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Pulmonary Arterial Hypertension

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Fen Phen and Primary Pulmonary Hypertension News

ONLINE DRUGS: Easy to buy, tough to control

Come along on a ride to some unchecked virtual drugstores

The Plain Dealer - December 19, 2004 - I had never met or spoken to Dr. Akhil Baran wal, a cancer doctor in Waycross, Ga. But his name appeared on a bottle of Didrex - a highly addictive prescription weight-loss drug - delivered to my doorstep last August. Getting it was a snap. All I needed was Internet access, a valid credit card and five minutes to complete a 10-question "medical history" questionnaire online.

Eight days later, they arrived: 30 tablets of Didrex, 50 milligrams each, enough to last a month for a true-blue dieter. Less for a thrill-seeker. At $189, the markup was substantial - more than four times retail - plus a $49.95 "dispensing fee." And $18 for shipping. But the apparent supplier, an outfit called "RxMedications.biz," offered certain conveniences over my friendly neighborhood drugstore.

A virtual smorgasbord of prescription drugs, with everything from painkillers to cholesterol medications, sleeping pills, weight-loss medicines and an array of sexual performance drugs, "RxMedications.biz" offered drugs "Shipped to Your Door" with "No Prior Prescription Required." And therein lies the secret -- and the danger -- behind the surge in Internet drug sales. No waiting rooms. No doctors. No physicals. No fuss.

Ohio medical board rules forbid doctors from prescribing drugs like Didrex without a physical exam, except in extraordinary circumstances, state officials say. Several other states have similar regulations. An appetite suppressant, Didrex stimulates the central nervous system and causes an increase in heart rate and blood pressure, according to Ohio State University's Drug Information Center. Potential side effects include blurred vision, dizziness and sleeplessness. And because it is so addictive, it is not recommended for anyone with a history of drug dependency or abuse.

But all I had to do to get some was answer a few questions online, including my height, weight and date of birth, whether I smoke (I don't), whether I was pregnant (I wasn't), and whether I consume more than two drinks a day (No comment). I was also required to disclose the "specific medical reason" for my order. I replied: "To lose weight." Then, I provided a credit card number and a delivery address and, presto, the drugs were in my mailbox a week later.

But the path they took to get there -- as with several other "prescriptions" I ordered for this story -- was anything but straightforward. And that helps to explain why the emerging Internet drug bazaar has become so difficult for officials to control.

Doctor denies writing my prescription

The personal e-mail heralding the "RxMedications.biz" Web site, cluttered with gibberish apparently to evade The Plain Dealer's spam detectors, was dispatched by one "Alisa Bourgeois," not likely a real name. (Just a hunch.) The Web site was registered to an entity based in Spain. But that's about as far as the ownership tree extends, at least in the public record. My "prescription" apparently was written by Akhil Baranwal, the cancer doctor in Georgia, a state that prohibits prescribing such drugs "solely by electronic means."

Since we had never met or spoken, I gave Dr. Baranwal a call to find out how his name wound up on my Didrex bottle. He said he had no idea and denied having written the prescription. But it was filled nonetheless, and mailed to me by the Fallston Pharmacy, based in a suburb of Baltimore, Md. I made a similar call to owner Michael Beatty. Beatty said his pharmacy was involved "for about a week" earlier this year with an outfit called Jive Network, a Florida- based operator of prescription- drug Web sites.

For a fee of $4 each, Beatty said he started filling prescriptions for the Web-site customers, selecting the prescribing doctors -- including Baranwal -- from a list of physicians supplied by the site's operators. He would not divulge the identities of those operators. But Beatty said he ended the practice after noticing a disturbing trend: The vast percentage of the prescriptions were for commonly abused weight-loss drugs like Didrex and its potent cousin, phentermine. "It was something like 80-90 percent," Beatty said. Even more worrisome, he said, was that instead of interviewing prospective customers, doctors appeared to be using flimsy online questionnaires to justify the prescriptions.

"Once we got a feel for what was actually going on, we just weren't comfortable and stopped doing it," Beatty said. He did not report the operation to authorities, Beatty said, because he was unsure if any laws had been broken. "It's a gray area, and the laws vary from state to state," he said. A few weeks after my Didrex arrived, I ordered a batch of phentermine, from a site called "ordermedications.biz," which is linked to the "RxMedications.biz" site.

Phentermine, which regulates sleep, body temperature and appetite, according to Ohio Northern University pharmacy professor Karen Kier, was a component of "Fen-phen," the popular diet drug withdrawn from the market in 1997 because of links to heart- valve disease. The phentermine was just as easy to get as the Didrex, but arrived by a different -- though equally tortured -- route.

This time, the prescribing doctor was someone named Alexis Roman, also a total stranger. Public record searches failed to turn up any physician licensed in the United States by that name. The phentermine "prescription" was filled by Budget Drug RX, a pharmacy in Feasterville, Pa., near Philadelphia. A Budget Drug employee said the owner was out of town and unavailable for comment. A customer-service contact number that came with the prescription was answered by a Jive Network representive. The phentermine cost $169 for 30 tablets -- four times retail -- plus the "dispensing fee" of $49.95 and the $18 for shipping.

Both the Didrex and the phentermine came with instructions and at least looked like the real thing, according to Margaret Cunningham, of the Greater Cleveland Poison Control Center -- the agency used by many local pharmacists to evaluate questionable substances. That's not always the case with Internet drugs.

Over the past several months, I purchased prescription drugs from eight Internet sites for this story. Some of those sites were linked to spam e-mails sent by individuals -- with names like "Alisa Bourgeois" -- who are paid to drum up sales, according to Congressional testimony. Others were chosen through Internet searches. In addition to Didrex and phentermine, I ordered and got hassle-free access to pain pills like Vioxx, Darvocet and Vicodin and to mood altering drugs like Zoloft and Xanax.

Batting an easy one thousand so far, I decided to swing for the fences and order a month's worth of Oxycontin as well, the addictive pain killer known as "Hillbilly Heroin." But thanks in part to the federal government's aggressive prosecution recently of Oxycontin dealers, and the public travails of notables like Rush Limbaugh, I struck out.

The few sites that purported to offer Oxycontin replied that they were sold out. (I did stumble upon several personal e-mail addresses that promised ample supplies of the drug, in what seemed like the electronic equivalent of a street-corner sale. Lest I attract the notice of curious federal agents, however, I opted against that route.)

Among the seven Internet sites that shipped me painkillers and antidepressants, only two made any medical inquiries at all -- and those involved the mere completion of simple online questionnaires. Neither site made any effort to verify the information I provided. The five other sites sought nothing more than a credit card number and shipping address. Three of the sites provided their own prescriptions from physicians I had never heard of, one of them from as far away as Switzerland.

Five of the medications -- including pills purporting to be Zoloft and Vioxx -- arrived without any dosage information, and without advisories about side effects or possible interactions with other drugs.

Many drugs came from India

They appeared to have come from overseas, but their precise point of origin remains unclear. Four of those shipments arrived in crude packaging with no documentation and no receipt. Three appeared to have originated in the same city -- in India. I ordered a batch of Zoloft -- an antidepressant used to treat such conditions as depression, panic attacks and post-traumatic stress syndrome -- from a Web site called "ynotsavem0re.com." The site's domain name is registered to an individual in Korea.

But the envelope that contained the pills bore a return address of someone named Yogesh R. Seth, of Mumbai (formerly known as Bombay), India. My bottle of Vioxx also came from Mumbai. I had ordered the once-popular pain medication -- which until recently was often prescribed to stem the swelling from arthritis -- from a Web site called "rx-land.com." on Sept. 9. The site also bills itself as "OffShoreMeds," but its domain name is registered to an entity in Westchester, Calif.

The pills arrived from India a few weeks later, from someone named Harish L. Shetty. Someone with an Indian accent and claiming to be a representative of OffshoreMeds telephoned on Nov. 11 asking me to renew the order. Both Shetty and Seth are strangers to me. Both the Vioxx and the Zoloft arrived without a prescription or paperwork. And neither Web site required any information other than a credit card number to place an order. (Warning: Not long afterward, my credit card number was used to pay off somebody's traffic tickets in Ft. Lauderdale, Fla.)

Only weeks after the Vioxx arrived, the U.S. manufacturer pulled it from the market after studies revealed that high doses may cause an increased risk of heart attack. A supply of the generic equivalent of Darvocet, a pain medication, ordered from the Web site "rx-prescription.biz" also originated in Mumbai. Seeking a source closer to home, I placed an order for Xanax from a Web site billing itself as "Canadian Pharmacy," registered in Staten Island, NY.

But the origin of the resulting drug shipment remains a mystery. The tablets purporting to be the popular anti-anxiety drug arrived without any paperwork, in an express-mail envelope that bore the return address of a shipping company in New Jersey. But that's likely an illusion: The drug packaging bears the markings of Cipla Ltd., a company located in -- you guessed it -- Mumbai.

Suspicions about the point of origin were partially confirmed during conversations with representatives of "Canadian Pharmacy," several of whom called in recent weeks to urge me to refill my order. One confided that the pharmacy's drugs come mostly from India or elsewhere in Asia and are shipped through Canada to a company in New Jersey. But questions about its origins aside, the Xanax did come with a limited-time-only bonus -- presumably to help with any residual anxiety that the pills failed to remedy:

Four free tablets of Cialis, a drug designed to help with sexual performance.

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