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Patients who used the online pharmacy showed similar numbers of side effects and similar treatment efficacy compared to those receiving Viagra through a local pharmacy. They also provided a more complete medical history [ 21 ].

To manage the increased use of online pharmacies, however, more omline are being proposed, including the Online Pharmacy Safety Act and the development of state-run online pharmacy programs [ 2223 ].

In a major effort to steer consumers toward online pharmacy no prescription phharmacy pharmacies that are safe to use and away from rogue online pharmacies that pose a potential threat to consumer safety, the National Association of Boards of Pharmacy developed the Verified Internet Pharmacy Practice Sites VIPPS online pharmacy no prescription to accredit online pharmacies based on a number of phar,acy criteria [ 24 ].

Unfortunately, this accreditation is limited to domestic online pharmacies and, as it only approves online pharmacies that prescripiton a valid prescription [ 24 ], it does not address the larger issue of people seeking medications through NPOPs outside of a typical doctor-patient-pharmacy relationship.

It should be stressed that no matter what legislative controls are adopted, there is hparmacy simple online pharmacy no prescription to bypass these restrictions: move the NPOPs offshore, which is rapidly occurring with little government control [ 725 - 31 ]. This lack of oversight generates a number of safety concerns for NPOP consumers in distribution, information, and medication-related issues.

Distribution perscription include damaged packaging that exposes pills to light and moisture, shipments that do not meet manufacturer specifications such as temperature-controlled or insulated packagingand the ability of the consumer to reorder as many pills as desired [ 8 - 1032 - 33 ].

The lack of prsecription labeling or safety information is common with NPOP-purchased medications and provides consumers with little to no information on dosage scheduling, dosage administration, or potential side effects [ 932 - 36 ]. Finally, the medications themselves could be expired, counterfeit, ;harmacy cut with other substances. Even genuine drugs purchased from NPOPs could lead to a number of adverse events, including death, if the user is unaware of dangerous drug combinations or contraindicated medical conditions [ 3online pharmacy no prescription3237 ].

While the recent focus, appropriately, has been placed on the regulation of online pharmacies, there is very little systematic research outside of case reports on two potentially more important basic issues: 1 why consumers use online pharmacies in the place of legitimate medical channels; and 2 with such a variety of safety concerns, why consumers nl drugs purchased from NPOPs have worse health outcomes than those who obtain the same the drugs through legitimate healthcare channels.

The phafmacy described in this paper was designed to address these issues. Since most online pharmacies offer dozens of drugs for purchase, we needed to narrow the focus to users of a single representative target drug. Tramadol was selected as the representative drug for this study because it is extensively prescribed the third most frequently used analgesic [ 38 ] and it is one of the most commonly offered authentic drugs from NPOPs with few restrictions on refills or quantity of tablets offered [ 810 ].

Tramadol has a demonstrated abuse profile [ 39 - 41 ], but its rate of abuse is not as high as other opioids prescripyion its noncontrolled status in the Controlled Substances Act. Like all drugs, there is also the potential for adverse side effects that can pose serious health risks. For example, tramadol not only has the potential to produce many of the same adverse events as other opioids eg, constipation and dependence [ 39 ]but also carries a serious risk of potentially fatal grand mal seizures, which are nno by contraindicated medications and medical conditions [ 42 - 44 ].

In a prior report, we documented the ease of obtaining tramadol over the Internet, the authenticity of which was certified by a chemical analysis [ 8 ].

The purchase required the completion of a brief questionnaire that served as a medical examination.

No Prescription Needed? | Clinical Pharmacy and Pharmacology | JAMA | JAMA Network

Subsequently, a virtual prescription was generated and filled by a pharmacy in Canada. The tramadol was received within 24 hours, and numerous phone calls and emails were received almost immediately to refill the prescription some offers included up to pills in a single order and have continued on a monthly basis for over three years thus far.

It has been widely documented that recruiting and administering surveys over the Internet is an acceptable and beneficial research methodology online pharmacy no prescription 45 - 46 ]. While these methods provide quick access perscription thousands of pharrmacy, they are phaemacy easily used to attract a targeted audience. To circumvent this problem, we developed a recruitment program that directly targeted a population of tramadol users with access to the Internet.

Thus, our advertisement only appeared to Internet users who had an interest in tramadol or tramadol-related topics, making our target population more likely to include potential participants ie, users of tramadol.

Internet Supply List: Overview

When users clicked the ad, they were automatically directed to an online consent form and the subsequent survey hosted on an institutional website. Subjects were screened to be 18 years of age, users of tramadol in the past 30 days for any reason, and United States residents.

Since this study represents a preliminary approach into this area of research, no standardized instruments could address all points of inquiry.

As such, we developed a descriptive tool centered on our representative online pharmacy no prescription, in which questions about dosage online pharmacy no prescription, adverse events, etc, were specifically related to tramadol. While we developed this descriptive tool to meet the objectives of this pilot study, we hope that the results can provide a basis for a more standardized instrument that can be used to investigate the same objectives for any number of drugs purchased from NPOPs in future studies.

Other than demographics, the survey covered a broad variety of topics related specifically to tramadol, including the following: dosage schedule, intended use, please click for source, legitimate and illegitimate drug use, and adverse events. Participants who listed NPOPs as a source of tramadol were presented with a subset of questions to determine the underlying factors behind their use of online pharmacies.

A total of tramadol users qualified for and completed this study. Of these participants, indicated that they received tramadol solely through a valid prescription from their local doctor and filled it at a local read article. As shown in Table 1both traditional and nontraditional users were primarily white and female.

Traditional users were significantly older than nontraditional users. The values given are the percent of respondents who endorsed a motivation listed or specified a motivation that was not listed in quotation marks.

Table 2 shows that nontraditional users were more likely to take the higher dose mg traditional users. Nontraditional users were also considerably more likely to use tramadol more frequently 5 or more times per week. 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 Online pharmacy no prescription 2.

Percent of traditional and nontraditional users who experienced each adverse event while taking tramadol. Both groups had high rates of https://canadianpharmhealth.com/2-online-pharmacy-school-xoq.php 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.

Percent of traditional and nontraditional users who experienced each withdrawal symptom as a result of the abrupt cessation of tramadol. 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, leading 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 online pharmacy no prescription dosage schedules, contraindicated conditions, and concomitant medications was responsible for the increased intensity 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 pain 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 the 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 economic differences in access to medical care in 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, click to see more 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 observed 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 online pharmacy no prescription 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 - 61 ], and a more thorough analysis of the advantages and disadvantages of online health read article 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 https://canadianpharmhealth.com/1-pharmacy-online-mexico-zumig.php 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, if not better, at capturing patient information necessary for health care decisions [ 2162 ].

Because of aggressive marketing and pricing strategies, as well 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 be 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, online pharmacy no prescription efforts are needed to ensure that patients and physicians understand the positive and negative aspects of online pharmacies.

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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 online pharmacy no prescription 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 and 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.

Conflicts of Interest: Conflicts of Interest: None declared. J Med Internet Res. Published online Dec 6.

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Louis, Campus BoxS. Euclid Ave. Author information Article notes Copyright and License information Disclaimer. Corresponding author. This article has been cited by other articles in PMC. Abstract Background Many prescription drugs are freely available for purchase on the Internet without a legitimate prescription from a physician.

Objective This study focused on the motivations for using no-prescription online pharmacies NPOPs to purchase prescription drugs rather than using the traditional doctor-patient-pharmacy model. Methods We selected tramadol as a representative drug to address our objective because it is widely prescribed as an unscheduled opioid analgesic and can easily be purchased from NPOPs. Results Respondents in both groups were primarily white, female, and in their mid-forties nontraditional users to upper forties traditional users.

Keywords: prescription drugs, health care quality, access, evaluation, health policy, substance-related disorders. Methods Selection of Target Drug Since most online pharmacies offer dozens of drugs for purchase, we needed to narrow the focus to users of a single representative target drug. Recruitment It has been widely documented that recruiting and administering surveys over the Internet is an acceptable and beneficial research methodology [ 45 - 46 ].

Survey Instrument Since this study represents a preliminary approach into this area of research, no standardized instruments could address all points of inquiry. Data Analysis A total of tramadol users qualified for and completed this study. Results Demographics As shown in Table 1both traditional and nontraditional users were primarily white and female. Table 1 Demographics and health information for traditional and nontraditional users. Open in a separate window. Figure 1.

Tramadol Use Table 2 shows that nontraditional users were more likely to take online pharmacy no prescription higher dose mg traditional users.

Table 2 Tramadol use among traditional and nontraditional users. Figure 2. Physical Dependence 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: Figure 3. Discussion 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.

Limitations Inherent in this study are all of the limitations typical of epidemiological and survey research, most notably generalizability and veracity of information gathered. Conclusion 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.

Acknowledgments This study was financed with institutional funds and was approved by the Institutional Review Board at Washington University in St. References 1. Quality of global e-pharmacies: can we online pharmacy no prescription consumers?

Eur J Clin Pharmacol. Controversies and legal issues of prescribing and dispensing medications using the Internet. Mayo Clin Proc.

So-Called Canadian Internet Pharmacies Selling Not-So-Canadian Drugs. questionnaire, as well as those requiring no prescription at all. Rogue online pharmacies offer potentially dangerous prescription drugs to U.S. offering prescription drugs without a prescription;.

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