According to the Pew Internet and American Life Project, the overwhelming majority of Americans use the Internet – 93% of youths ages 12–17, and 74% of adults ages 18 and above (Pew, 2009
). Although the 12–17 year age cohort contains the highest proportion of users, young adults ages 18–29 are not far behind. E-mail is the major online activity for all age groups, however, market research and industry analyses indicate that online sales for all types of products and merchandise are increasing in all age groups (Plunkett, 2009
). With regard to Internet sales of prescription drugs, in a recent analysis of 365 web sites offering controlled substances for sale online, 42% explicitly stated that no prescription was needed, 45% offered an “online consultation,” and 13% made no mention of a prescription (CASA, 2008
). Given the documented escalation of prescription drug abuse reported in both national and regional data sources, and the apparent proliferation of “no-prescription” Internet pharmacy sites as a source for prescription medications, this paper examined five national data sets for the purpose of indicating how common obtaining prescription drugs from the Internet actually is, which medications are being purchased without a prescription, and who might be the possible populations of “end users” of the these drugs. The data sets included in these analyses are three programs in the RADARS System (2005–2008), the 2007 National Survey on Drug Use and Health, and the 2007 Monitoring the Future survey.
Among the 4008 respondents in the RADARS SKIP System, the three most frequently accessed sources for acquiring a primary prescription drug were dealers (62%), friends and/or relatives (52%), and a doctor’s prescription (41%), with the Internet accounting for only 3%. Compared to other drugs, hydrocodone was more frequently acquired via the Internet, whereas controlled-release oxycodone was less frequently acquired. Moreover, there seemed to be a declining use of the Internet as a source, ranging from a high of 4.3% in 2006 to 1.5% in 2008.
Among the 9008 respondents in the RADARS OTP System, the three most frequently accessed sources for acquiring a primary drug were dealers (78%), friends or relatives (44%), and a doctor’s prescription (23%), with the Internet accounting for only 2.1%. The use of the Internet peaked at 3.7% during the 4th quarter of 2005, declining to 2.2% in the last quarter of 2008. Consistent with SKIP results, compared to other drugs, hydrocodone was more frequently acquired via the Internet, whereas controlled-release (CR) oxycodone was less frequently acquired. Methadone (like CR-oxycodone, a Schedule II medication) was also less frequently acquired via the Internet.
The findings from these two large, longitudinal samples of drug abusers in treatment suggest that dealers were the major source for obtaining prescription drugs among opioid abusers. Moreover, the findings add to the emerging data-based literature documenting that the Internet represents a negligible and declining source for accessing scheduled opioid medications (Cicero et al., 2008
; Boyer and Wines, 2008
; Inciardi et al., 2009a
; Surratt et al., 2006
). The positive association between the Internet as a source for hydrocodone (a Schedule III medication) and the negative association between the Internet as a source for two Schedule II medications (methadone and controlled-release oxycodone) may reflect the comparatively greater difficulty in acquiring Schedule II medications from online sources. Tramadol, an unscheduled opioid-like medication, has been previously reported to be easily available from the Internet (Cicero et al., 2008
). But since only 9 respondents in SKIP and 10 respondents in OTP reported tramadol as their primary drug, sample size limited our ability to conduct analyses to adequately determine whether the Internet was a significant source for this medication among prescription opioid abusers.
Among the 214 respondents in the RADARS System College Survey, the three most frequently accessed sources for acquiring prescription drugs were friends and/or relatives for free (60.7%), physicians (40.7%), and purchases from dealers, friends/relatives, or others (20.6%). Only 7 (3.3%) respondents reported using the Internet a source for obtaining prescription drugs.
If not treatment clients or college students, then who are the end users of drugs purchased via the Internet without a prescription? The NSDUH data may provide some preliminary insights. In the NSDUH survey, for example, 6.6% of persons ages 12 and above reported the misuse of prescription drugs during 2007. On a national basis, this prevalence estimate would correspond to some 16 million persons. And among these users, 0.5% or 80,000 individuals reported obtaining pain relievers via the Internet, 1.0% or 160,000 persons for tranquilizers, 4.1% or 656,000 persons for stimulants, and 0.7% or 112,000 persons for sedatives. Here again we see that the online purchase of prescription medications is proportionately low. Nevertheless, considered from a slightly different perspective, the NSDUH survey would appear to indicate that there are significant numbers of individuals in the general population obtaining prescription drugs via the Internet, and that stimulants are the drugs most often purchased through this mechanism. Although data on the specific stimulants purchased from the Internet are not available from this national survey, recent research indicates that Schedule III stimulants are more widely available for online purchase than Schedule II stimulant medications (Schepis et al., 2008
The three RADARS programs we examined, along with NSDUH and MTF, indicate that the use of the Internet as a source for prescription drugs is generally rare. The use of these multiple data sources, each with a national focus, is an important strength of our approach to this analysis. We believe that the concordance of data drawn from these widely disparate sources constitutes a significant piece of evidence that prescription drug acquisition on the Internet is limited in scope, particularly among the individual end-users of these drugs. The broad inclusion of diverse populations in our analysis, including Internet-savvy high school and college students, chronic drug users, and members of the general population, clearly lends broad support to this overall finding.
Despite these consistent findings, there are several limitations to the data in this report. First, despite the fact that all three RADARS programs are national in scope, they cannot be considered nationally representative samples. The individuals surveyed as part of SKIP, for example, included 4008 patients in 101 programs in 42 states. Although the geographical coverage is quite broad, they represent only a small proportion of the more than 700,000 annual substance abuse treatment admissions for “opiates” in the U.S. – defined in the Treatment Episode Data Set to include codeine, hydrocodone, hydromorphone, meperidine, morphine, opium, oxycodone, pentazocine, propoxyphene, tramadol, and any other drug with morphine-like effects, except methadone (SAMHSA, 2006
). A similar situation is present in the OTP system. Data were collected in 81 methadone maintenance treatment programs located in 34 states, nevertheless, the sample contains few of the 1200 methadone programs and almost 266,000 methadone patients in the United States (SAMHSA, 2009
). In addition, because both SKIP and OTP concentrated their data collection in high prevalence areas for prescription opioid abuse, the sampled users may have reported more extensive opioid involvement than would be found in nationally representative samples of treatment and methadone clients. Nevertheless, even among these heavily opioid-experienced groups, the use of the Internet to obtain such medications is quite low and comparable to the reports from the other data sources reviewed in this paper.
The RADARS System College Survey data set possesses similar limitations to those described for SKIP and OTP. Although the survey distribution is broad with attention to geographic diversity, the sample we utilized in this report is quite small and is likely not representative of the U.S. college population. The survey was originally sent to a sample of 60,010 students, of which only 18.6% (N
= 11,174) actually filled it out. Of these 11,174 students, only 16.7% (N
= 1866) met the eligibility criteria and completed the questionnaire correctly. However, it should also be noted here that this low figure is also due to the fact that the survey closes after 2000 valid responses are received, usually within only a few days after launch. Nevertheless, because of the substantial level of non-response, sample bias is a potential issue in the College Survey. Unfortunately, we are unable to examine this potential due to the lack of available data on non-responders in this system. Prior research with college student samples has generally found either no significant differences on substance use measures between responders and non-responders to web-based surveys (McCabe, 2008
), or higher levels of substance use among responders (Cranford et al., 2008
). If we assume that responders in the present College Survey follow the previously reported patterns of equal or higher drug-involvement than non-responders, the reported low prevalence of Internet use to obtain prescription medications would appear to be compelling.
An additional caveat to the SKIP and OTP data sets is that source data were collected only for the respondents’ primary drug, although many respondents endorsed the use of other opioids as well. Also, these two data sets were limited in scope to opioid medications.
A final limitation to the study involves all of the data sets we analyzed, including the MTF and NSDUH studies. It is not known, for example: (1) how often the Internet was used to purchase prescription drugs; (2) how many drugs were involved in each purchase; (3) whether the drugs received were those that were ordered; and, (4) if any prescription drugs were actually received.
A finding of particular interest is the high proportion of respondents who indicate accessing prescription opioids from dealers: 62% of the patients in the RADARS SKIP System and 78% of the clients in the RADARS OTP System. Despite these and other reports indicating dealers as a primary source for diverted medications, additional data on this phenomenon are generally unavailable – primarily because dealers are a difficult population to access. Both the Drug Enforcement Administration (DEA) and the National Drug Intelligence Center (NDIC) have reported that large quantities of Schedule III and IV medications are being acquired through the Internet, yet both agencies are vague as to whether it is drug dealers or individual users who are making the purchases (NDIC, 2009). NDIC has indicated that street gangs and outlaw motorcycle gangs are becoming increasingly involved in the retail distribution of drugs obtained via the Internet, but no supporting documentation has generally been provided (NDIC, 2009).
One of the few recently published papers addressing the sources of “dealers” and “pill brokers” was a small rapid assessment study conducted in Wilmington, Delaware, during December 2006 (Inciardi et al., 2009b
). Three dealers and two pill brokers were interviewed at length. Prescription drug “dealers” in this study were typically drug abusers who hustled prescription medications and other drugs whenever and however they could to help support their own drug habits. None of these dealers reported accessing the Internet, and all three generally had only small supplies for sale. By contrast, the two “pill brokers” interviewed tended to be more organized than dealers, and were not abusers. Most specialized in any type of prescription medication, regularly worked with a consistent crew of people–purchasing drugs from a given set of “doctor shoppers,” pain patients, pharmacists, or even physicians. Neither of these brokers had used the Internet to obtain drugs.
Our analysis offers some useful insight on the Internet as a source for purchasing prescription medications. Importantly, we documented uniformly low rates of prescription drug acquisition from online sources across all five data systems we examined. The consistency of this finding across very diverse populations suggests that the Internet is a relatively minor outlet for illicit purchases of prescription medications by the individual end-users of these drugs. Nevertheless, Internet acquisition of prescription medications by dealers and distributors would appear to be quite visible to law enforcement agencies, and may comprise the bulk of online prescription drug purchasing activities in the U.S. at this time.