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All traditional users used tramadol for its indicated purpose ie, to treat painwith only 2. Nontraditional users experienced a much more severe adverse event profile than traditional users Figure 2. Both groups had high rates of suddenly stopping their use of tramadol, but nontraditional users were significantly more likely to cease use abruptly traditional users: Upon cessation, nontraditional users experienced more severe withdrawal symptoms than traditional users see Figure 3.

Our data indicate that those who eschew the typical doctor-patient relationship to obtain tramadol through NPOPs do so primarily for reasons related to cost and accessibility and, most importantly, expose themselves to great health risks.

We found that nontraditional users who used NPOPs had much higher rates of all recorded adverse events, particularly life-threatening seizures, than traditional users who obtained a prescription for tramadol from their physician.

While the precise mechanisms are unknown, seizures are more prevalent in people who take high doses of tramadol [ 4252 ], have predisposing medical conditions eg, history of head injuries [ 53 ], or take contraindicated medications eg, tricyclic antidepressants [ 54 - 55 ]. Physicians are trained to recognize such predisposing factors, but nontraditional users are likely to be unaware of these potential complications, online pharmacies no prescription to poor health outcomes.

Moreover, we found that nontraditional users experienced much more intense opioid withdrawal symptoms when they stopped taking tramadol. The most logical explanation for these findings is that the lack of physician oversight in monitoring dosage schedules, contraindicated conditions, and concomitant medications was responsible for the increased online pharmacies no prescription and frequency of adverse events in nontraditional users.

Nearly all nontraditional users in our study indicated that their tramadol use was motivated, at least in part, by a need to treat a health condition eg, pain that was not otherwise managed through legitimate health care channels. It was this perception of their unmet medical need ie, inadequate online pharmacies no prescription management that drove them to use NPOPs.

This finding raises an important question: Why were normal medical channels shunned in favor of an online pharmacy? There appear to be three distinct motivations for using online pharmacies: 1 inability to pay online pharmacies no prescription costs associated with obtaining a legitimate prescription; 2 limited access to a doctor who would prescribe tramadol or prescribe it at doses sufficient to fully relieve pain; and 3 unwillingness, not inability, to use legitimate medical channels.

There are several possible interpretations of the latter motivation. Second, the physician denied the patient additional tramadol because the doctor incorrectly believed the pain was managed to the extent possible ie, inadequate pain management.

Third, the physician was reluctant to prescribe opioid analgesics, even a weak one such as tramadol, at sufficient levels to adequately relieve pain due to the inherent fear of iatrogenic dependence. At this time, it is unclear which of these was the strongest motivation to use NPOPs, but lack of access to appropriate medical treatment appears to be a major factor. This should not be surprising given the well-documented regional, social, and continue reading differences in access to medical care online pharmacies no prescription the United States [ 56 - 59 ].

It is also possible that some NPOP users, while initially using tramadol for therapeutic purposes, had predisposing factors that led to the development of tramadol misuse or abuse. This euphorigenic use, a health outcome itself, would have led to higher dosages and increased frequency of use, playing a role in the higher rates of adverse events. In a physician-patient relationship, however, a doctor may have recognized predisposing factors for misuse and not prescribed an opioid analgesic or, if already prescribed, recognized the signs of abuse and misuse and switched from tramadol to a less addictive drug.

Although we used tramadol as a prototype in these studies, there is no reason to believe that different results would be observed with dozens of equally accessible prescription drugs obtained through NPOPs that are used without the oversight of a physician. The dangers of overdose and other adverse events with these medications, especially when little to no information about contraindicated medications and medical conditions is included with purchase, have the potential to be more clinically significant with other medications than those we online pharmacies no prescription with tramadol.

As such, the geometric growth in the use of online pharmacies around the world, both legitimate and illegitimate, should prompt intense medical and regulatory discussion about their role, if any, in the provision of medical care. Currently there are several bills and regulations being discussed to control the use of online pharmacies, some of which ban the use of those located outside of the United States [ 2223 ], but the following two factors need to be considered.

First, the passage of online pharmacy regulations that promote verification programs [ 24 ], licensure and location disclosures [ 3 ], standardized criteria for Internet-based prescriptions [ 60 - online pharmacies no prescription ], and a more thorough analysis of the advantages and disadvantages of online health care services eg, the ability of online pharmacies to detect interactions between medications instantly [ 5 ] may help integrate online pharmacies into health care utilization models.

The reality, however, is that regulating these legitimate online pharmacies is likely to have no effect on those using NPOPs. These users have already turned their back on typical medical channels and seem to be able to quickly adapt to any change in access to online pharmacies eg, shift of NPOPs to foreign countriesand no amount of regulatory oversight would likely change their drug-purchasing behaviors.

Second, so long as a licensed doctor provides a prescription and the pharmacy verifies the legitimacy of the prescription, it would be inappropriate, perhaps unethical, to ban a patient from shopping around to find the most economical and convenient means of filling their prescriptions.

Whether this doctor-patient relationship needs to be on a physical basis merits further discussion. Research has shown that email and virtual consultations are just as good, canadian pharmacy canada not better, at capturing patient information necessary for health care decisions [ 2162 ].

Because of aggressive marketing and pricing strategies, as online pharmacies no prescription as the recent shift in patients becoming more involved in their own health care decisions, people using online pharmacies are in danger of unconsciously transforming from patients to consumers, and then back to patients again when they suffer from adverse effects from the use of the drug [ 1363 - 64 ].

Patients should be aware of the real possibility that while offshore pharmacies may online pharmacies no prescription cheaper and easier to use, the medications received may not be what was advertised. For this reason, recent US Food and Drug Administration FDA and WHO reports have advocated global drug safety, including international cooperation regarding the regulation of online pharmacies [ 1131 ]. Such an effort is badly needed because if one country attempts to ban online pharmacies, most users will simply try a website from another country.

Clearly, in addition to regulatory activity, educational efforts are needed to ensure that patients and physicians understand the positive and negative aspects of online pharmacies. Perhaps most importantly, more research is needed to better understand the motivations of people who, despite the availability of legitimate online pharmacies, continue to seek medications using NPOPs.

Inherent in this study are all of the limitations typical of epidemiological and survey research, most notably generalizability and veracity of information gathered. With regard to the latter, most studies indicate that the results obtained from self-administered surveys are comparable to those elicited by trained interviewers.

In our study, there were no right or wrong answers. There was no incentive or need to lie about any information because respondents were paid for their participation regardless of their answers.

In terms of a biased sample, it is true that our subjects might have greater economic status and certainly more computer literacy than the average person, but these users would most likely to be exposed to advertisements touting online pharmacies.

Our data suggest that online pharmacies may have a role in supplying prescribed medications because they are convenient and may charge less than traditional brick-and-mortar pharmacies. However, from a public health perspective, the potential benefits of online medical care need to be balanced against the use of unregulated pharmacies that could sell counterfeit or adulterated drugs online pharmacies no prescription the dangers inherent in self-medication without any physician supervision.

This study was financed with institutional funds and was approved by the Institutional Review Board at Washington University in St. Edited by G Eysenbach; submitted Skip to Main Content Skip to Footer. Article Authors Cited by 18 Tweetations 10 Metrics.

Original Paper.

If an illegitimate pharmacy offers prescription medications at a deep Additionally, in those online pharmacies where no physician is. Objective: This study focused on the motivations for using no-prescription online pharmacies (NPOPs) to purchase prescription drugs rather.

Louis Campus Box S. Euclid Ave. Table 1. Demographics and health information for traditional and nontraditional users. Table 2. Tramadol use among traditional and nontraditional users. Quality of global e-pharmacies: can we safeguard consumers? Eur J Clin Pharmacol Dec;58 9 Controversies and legal issues of prescribing and dispensing medications using the Internet.

Mayo Clin Proc Feb;79 2 Online pharmacies: safety and regulatory considerations. Int J Health Serv ;37 2 Buying prescription drugs on the internet: promises and pitfalls. Source of drugs for prescription opioid analgesic abusers: a role for the Internet? Pain Med Sep;9 6 Quality of online pharmacies and websites selling prescription drugs: a systematic review. Pharmacoepidemiol Drug Saf Sep;19 9 World Health Organization. Safety and security on the internet: challenges and advances in member states.

The Partnership at Drugfree. Thirty-six million Americans have bought medications online without a doctor's prescription.

Marketing and pricing strategies of online pharmacies. Health Policy Oct;92 Availability of opioids on the Internet. JAMA Aug 20; 7 The Internet as a source of drugs of abuse. Curr Psychiatry Rep Oct;8 5 Interim final rule with request for comments. Fed Regist Apr 6;74 64 Prescription drugs purchased through the internet: who are the end users?

Regulation of Internet Pharmacies: A Continuing Challenge - PMC

Drug Alcohol Depend Jul 1; Prescription opioid abuse among enrollees into methadone maintenance treatment. Drug Alcohol Depend Sep 6;90 1 Impact of Internet pharmacy regulation on opioid analgesic availability. National Association of Boards of Pharmacy. Internet-based prescription of sildenafil: a patient series. United States Congress. Online Pharmacy Safety Act, H.

State and Federal Regulation of Internet Pharamcies. United States Government Accountability Office. Operation cyber chase and other agency efforts to control internet drug trafficking. The "virtual" enforcement initiative is virtually useless.

Regulation of Internet Pharmacies: A Continuing Challenge

J Leg Med Jun;27 2 US Food and Drug Administration. Yahoo News. Washington Post. US Government Accountability Office. Comparison of simvastatin tablets from the US and international markets obtained via the Internet.

Ann Pharmacother May;42 5 Quality assessment of internet pharmaceutical products using traditional and non-traditional analytical techniques. Int J Pharm Dec 8; Not a good buy: value for money of prescription drugs sold onlinne the internet. Health Policy Aug; 3 Packaging and labeling of pharmaceutical products obtained from the Internet. Prevent medications from being prescribed or dispensed based upon telephonic online pharmacies no prescription online medical consultations that do not result from canada drugs direct pre-existing prescriber-patient prescriptin.

Patient information Develop and enforce policies and procedures that ensure reasonable verification of the identity of the patient, prescriber, and caregiver if applicable. Obtain and maintain patient medication profiles.

Conduct a prospective drug use review prior to medication dispensing. Ensure patient confidentiality and protect patient-specific information when such information is transmitted over the Internet. Communication Develop and enforce policies and procedures that require pharmacists to offer consultative services to patients.

Develop a system regarding reporting of adverse drug reactions and errors. Develop a mechanism for contacting patients regarding delays in delivering a prescription medication as well as drug recalls.

Develop a mechanism for educating patients regarding disposal of expired, damaged, or unusable medications. Storage and shipment Develop a system for shipping controlled substances safely and securely. Ensure that medications are shipped to patients appropriately. Over-the-counter products Comply with all federal and state laws regarding the sale of over-the-counter products that may be used in the manufacture of illegal drugs.

Quality improvement programs Maintain a quality improvement program. Open in a separate window. References 1. The Federal Bureau of Investigation. March pharmaciss Controversies and legal issues of onnline and dispensing medications using the Internet.

Mayo Clin Proc. Evaluating aspects of online medication safety in long-term follow-up of Internet pharmacies: Illegal rogue online pharmacies flourish and are long-lived. J Med Internet Res. Hellerman C. FDA shuts down online pharmacies. The possible dangers of buying medicines over the Internet. National Association of Boards of Pharmacy. VIPPS criteria. Provide NABP with the necessary documents to ensure that the pharmacy is licensed to operate in all applicable jurisdictions.

Develop and enforce policies and procedures that ensure the integrity, legitimacy, and authority of the prescription drug order. Develop and enforce policies and procedures that ensure reasonable verification of the identity of the patient, prescriber, and online pharmacies no prescription if applicable.

Develop and enforce policies and procedures that require pharmacists to offer consultative services to patients.

“No prescription” websites are online venders that sell prescription drugs (particularly opioids and other controlled drugs) without a valid prescription. Offer to dispense prescription-only medications without a valid order from a licensed prescriber. Deliver medications that are of unknown quality or origin or.

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