Click, click: the internet and prescription drugs

Introduction
Need information about prescription drugs? Click, click - there it is. Want to order a drug from the privacy of your own home without seeing a doctor? Click, click - it's on its way. Those are the promises, or threats, of the internet.

Information or advertising?
Consumers want, and deserve, more information about the drugs that they use. The question is what kind of information are they going to get when they connect to the internet. Drug companies are eager to provide information on web sites, especially since, in most areas of the world, they are forbidden from advertising prescription drugs directly to the public. Before we advise our patients to rush home and turn on their computers, there are a few caveats to consider.

Will consumers even know that they are looking at advertising when they click on a web site? It is clear when you see an advert in a magazine or on television what you are looking at (with the exception of advertorials). Web sites are more confusing; the entire page can rarely be seen on the screen at one time. Unless you scroll to see the whole page, you might not even know that you are looking at an advertisement.

Another difference between the internet and printed information is the ease of finding the information that you want, or at least recognising that it is missing. When you see a page of print you can scan it quickly to find safety or dosing information if that is what you are interested in. Since electronic sites can potentially be endlessly expandable and thereby offer huge volumes of information you may have to go through a number of screens of material before you find what you want. If directions on the web site are not clear, some consumers may simply give up and see only the first few pages with the bold colours and imaginative graphics and never find the key piece of information they are seeking. Consider the Café Herpé web site set up by Smith Kline Beecham, makers of Famvir (famciclovir).¹ The material on the main pages is useful and objective but it is not complete. It is not until you get past the designer pages to the pages of pure print and read closely that you discover that famciclovir does not cure herpes labialis or stop transmission. Just as in any form of advertising, companies will present the information that they want consumers to have in the most prominent way and the other information, while there, will take some work to find.

Regulation
The answer to concerns about the internet is that the contents of web sites should be regulated. At present, drug advertising on the internet is so new that there are few standards. The fact that any web page can be accessed from anywhere in the world is going to add an entirely new dimension to the problems of deciding on standards. If a company in the USA sets up a web site, anyone in Australia with a computer can see that web site. What happens if the information on that site does not conform to the Australian standards recently launched by the Australian Pharmaceutical Manufacturers Association?² You can argue that we already have to deal with that problem since American magazines with direct-to-consumer advertising are read in Australia, but people at least know that they are reading an American magazine with information geared to an American audience. Who knows where the web site is based? Will the company go to the expense of maintaining a purely Australian web site for the same product? If they do not like the Australian standards why spend the money, since the company will not be losing any of its potential audience: a web site based at the North Pole can be accessed just as easily as one operated from Sydney. There is no regulatory mechanism for web sites to be inspected before going on-line. As with other forms of advertising on the internet the only regulation is self-regulation.

How do we apply sanctions if there is only a single worldwide web site for any given product? Is it fair to punish an Australian subsidiary because the American company's web site lists indications that have not been approved in Australia or omits safety information that is required by the Therapeutic Goods Administration?

Besides the concerns listed above, a public meeting in September 1996, convened by the United States Food and Drug Administration, brought forward others:

• distinguishing between advertisements aimed at consumers and health professionals can be difficult
  
  
• pharmaceutical companies' home pages may be linked to other sites giving out information on unapproved use of drugs
  
  
• conditions of company sponsorship of 'chat rooms' and 'newsgroups' are unclear.³

World Health Organization
In September 1997, the World Health Organization (WHO) convened a working group as a follow-up to a resolution passed at the 50th World Health Assembly.⁴ The working group made recommendations for ways in which WHO, national drug regulators, the industry and consumers could act to improve the standard of information available on the internet. The meeting stressed that both regulatory standards and voluntary codes should aim to ensure that all internet promotional activities complied with the WHO Ethical Criteria.⁵ Some specific recommendations for the pharmaceutical industry included:

• disclosure of web site ownership or financial support
  
  
• statements about who the intended audience is and the purpose of the information
  
  
• provision of accurate, balanced information, including information on dangers and adverse effects
  
  
• careful selection of internet linkages.^6,7

Internet prescribing
Trying to come up with acceptable standards to govern internet advertising is something like trying to find your way around a new city without a map. If we are going to need a road map to deal with advertising, then we are going to have to build the roads when it comes to prescribing and accessing drugs over the internet.

Months before sildenafil was available in the UK, people there were able to order it through web sites and have it mailed to them. No prescription was required, no examination by a doctor, just a credit card to pay for the product. These web sites were not operated in the UK so the authorities there had no power over them. Intercepting the drugs in the mail on a large scale was just not possible.

An American survey found 77 web sites which offered sildenafil without the need to see a doctor. Less than half the sites asked if the consumer had erectile dysfunction and only 55% included information about contraindications. Only 18% required the consumers to verify that they understood the adverse effects.⁸

In the USA people can click onto a web site, fill out a questionnaire about their health problem, have the questionnaire evaluated by a doctor halfway across the country who never sees them and who is not even registered to practise medicine in the same State, and then have the prescription mailed to them from a third point in the country. So far the authorities in the USA appear to be virtually helpless to deal with this phenomenon.

The situation in Australia may never get as bad as in the USA, but the existence of 'virtual pharmacies' is not hard to imagine. Doctors e-mail a prescription to a web site address and the prescription is then mailed or otherwise delivered to our patients' homes. In some ways this may prove to be an advantage. An e-mailed prescription is always going to be legible. Not having to physically take the prescription to a pharmacy may be convenient for some people, especially the elderly who find it difficult to get around or in rural areas where the nearest pharmacy may be a long way away.

What about the traditional role of the pharmacist in giving advice to people? The virtual pharmacy can offer an on-line pharmacist to answer questions and some people may find it easier to 'talk' to someone via computer than face-to-face. On the other hand, on-line pharmacists are going to miss all the non-verbal clues that provide an essential element of communication. How do you show an on-line pharmacist the rash that you think may have been caused by the drug you are taking?

Conclusion
The internet can give consumers access to information about medicines. There are, however, no controls on the quality of this information. The internet also allows the consumer to bypass the advice of their doctors and pharmacists.

Click, click - there are the problems; click, click - where are the solutions?