Innovations: Alcohol & Drug Abuse: Narcotics on the Net: The Availability of Web Sites Selling Controlled Substances

With approximately 200 million Internet users in the United States and more than 125 million individuals going online every week (1), the Internet is a vital medium for communication, entertainment, and commerce. The Pew Internet and American Life Project reported that in the United States 100 percent of college students, 78 percent of 12- to 17-year-olds, and 63 percent of all adults go online at least monthly (2). However the Internet differs from other media in that it can facilitate business transactions 24 hours a day, across the globe, with relative anonymity. As a consequence, individuals who wish to engage in clandestine activities, such as illicit drug sales, can do so with reduced risk of detection.

The U.S. Controlled Substances Act prohibits the sale of schedule I drugs (for example, marijuana, heroin, psilocybin, and crack cocaine) and regulates access to schedule II-V drugs (for example, sedatives, analgesics, stimulants, and steroids) by requiring that prescriptions be written by licensed health care professionals (3). However, some countries have drug policies that differ from those of the United States or have similar laws but less enforcement. As a result, an online pharmacy can be hosted on a computer in Uzbekistan; have its URL registered to a holding company in a Mexico; have the drugs shipped from China, India, or Pakistan; have payments deposited in a Cayman Islands bank; and have an owner who lives in Miami. Moreover, all the links in this online enterprise can be changed easily in just a few hours. The fluidity and semi-reality of cyberspace are ideally suited to illicit drug transactions, creating a complex challenge for law enforcement (4,5).

Obtaining prescription opioids online

The National Survey of Drug Use and Health (6), the Monitoring the Future study (7), and the Drug Abuse Warning Network Report (8) have each noted significant increases in prescription opioid use over the past five years, particularly among young people. The causes for this increase are unknown. However, the leadership of the National Institute on Drug Abuse, the White House Office of National Drug Control Policy, and the U.N. International Narcotics Control Board have all expressed concern that online pharmacies that sell opioid medications without a prescription may play a role (9,10,11). To assess whether "no prescription Web sites" (NPWs) deliver drugs as advertised, the U.S. General Accounting Office conducted an investigation in which it attempted to purchase prescription drugs without a prescription (12). In total, investigators placed 90 orders for prescription drugs without a prescription; of these orders 45 (50 percent) were filled. Ninety-one percent of the orders that were placed for hydrocodone and oxycodone were filled without a prescription (ten of 11 orders).

Leaders at the highest levels of federal law enforcement and policy (4,5) have been aware of these Web sites since at least 1999. Yet NPWs continue to operate openly and are easy to find. Our own research has documented that NPWs offering to sell opioids, stimulants, sedatives, and steroids are readily identified in Google and Yahoo searches when terms such as "no prescription codeine" or "no prescription steroids" are used (13,14). My colleagues and I have conducted more than 50 Internet-based studies in which the first 100 links were examined to determine whether the resulting Web sites offered to sell controlled substances without prescription. Overall, about half the links returned led to NPWs. Additionally, in a related series of online investigations, searches for marijuana, psilocybin, peyote, amyl nitrate, coca leaves, and opium poppies yielded several Web sites that offered to sell these controlled substances.

Eventually NPWs may be pushed to the fringes of the Internet through regulation and the voluntary cooperation of the credit card companies and commercial delivery services, both of which perform critical roles in the supply chain. Already NPWs are switching to cash on delivery, checks, and cash-only business models in anticipation of a crackdown. For more than a year, some online marijuana dealers have done business through 2,048-bit encrypted e-mail services, such as www.hushmail.com, which are freely available yet virtually impervious to surveillance.

Little is known about who is purchasing controlled substances online, what effect these Web sites have on public health, and what clinical strategies are best for addicted individuals who have been getting their drugs online. In a pilot study 100 newly admitted patients at a private residential addiction treatment program were asked how they obtained their drugs in the 30 days before admission (15). Twenty-nine percent stated that they knew illicit drugs could be purchased online, 9 percent reported making illicit online purchases, and 2 percent said that they found their dealer online. Among the nine patients who reported buying drugs from an NPW, six purchased prescription drugs (opioids and anxiety medications) and three bought unspecified "club drugs."

Clinical and policy implications

The Internet presents new challenges for individuals who are recovering from substance use disorders, the clinicians who work with them, and the general public.

Most people who use e-mail have experienced sifting through unsolicited e-mails (spam) that offer controlled substances online. For individuals addicted to prescription drugs, especially for those who have made purchases from NPWs in the past, these e-mails are equivalent to getting a phone call from a drug dealer. Indeed, to a certain degree the use of e-mail and the Internet may be a conditioned cue for craving and drug use. Well-meaning clinicians who have advised patients to consider joining online support groups may have inadvertently introduced them to online dealers.

To effectively assist patients for whom the Internet is a relapse trigger, clinicians must expand their knowledge of technical solutions. Similarly, parents, teachers, and school-based counselors need to incorporate this new reality into the work of preventing drug abuse.

The availability of controlled substances over the Internet has opened a new and complex front for the war on drugs. If NPWs cannot be controlled or if the price for achieving control is unacceptably high, then current drug control priorities and strategies will need to be adapted to address this new reality.

As an analogy, in not much more than a year the entire music industry was radically transformed by the appearance of Web sites that enabled the swapping of music files. People who wanted the latest music free of charge enthusiastically embraced these Web sites, while music industry executives and regulators brought lawsuits against the Web sites and sought legislative relief from illicit online music swapping. Then an outsider to the music industry, Apple Computer, launched its enormously popular and now widely imitated iPods and iTunes. Apple saw an opportunity to effectively compete with the Web sites that allowed illegal file swapping by providing an attractive, inexpensive alternative. Consumers preferred to legally purchase music at the reasonable cost of 99 cents per song instead of illegally obtaining music online.

Similarly, the unregulated availability of narcotics online may serve as a tipping point for current approaches to the drug problem. Currently U.S. drug policies lean heavily on enforcement and interdiction, with public health and medical strategies playing an important but smaller role. If illicit drugs continue to be readily available over the Internet and illicit drug supplies continue to increase unabated, public demand for effective solutions will surge. The recent increases in prescription opioid dependence, abuse, and overdose may just be the tip of the iceberg.

In addition to increased reliance upon traditional addiction treatment approaches, agonist-based treatment therapies, such as methadone and buprenorphine (for opioid dependence and anti-craving medication—that is, depot naltrexone), may receive greater priority because of their ability to effectively compete with illicit substance use.

It is impossible to predict whether NPWs will be just a short-lived blemish on the drug scene or a major upheaval in the overall landscape. In the meantime, clinicians have the immediate challenge of helping patients cope with the hazards that uncontrolled access to controlled substances represent. Below are several clinical approaches that may be helpful in working with patients who have received drugs online.

Recommendations

Change online identity

When a person purchases drugs online, his or her e-mail address may be stored in a database for advertising promotions and possibly for sale to other e-pharmacies. As a result, customers who have used NPWs in the past may be subject to ongoing unsolicited e-mails long after they have stopped using drugs. To avoid the receipt of future online offers, three steps can be taken. First, terminate the current e-mail address. Second, all Internet "cookies" should be reviewed and suspect ones removed, because some NPWs may have installed a cookie in order to stay in touch with former customers. Finally, spyware elimination programs should be run to ensure that any spyware installed by an NPW has been removed. A number of spyware elimination software applications are available, and some of the best are free of charge (for example, www.microsoft.com/athome/security/spyware). These three steps, if properly executed, should be sufficient to wash away one's cyber past and eliminate unsolicited e-mails from former online dealers. Unfortunately, however, additional action may be necessary.

Disconnect

For some patients, the use of e-mail and the Internet may be a potent cue, much in the same way that beer advertisements can be a relapse trigger for alcoholics. For these individuals it may be necessary to discontinue use of the Internet and e-mail, at least temporarily. This interruption may be impractical for people who are required to use the Internet and email at work; however, at a minimum, they may need to take a break from their computer at home. When the patient and the therapist decide that it is time to start using the Internet again, a plan could be established to reconnect safely.

Monitor and support abstinence

A third solution to support individuals who are struggling to stay drug free despite the ready availability of drugs online is the use of keystroke monitoring applications. Monitoring applications (such as Spector Pro; www.spectorsoft.com) create a record of all computer usage. Similar to urine drug screens, which can be used to monitor and reinforce drug abstinence, keystroke monitoring applications can be used to support and document the success of patients' staying away from NPWs. Patients could agree to voluntarily install this application on their computer and bring it in to the therapist on a weekly basis to document their "abstinence" from NPWs and other drug-related Web sites. This monitoring may be particularly important for people who have previously found dealers in drug-oriented chat rooms and forums and have established an online identity within these virtual drug cultures (for example, www.420times.com/forums).

Recommend Internet software filters

Finally, because all of us are subject to receiving online spam offers, individuals who are in recovery should consider enabling the spam blockers that are freely available within their Internet browsers and e-mail programs. Spam filters have become very effective, but they work only if they are enabled. If these filters are not adequate, commercial software applications are available that provide an additional layer of insulation from online drug offers.

Conclusions

Although the Internet provides a host of delightful and valuable resources, it was inevitable that drug dealers and others who do business in the shadows would leverage its unique characteristics of relative anonymity and global access. The loopholes in the Internet drug-supply chain can be tightened considerably but only with international cooperation. Given the numerous challenges such an effort must overcome—and the considerable resources that the NPWs might employ to keep their businesses operating—it is unclear when or if NPWs will ever go away. In the interim, clinicians, researchers, and other health care professionals must develop and disseminate strategies for assisting individuals who are affected by NPWs.

Acknowledgments

The author thanks his colleagues, Tom McLellan, Ph.D., and George Woody, M.D.; his research assistants, Ovgu Kaynak, M.S., Valerie Hoover, B.A., and Christen McDonald, B.A.; and the National Institute on Drug Abuse, for its support.

Dr. Forman is affiliated with Alkermes, Inc., in Cambridge, Massachusetts and the Center for Studies of Addiction at the University of Pennsylvania in Philadelphia and the Treatment Research Institute, 600 Public Ledger Building, 150 South Independence Mall West, Philadelphia, Pennsylvania (e-mail, [email protected]). Shelly F. Greenfield, M.D., M.P.H., is editor of this column.