription medication through the Internet. Online pharmacies, such as those based in Mexico and Asia, will dispense prescription medications without a prescription, including commonly misused pharmaceutical drugs (eg, diazepam, oxycodone, temazepam and anabolic steroids).

In 1998, results of the National Drug Strategy Household Survey indicated that 46% of Australians have used an illicit drug at some time. Analgesics were identified as second only to marijuana as the most widely used illicit drugs.2 When compared with the total Australian population, the group with the highest proportion of current users of any illicit drug was young people aged 14–29 years, and in the period 1995–1998 recent illicit drug use by teenagers rose.3 Although illicit drug use is not exclusively a youth issue, young people are competent users of the Internet, with 75% of 18–24 year olds accessing the Internet in 2000, compared with only 9% of those over 65 years.4

A 20-year-old patient was referred for management of anxiety and polydrug misuse. The patient related that anyone could be a misuser and pusher of drugs without relying on illicit suppliers of such drugs or “doctor shopping”. A click of a mouse could supply whatever drug a patient wanted from online pharmacy services available 24 hours a day. These sites are easy to use and often require little more than a credit card number to gain access to a wide range of prescription drugs, such as diazepam, alprazolam, temazepam, methylphenidate, morphine and codeine.

The patient had a 2-year history of using large amounts of zolpidem, temazepam, alprazolam and diazepam with alcohol, as well as regular use of marijuana. These medications were originally obtained by doctor shopping for prescriptions. However, while researching these medications on the Internet, our patient discovered the online pharmacies that dispensed prescription medication without a script. Zolpidem, oxycodone and methylphenidate were all ordered by the patient from online pharmacies based in Mexico and Thailand. He “surfed” the Internet for the site with the cheapest drugs and found one that sold 100 zolpidem, his drug of choice, for US$70.00, with a delivery charge of US$5.50. He was able to order quantities of 100, 200 or 500 tablets. It took 2 weeks for the discreetly packaged drugs to arrive at the patient’s door.

The patient volunteered this information during therapy for drug addiction and was quick to see the negative implications. After a period of counselling about the causes of medication misuse, he was motivated to cease further ordering and willing to undergo drug detoxification.

We accessed many of the sites used by the patient to obtain medications. Online pharmacies are subject to the laws of the country in which they are based. Those in Australia require a valid Australian prescription before prescription medication will be dispensed (Peter Waterman, Media Spokesperson, Pharmacy Guild of Australia, personal communication). However, in some countries, such as Mexico, many prescription medications can be purchased over the counter, and they can be sold over the Internet without prescription. Of 33 surveyed pharmacy websites in the United States most (88%) require a prescription before medication will be dispensed,5 and the remaining sites either dispense prescription medication without a prescription, or accept scripts by fax or email. This may mean that one script could be recycled through many of these online pharmacies. Other overseas sites offered to provide consumers with a prescription after an online or phone consultation. Some sites charge a membership fee before medications like morphine and oxycodone can be obtained. There are also sites that provide, for a fee, a directory of online and land-based pharmacies that dispense prescription medications without prescription. Many sites boast of proven methods for getting packages past customs, and some offer to re-ship medication if a seizure notification from customs can be produced.

The Therapeutic Goods Administration (TGA) in Australia, the government organisation responsible for controlling and regulating importation and manufacture of medications, prohibits the importation of prescription medications without a permit or prescription. The medications must be for personal use only and cannot be on-sold, but this is difficult to police. Importers can bring up to 3 months’ supply of medications into the country per importation.6 These regulations can only be enforced if the contents of packages are discovered, and it seems that some packages do slip through.

We have written to and discussed these issues with the following people:

• Managing Director of Australia Post;

• Chief Executive Officer of the Australian Customs Service;

• Drug Intelligence Network (Australian Federal Police);

• Crime Stoppers (New South Wales Police); and

• Local police.

We could not determine what actions these authorities were pursuing in regard to this issue. Australia Post does not have the authority to open postal articles because of privacy issues (Sal Perna, Group Manager, Australia Post, personal communication). Customs informed us that their surveillance capacity has been increased over the past 2 years to meet the challenges posed by Internet purchases of medications and other restricted goods. Customs also regularly prosecutes those who attempt to import prohibited goods without permits. At present all international mail and 70% of air cargo arriving in Australia is examined either physically or by x-ray (J H Jeffery, Acting Chief Executive Officer, Australian Customs Service, personal communication).

The use of the Internet as an alternative source of supply of prescription medications for people using illicit drugs is unlikely to overtake the street market or doctor shopping for scripts as a means of obtaining illicit drugs; in 1999–2000 the Health Insurance Commission identified over 9000 “doctor shoppers” (defined as people who had attended 15 or more different general practitioners in 1 year).7 However, the extent of the current use of the Internet as a source of drug supply is unclear. Although medications can be ordered from home, without contacting medical practitioners or pharmacists, ordering drugs over the Internet is still expensive and entails a 2-week wait for the medications. However, it may have the potential to encourage people who would not purchase drugs on the street or “doctor shop” to purchase drugs over the Internet.

The purchase of medication from offshore pharmacies also raises the issue of the quality of the medication. Drugs manufactured in Mexico are not as closely regulated as they are in Australia or the US, and are not subject to the same quality standards. This increases the potential for increased rates of addiction and accidental overdose.

Although the Internet may not be the major source of supply for illicit drug users, restricting access to Schedule 4 and 8 drugs through this channel can do no harm. This is where Customs plays an important role. The decrease in the availability of heroin in Australia caused by the 2001 “heroin drought” led to a marked fall in the number of heroin-related deaths, but did not necessarily lead to a decrease in rates of illicit drug use.8 Many heroin users simply substituted pharmaceutical drugs for heroin. Thus, restricting supply is not the answer to the complex problems posed by drug misuse. Prescription medications are still widely available on the Australian black market and through doctor shopping. However, restricting Internet access to these drugs may help to prevent the creation of new users. Another factor to take into account is that, if drug users are no longer presenting to GPs to acquire scripts, it may be difficult to determine their past drug use histories, as the use of online pharmacies to acquire prescription medication is unrecorded.

Because of the nature of the Internet, problems with online pharmacies need to be dealt with at an international and national level. Customs plays a vital role at a national level and has informed us that they and the Australian Government are aware of and are addressing the issue (J H Jeffery, personal communication). We also suggest that the Australian Government could initiate discussions with the countries where these pharmacies are based, perhaps encouraging them to tighten controls. At a local level, doctors and other professionals working with people who misuse drugs, and especially with young people, should be educated about drug availability on the Internet. All those working with these people should be made aware that the avenues for acquiring drugs are changing, and they should continue to provide support through education and harm-minimisation strategies.

We realise that it will be impossible to completely stamp out Internet availability of illicit drugs. However, a concerted and concentrated campaign by all involved parties will ensure the vast majority are denied access to such drugs through the Internet.