-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-892						        

TITLE:     INTERNET PHARMACIES: Hydrocodone, an Addictive Narcotic 
Pain Medication, Is Available Without a Prescription Through 
the Internet

DATE:   06/17/2004 

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United States General Accounting Office

GAO Testimony

Before the Permanent Subcommittee on Investigations, Committee on
Governmental Affairs, U.S. Senate

For Release on Delivery Expected at 9:00 a.m. EDT Thursday, June 17, 2004


Hydrocodone, an Addictive Narcotic Pain Medication, Is Available Without a
                       Prescription Through the Internet

Statement of Robert J. Cramer
Managing Director, Office of Special Investigations



Mr. Chairman and Members of the Subcommittee:

I am pleased to be here today to summarize the results of our
investigation of some of the business practices of certain U.S. Internet
pharmacies that sold narcotics without a prescription. Our testimony is
part of a larger body of work GAO has performed that is the subject of a
report and additional testimony we are releasing today that examines
issues surrounding the availability and safety of prescription drugs sold
over the Internet and the business practices of certain Internet
pharmacies.1 We conducted our work from March 2004 through June 2004 in
accordance with quality standards for investigations as set forth by the
President's Council on Integrity and Efficiency.

At your request, Mr. Chairman, we attempted to obtain information about
the sources of hydrocodone2 that we purchased without a prescription from
eight U.S. online pharmacies. Hydrocodone is an addictive narcotic pain
medication, and illicit use of this drug has increased significantly in
recent years. We contacted one of the pharmacies that had sold us
hydrocodone in an attempt to determine the relationship between the
Internet site and the pharmacy that dispensed the narcotic and to find out
what role a physician may have played in facilitating our purchase. We
also spoke to a physician who actually prescribed the narcotic for one of
our purchases and appears to be operating an Internet drug business that
caters almost exclusively to individuals purchasing hydrocodone. Although
the Internet Web site and the physician have taken some measures to
disguise their operation as a legitimate enterprise, their business
practices suggest otherwise.

We determined the location of the pharmacy that we contacted based on the
return address on the package in which the sample was delivered. Further,
posing as a relative of the customer who had purchased hydrocodone from
this Internet pharmacy, one of our investigators spoke to the pharmacist
who dispensed the drug as well as the prescribing physician. Subsequently,
we conducted surveillance of the office where the physician processes
Internet drug orders.

1U.S. General Accounting Office, Internet Pharmacies: Some Pose Safety
Risks for Consumers, GAO-04-820 (Washington, D.C.: June 17, 2004);
Internet Pharmacies: Some Pose Safety Risks for Consumers and Are
Unreliable in Their Business Practices, GAO-04888T (Washington, D.C.: June
17, 2004).

2Hydrocodone, a Schedule III controlled substance, is the generic version
of Vicodin.

                               Page 1 GAO-04-892

In summary, we found that (1) one can purchase hydrocodone from certain
Web sites on the Internet without providing a prescription or being
examined by a physician; and (2) the Internet pharmacies from which we
made our purchases of hydrocodone charge significantly higher prices for
the drug than walk-in pharmacies. We concluded that those who participate
in Internet drug operations that operate in this manner appear to be in
the business of knowingly servicing, and profiting from, individuals who
may purchase pain medication for illicit purposes.

Purchases of Narcotic Pain Medication Without Prescriptions

We obtained hydrocodone from eight domestic Web sites on which we placed
orders without submitting a prescription or undergoing an examination by a
physician. Six purchases, each from different Web sites, were dispensed by
a single pharmacy located in a Southeastern state. The two remaining
purchases were ordered from two separate Web sites and were dispensed by
separate pharmacies located in states in the Southeast and Southwest.

We obtained the hydrocodone online by completing questionnaires on which a
GAO staff member (the "customer") claimed that he had pain. In addition,
he claimed that his doctor had prescribed hydrocodone for the pain, but
that he had recently lost his health insurance and could not return to his
doctor for a new prescription. Five Web sites sent the narcotic after
receiving our order and credit card payment information. We received
telephone calls from the three other suppliers before our order was
completed. They asked questions about our purported need for the
hydrocodone and prior use of the drug.

In our attempt to determine the relationship between the Internet site and
the pharmacy that dispensed the narcotic, and to find out what role a
physician may have played in facilitating our purchase, we contacted one
of the pharmacies that had sent us hydrocodone. We also contacted the
physician who "prescribed" a 30-day supply of the narcotic without seeing
or speaking to the customer and without any confirmation from a physician
that the customer had previously been under a doctor's care or had
received a prescription for pain relief.

This specific purchase originated on February 26, 2004, when the customer,
posing as a patient experiencing pain, used a pseudonym to place an order
for hydrocodone. Customers are advised on the site that they are required
to (1) fill out an online questionnaire, (2) receive a phone call from a
medical professional to discuss the customer's medical condition to

                               Page 2 GAO-04-892

determine if he or she is approved for the drug, and (3) undergo a
complete physical examination. If approved, the medication is billed to
the customer's credit card.

Despite the claims on the Web site that customers must satisfy these
requirements, we obtained the hydrocodone without undergoing a physical
examination or producing any tangible evidence showing treatment by a
doctor in the past. Indeed, the customer simply completed the online
questionnaire and spoke by telephone to the physician's representative,
who offered the customer two options for satisfying the physical
examination requirement: (1) for $199, the customer could visit a
physician at one of two clinics in the area where the customer lived; or
(2) for $49, the representative would fax or e-mail paperwork that the
customer could take to his own physician to fill out and return to the
pharmacy's physician. In addition, the representative told the customer
that if he chose and paid for one of these two options with a credit card
during their telephone conversation, the physician would immediately issue
a 30-day prescription so that he could get his medication right away.

The customer told the representative that he needed to think about both
options. However, the representative reemphasized that if he chose either
the $199 or the $49 option and paid for it immediately, he could get his
30day supply of hydrocodone right away. The customer then chose the $49
option and gave the representative his credit card information. After the
transaction was complete, the representative reviewed the information that
the customer submitted online and said that he would receive e-mails from
her and from the Web site containing paperwork and information on how to
pay for the medication.

The customer then asked if he needed to set up an appointment for a
consultation with the physician, and the representative replied that she
had already completed the consultation. Later that day, the customer
received the paperwork and an e-mail link for a payment site. He went to
the site and used his credit card to pay a total of $190 for his initial
30-day supply of hydrocodone.

Subsequent 	Subsequent to receipt of the hydrocodone, a GAO investigator,
posing as a relative of the customer, contacted the pharmacy listed on the

Investigation	address of the package in which it was delivered. The
pharmacist confirmed that he had sent the drug and explained that he has a

                               Page 3 GAO-04-892

relationship with the Web site on which we ordered it, and with a
physician who sent a prescription for it to the pharmacist.

The investigator then telephoned the physician who confirmed that he
prescribed the hydrocodone. The physician claimed that he never writes
prescriptions for new medications for patients and that he always confirms
that the patient has been on the medication in the past. The investigator
asked whether the doctor had actually spoken with his relative, and the
physician responded that one of his associates had in fact spoken to him.
He said that he has a staff of several people who make such telephone
calls to confirm that the customer has been on the medication in the past.
He repeatedly asserted that the staff calls and speaks with the customer's
physician who previously prescribed the medication. However, he confirmed
that the telephone number his staff had called with respect to our
purchase was simply the telephone number of the customer himself, not that
of a physician.

The physician indicated to our investigator that he was handling his
Internet drug business from a clinic he operates. When asked the name of
the clinic, he indicated that it is part of a health care network and gave
a name that does not correspond to the name of any existing health care
network we could find or to any actual medical practice with which the
physician is in fact affiliated. He said to our investigator, "90 percent
of our business is for hydrocodone." He acknowledged that he currently
provides prescriptions for five different Internet drug sites and
disclosed that he previously wrote prescriptions for two Web sites that
have been shut down.

When asked about the possibility of children buying narcotics through him,
the physician claimed that the need for a credit card is the "safeguard"
to prevent that from happening and that "a kid shouldn't have a credit
card." However, he admitted that "parents call [him] all the time saying
that their children have gotten hold of their credit cards." While he
stated that the system can be used by customers to purchase drugs for
illicit purposes, he repeatedly stressed that his online pharmacy business
offers "a service for patients who don't have insurance, who can't afford
to go and see a doctor."

However, this assertion is patently false. To the contrary, the customer
paid a total of $190.00, and an additional $49.00 "consultation" fee, for
60 tablets of hydrocodone that can be purchased for an average price of
about $26.00 at local retail pharmacies at which we inquired. Thus, we
paid nearly ten times the ordinary retail price of the drug because we did

                               Page 4 GAO-04-892

have a prescription. The Drug Enforcement Administration provided us with
information that the "street price" or illegal sales price of the
hydrocodone we bought online is about $5 to $6 per pill. Thus, we paid
slightly less than the street price for the drug from this source. The
prices we paid for hydrocodone at the other seven Web sites from which we
ordered it were also significantly higher than the retail price at local
pharmacies. Overall, we paid the eight online pharmacies prices that were
3 to 16 times the price charged for hydrocodone at local pharmacies.

During our visit to the site where the physician purports to operate a
clinic, we saw no evidence of a health clinic. The site is a one-room
storefront set up with several computers and telephones. The only
individuals we saw going to or leaving the storefront appeared to be
employees, and there was no sign on the premises indicating that the
business was health related. When one of the employees was asked what kind
of business is operated at the location, she responded that they do
"computer consultations."

Concluding	Our investigation revealed that customers can purchase
hydrocodone, a potentially dangerous and addictive controlled substance,
from certain

Observations	domestic Internet sites that do not require prescriptions.
These Web sites appear to purposely cater to hydrocodone customers who are
willing to pay a substantial markup for the painkillers because they do
not have prescriptions. As a result, these sites appear to be in the
business of profiting from illicit drug use rather than providing a safe,
inexpensive alternative source of drugs for customers.

                           (601205) Page 5 GAO-04-892

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