“Keep Internet Neighborhoods Safe”
Preventing the Illegal Internet Sales of Controlled Substances to Youth
In response to growing evidence that increasing numbers of internet websites offer to sell controlled substances without prescription, Drug Strategies; the Treatment Research Institute at the University of Pennsylvania; the Center for International Criminal Justice and the Berkman Center for Internet and Society at Harvard Law School; and the Weill Medical Center at Cornell University created a Public-Private Partnership in January 2005 to address the problem of drug trafficking over the internet of prescription narcotics without prescription. Since then, this core group has brought together leaders of companies that play key roles in internet commerce. These include Internet Service Providers (ISPs), such as Verizon Online; AOL; AT&T; Earthlink; Microsoft; and Comcast; search engines, such as Google and Yahoo; banks, such as UBS and JP Morgan Chase; credit card companies, such as Mastercard, Visa and Paypal; and private carriers, such as UPS, DHL and Fed Ex. We have also included officials of key U.S. government agencies, such as the National Institute on Drug Abuse, the Department of Justice, the Drug Enforcement Administration, Customs and Border Protection, the Department of State, and the U.S. member of the United Nations International Narcotics Control Board.
Our collaborative effort is informed by academic, legal, and technology experts as well as leaders in public education through the media, such as the Partnership for a Drug Free America. The goal is to develop new strategies to curtail Internet drug trafficking to youth, taking into consideration such issues as Internet regulation, online advertising, payment transfers, delivery services, U.S. and international law as well as prevention initiatives.
This initiative, which we named “Keep Internet Neighborhoods Safe (KINS),” involved more than fifty participants and held six plenary meetings at Harvard Law School and several specialized meetings with government officials and private company executives in Washington, D.C. since early 2005. On July 6-7, 2006, we convened a major conference at Harvard to discuss potential strategies to curtail illegal Internet sales of controlled substances to youth by targeting key points of control. (The conference agenda and the names of participants are attached in Appendix A.) We are grateful for the help of all those involved in this important initiative: leaders from the private sector as well as from key government agencies generously contributed their time and their best advice. The resulting white paper does not represent a group consensus but rather the views of the core organizing group (Drug Strategies, Harvard Law School, Weill Medical Center and the Treatment Research Institute) built upon the two years of research and meetings.
Why We Are Concerned
1. Sales of Psychoactive Prescription Drugs over the Internet is Becoming a Major Enterprise, Presenting New Challenges to Drug Abuse Prevention and Treatment.
Adolescent use of highly addictive prescription opioid drugs, such as Vicodin and Oxycontin; sedatives, such as Ambien; and tranquilizers, such as Valium and Xanax, without prescription increased, according to annual national surveys. Despite the encouraging news that past month illicit drug use overall declined 19% among youth ages 12 to 17 since 2001, there has been a significant increase in adolescent non-medical use of addictive prescription drugs. These drugs are widely advertised and sold over the Internet without prescription. Ready availability through “non-prescription websites (NPWs)” may be one important contributing factor to increasing adolescent use of these drugs.
The global reach of the Internet now makes it as easy for an adolescent to buy drugs as it is to buy a book or CD with a credit card, PayPal, or even cash. Some sites provide drugs initially free without immediate payment. Unlike many scams on the Internet, there is evidence that these drugs of abuse are real, potent, and actually delivered to buyers. (Research conducted by Dr. A. Thomas McLellan and his colleague Dr. Robert Forman at the Treatment Research Institute as well as by the Government Accounting Office cited in the Bibliography confirm that the psychoactive drugs delivered over the internet are not fake substances.) Of particular concern is the role that NPWs might play in initiating opioid and other non-medical drug use among adolescents, the age group that most frequently uses the Internet. For example, a sixth grader researching a school paper might enter the term “Vicodin” in a major search engine, like Google or Yahoo, and see a majority of the retrieved websites aggressively advertising to sell these drugs without prescription (Forman 2003, Forman 2006).
2. Prevalence of Adolescent Substance Abuse in the United States.
Two major federally funded annual surveys provide information on adolescent drug, alcohol and tobacco use nationwide. Monitoring the Future (MTF), begun in 1975, interviewed approximately 50,000 8th, 10th, and 12th grade students (Johnston et al 2005). The National Survey on Drug Use and Health (NSDUH), begun in 1971, interviewed approximately 70,000 randomly selected individuals aged 12 and older in order to provide national and state-level estimates of past month, past year, and lifetime drug, alcohol and tobacco use (Substance Abuse and Mental Health Services Administration 2006). The NSDUH collects data by age group (12-17; 18-25; 26 and older) rather than by grade level.
Both national surveys confirm that non-medical drug use is pervasive among American adolescents. According to MTF, 48 percent of 12th graders, 36 percent of 10th graders and 21 percent of 8th graders reported in 2006 that they had used an illicit drug at least once in their lifetime (Johnston et al 2006). The NSDUH reported that 10 percent of young people ages 12-17 (over 2.5 million adolescents) said they had used an illicit drug in the month prior to the survey, and 1.2 million youth ages 12-17 said they had abused or were dependent on an illicit drug at some point during the previous year (SAMHSA 2006). In 2005, a majority (52 percent) of the approximately 2.9 million persons (age 12 and over) who reported using an illicit drug for the first time within the year prior to the survey were younger than age 18 when they first used (SAMHSA 2006).
The MTF survey reported that there was a 23.1 percent decline in past month use of any illicit drug by 8th, 10th, and 12th graders combined between 2001 and 2006. This trend is driven largely by decreasing rates of marijuana use among these students: since 2001, past month marijuana use has fallen by 24.7 (Johnston et al 2006). The NSDUH reported that between 2002 and 2005, past month marijuana use by males ages 12 to 17 declined (9.1 percent in 2002, 8.6 percent in 2003, 8.1 percent in 2004, and 7.5 in 2005), as did usage levels for female youths (7.2, 7.2, 7.1, and 6.2 percent, respectively) during the same time period. The NSDUH survey also found that current rates of illicit drug use among teens in 2005 varied significantly by major racial/ethnic groups. Native American or Alaska Native youths reported the highest rates (19.2 percent), compared to 9.7 percent for youths identified with two or more races. White youths reported 10.1 percent; Hispanic youths, 9.4 percent; African-American youths, 11 percent, and Asian youths, 3.3 percent. In 2005, approximately 2.1 million people reported using marijuana for the first time within the past year (SAMHSA 2006).
The NSDUH also found about the same number of recent marijuana initiates between 2004 and 2005. Of the roughly 2.1 million recent marijuana initiates, 54 percent were younger than age 18. The survey reported that about 872,000 people used cocaine for the first time within the past 12 months. About one-third of these recent cocaine initiates were under 18 when they first used.
In 2005, an estimated 2.5 million people aged 12 or older reported using psychoactive drugs without prescription for the first time in the year prior to the survey. (Of this group, 850,000 were youth ages 12-17 and 847,000 were young adults ages 18-25.) With regard to prescription pain killers, 2.2 million people (age 12 and over) reported first time use without prescription. In addition, non-prescribed first time use of tranquilizers was reported by 1.3 million people; similar use of stimulants by 647,000 people and sedatives by 247,000. The number of new non-medical users of Oxycontin was 526,000, with an average age at first use of 26.3 years.
3. Increasing Non-prescription Use of Addictive Prescription Drugs by Youth.
Non-prescription use of opioids, sedatives and tranquilizers by adolescents is increasing. Of particular concern is the high rate of Oxycontin and Vicodin use among adolescents (Johnston et al 2005). Physicians generally prescribe these opiates to relieve severe pain, but they now are becoming widely used for non-medical purposes by young people. The 2006 MTF survey reported that 4.3 percent of 12th graders, 3.8 percent of 10th graders, and 2.6 percent of 8thgraders said they used Oxycontin at least once in the past year. It is important to note that questions regarding Oxycontin and Vicodin use were not added to MTF until 2002 so that earlier information on the prevalence of adolescent non-medical use of these drugs is not available. Even higher rates of annual use were reported in 2006 for Vicodin: 9.7 percent of 12th graders, 7.0 percent of 10th graders, and 3.0 percent of 8th graders said they used Vicodin without prescription in the previous year. (In 2006, 66.5 percent of 12th graders reported alcohol use and 31.5 percent reported marijuana use.) Vicodin became the second most widely reported drug used by 12th graders excluding tobacco and alcohol). Heroin, on the other hand, had an annual prevalence rate of less than 1 percent among 12th, 10th, and 8th graders (Johnston et al 2006).
The NSDUH reported that in 2005, 11.9 percent of youths ages 12-17 said they had tried psychotherapeutics for non-medical use at least once in their lifetime, including 1.1 percent using Oxycontin, 3.0 percent using tranquilizers, 4.6 percent using Vicodin, Lortab or Lorcet, 1.7 percent using hydrocodone, and 1.8 percent using codeine (SAMHSA 2006). Lifetime use of Oxycontin for young adults ages 18-25 rose from 3.6 percent in 2003 to 5.0 percent in 2005. During the same time period, lifetime use of Vicodin, Lortab, or Lorcent rose from 15.0% to 17.7% and hydrocodone use rose from 6.6% to 7.6% (SAMSHA 2005, 2006).
According to MTF, students also reported significant rates of non-prescription use of sedatives and tranquilizers. The annual MTF survey asks only 12th graders about sedative use: in 2006, 6.6 percent of 12th graders reported using non-prescribed sedatives in the previous year, more than double the rate reported in 1992 (2.8 percent). Similar increases in non-prescribed use of tranquilizers were reported by 12th graders (6.6 percent in 2006 compared to 2.8 percent in 1992) (Johnston et al 2006).
Nearly one in five teens (19 percent) report non-medical use of prescription medications, according to a nationwide survey by the Partnership for a Drug-Free America (PDFA 2005). As for prescription painkillers, around 18 percent of teenagers reported using Vicodin, and one in ten reported using Oxycontin. More than one third of teenagers (37 percent) said they had close friends who had used prescription painkillers such as Vicodin, Oxycontin and Tylox, without prescription. One in 10 teenagers, or 2.3 million young people, have tried prescription stimulants, such as Ritalin or Adderall without a prescription (PDFA 2005).
A 2003 study conducted via a web-based survey examined non-medical use of prescription drugs in a sample of 1,017 public school students ages 10-18 in the Detroit metropolitan area (Boyd et al 2006). The study found that 22 percent of girls and 10 percent of boys reported non-medical use of a pain medication at least once in their lifetime, while 15 percent of girls and 7 percent of boys reported such use within the year prior to the survey. The students reported that the single largest source for drugs was family members, followed by friends and dealers. The study did not include any youths who had obtained prescription drugs on the Internet. Furthermore, a 2006 study investigating non-medical use of prescription medications among undergraduate students found that college men are more likely than women to obtain prescription opioid medications for non-medical use from peer sources, while women are more likely to get them from family members (McCabe, Teter and Boyd 2006).
The NSDUH was the most recent source of information on the demographic characteristics of adolescents in drug treatment nationwide. The survey reports that in 2004, 276,000 youth ages 12-17 received treatment for non-medical use of an illicit drug during the previous year (SAMHSA 2006). Non-medical use of prescription drugs is a reason why many youth are in treatment: 15% of youths who received treatment reported use of pain relievers, 7% reported use of tranquilizers, and 3% reported use of sedatives.
4. Perceptions of Non-Medical Prescription Drug Use among Adolescents.
According to a 2005 survey by the Partnership for a Drug Free America, two in five teens, or around 9.4 million, said they believe that getting high from prescription medications is “much safer” than street drugs (PDFA 2005). Thirty one percent of adolescents, or 7.3 million, believe there is “nothing wrong” with using prescription drugs without a prescription “once in a while”. Nearly three out of 10, or 6.8 million, believe that prescription painkillers, even if taken without a prescription, are not addictive. The majority of teens (13.4 million) agreed that prescription drugs are easier to get than illegal street drugs, and that prescription painkillers are “available everywhere”.
5. Ease of Finding Internet Drug Pharmacies.
With more than 200 million Internet users in the United States, the web is a vital medium for communication, entertainment, and commerce (Clickz Network Statistics 2006). The Pew Internet & American Life Project reported that 87% of 12-17 year olds, and 82 percent of 18-24 year old go online at least monthly (Fox 2005). Similarly, 43 percent of teens and two-thirds of adult internet users go online to make purchases, and a large number of adults (79 percent) use the internet to look for health and medical information (Fox and Madden 2005, Lenart 2004). The digital divide between African-Americans, Hispanics and whites appears to be closing. A 2006 Pew national survey reports that 74 percent of whites, 61 percent of African-Americans and 80 percent of English-speaking Hispanic-Americans go online (Marriott 2006). In 1998, a Pew survey found that 42 percent of whites and 23 percent of African-Americans used the Internet.
About half of all adult Americans take a prescription medication regularly, and one in four have used the Internet to learn about prescription medications. The majority of Americans have greater confidence in their local pharmacy than Internet-based pharmacies, and only about 4 percent report having purchased medications online (Fox 2004). A wide range of controlled substances is offered for sale online including stimulants, steroids, sedatives, hallucinogens and marijuana (SAMHSA 2003). In addition to the many legitimate online pharmacies that operate in accordance with state and federal laws, hundreds of websites have appeared offering to sell controlled substances such as Vicodin and Oxycontin without prescription. No prescription websites (NPWs) are online pharmacies that supply consumers with controlled substances without a valid prescription. There are two general categories of NPWs: Retail NPWs directly offer to sell opioid medications without prescription while Portal NPWs provide multiple links to Retail NPWs. The majority of the NPWs identified in monitoring studies conducted since 2003 were classified as Portals (Gordon et al 2006).
While legitimate online pharmacies require a valid prescription from the consumer’s physician, there are hundreds of NPWs that sell prescription medications based solely on an online questionnaire, a telephone interview, or a simple online order without any interaction with a physician or other licensed healthcare professional. To assess the relative availability of NPWs versus websites that offered addiction health information (e.g. WebMD), during the first two weeks of August 2004, Gordon et al (2006) conducted 27 Google searches using a wide variety of opioid search terms. Two search terms – no prescription Vicodin, and no prescription hydrocodone –yielded 80-90 percent NPWs and no links to addiction health information websites. On the other hand, searches for several opioid medications, including Fentanyl, Duragesic, buprenorphine, and Subutex – with and without the no prescription prefix – yielded a majority of addiction health information websites and few or no NPWs.
Beyond qualitative examinations of typical NPWs, there has been no systematic study of the content of current Retail NPWs. Forman and Block (In press) looked at fifty NPWs by examining links within the top three portal NPWs identified during a search in June 2005. During the coding process, any website found to be a legitimate retailer that only sold medications to customers with a doctor’s prescription was eliminated from consideration and replaced by the next linked website until a total of fifty NPWs was reached. Nearly all (92 percent) of the NPWs contained an implied legitimacy or credibility claim of some kind. Over 80 percent of NPWs contained a medical legitimacy claim. Fewer NPWs displayed a retailer legitimacy claim (24 percent). 88 percent of NPWs accept payment via one of the major credit cards and over half (52 percent) mention delivery through a reputable carrier like FedEx or DHL. These findings suggest that working with credit card and shipping companies may be a viable mechanism for identifying ownership of NPWs and potentially suspending their credit card contracts. Approximately half (52 percent) of NPWs require some kind of online questionnaire to be filled out by the patient; a much smaller percentage offer to conduct a telephone consultation, either for free (8 percent) or a fee (20 percent).
Research conducted since 2002 by Dr. Robert Forman and his colleagues at the Treatment Research Institute (TRI) (Forman, 2003; Forman et al 2006) has identified more than 300 unique websites offering to sell non-prescription opioid drugs. In over 50 Internet monitoring replications in which search terms such as codeine, or Vicodin were used, more than 50 percent of the links returned for these terms led to websites offering to sell opioid medications without a prescription (Forman et al 2006). When the search prefix “no prescription” was added to the drug term (e.g. no prescription Vicodin), the proportion of NPWs obtained increased to 60-80 percent. During a one week investigation in 2004, the National Center on Addiction and Substance Abuse (CASA 2004) identified 147 anchor web sites that actually offered sales of Schedules II – IV controlled prescription drugs without a prescription, while only 10 websites requiring prescription verification were found. In a 2006 update of this study, CASA reported that the number of anchor sites selling Schedule II-IV controlled prescription drugs had grown to 165, while the number of sites requiring prescriptions had increased to 20 (CASA 2006).
6. Difficulty in Reducing On-line Access.
Legitimate online pharmacies (e.g., drugstore.com, caremark.com) provide convenience and efficiency to consumers while complying with state and federal regulations that require a valid prescription from the consumer’s physician. The American Medical Association (AMA) and the National Association of Boards of Pharmacy (NABP) have issued policy statements that support the Internet as a medium for processing legitimate prescriptions. However, hundreds of websites now sell prescription medications based solely on an online questionnaire, a telephone interview, or a simple online order without any interaction with a licensed healthcare professional (See Forman et al 2006). This has been recognized as a threat to public health (American Medical Association Policy H-120.956 – 3, American Medical Association Policy H-120.949, National Association Boards of Pharmacy 2003).
The benefits of the Internet are available to everyone, including individuals who commit unlawful acts such as software piracy, virus releases, identity theft, espionage, the sale of child pornography, illegal weapons, and controlled substances. Online stores can be hosted and registered anywhere in the world, advertising, selling, and delivering products internationally with relative anonymity and convenience – and with little regard for the laws of other countries. The United States Controlled Substances Act (U.S. Department of Justice 1970) prohibits the sale of Schedule I drugs such as marijuana, heroin, crack cocaine, and ecstasy and regulates access to Schedule II-V drugs, including opioid analgesics, sedatives, tranquilizers, stimulants and steroids by requiring a valid prescription from an appropriately licensed healthcare professional (U.S. Department of Justice 1970). However, many countries have drug policies that differ from those of the United States, or have similar laws but less enforcement.
The fluidity and virtual reality of cyberspace are ideally suited to illicit drug transactions, creating a complex challenge for law enforcement, policy makers and the general public (White House Executive Order 1999, U.S. General Accounting Office 2004). Businesses wishing to circumvent the U.S. Controlled Substances Act may do so by establishing multiple websites, in multiple countries, under multiple online identities (Forman and Block 2006). Many of the websites selling drugs are hosted outside the United States, and drug suppliers guarantee to (and actually do) replace any drugs intercepted by U.S. Customs or other law enforcement agencies. Recent studies indicate that Russia, Ukraine, and some South Asian countries are emerging as key locations for drug sales websites. For example, a “no prescription website” can be physically located on a computer in Uzbekistan; registered to a business address in Mexico; ship its drugs from Pakistan; deposit payments to a Cayman Island bank – while the owner resides in Miami. Importantly, all links in this online enterprise can be quickly dismantled and resurrected under a new set of virtual identities. The effect of this was seen following the April 2005 report of the DEA’s Operation “CyberChase” which resulted in the arrest of 20 individuals in eight U.S. cities and four foreign countries, operating over 100 websites (U.S. Department of Justice 2005a, 2005b). However, this widely publicized DEA operation did not appear to have any measurable impact on the availability of non-prescription controlled substances over the Internet (Forman et al. personal communication based on May through October 2005 searches of NPW sites). It is likely that in response to these domestic arrests, operators of NPWs will continue to move pieces of their operations off-shore, making prosecution efforts even more difficult. (Forman, Marlowe, and McLellan 2006).
7. Intercepting NPW Deliveries.
Since it is illegal to purchase prescription opioids and other controlled substances without prescription, there are limited data on the actual delivery rate of NPWs. It is easy to think that, like so many other Internet “scams,” there is no reality to the offers of sale from these websites. However, the U.S. General Accounting Office (GAO) recently conducted an investigation in which they attempted 11 purchases of opioids without prescription (including hydrocodone and oxycodone). Of those 11 attempted purchases, 10 were delivered. The GAO also found that many Internet suppliers promise to replace any drugs intercepted by U.S. law enforcement agencies and they actually do so. (GAO 2004). In June 2005, the Miami DEA announced the arrest of eight operators of illegal drug sales websites. Seized records showed these websites delivered over 28,000 orders for controlled substances without prescription per week, particularly hydrocodone (Vicodin).
On July 30, 1999, U.S. Deputy Attorney General Ivan Fong testified before the Subcommittee on Oversight and Investigations, Commerce Committee, United States House of Representatives, that “…online pharmacies allow consumers to purchase prescription drugs without any pretense of a prescription” and that these websites introduce “potential risks to public health and safety” (Fong 1999). A week later the White House issued Executive Order 13133 creating the “Working Group on Unlawful Conduct on the Internet” leading to the publication of “The Electronic Frontier” (Attorney General’s Office 2000). The Drug Enforcement Administration (DEA) subsequently published guidance (Department of Justice 2001) which specified four conditions under which legal prescriptions can be issued over the Internet: a) a patient presents a medical complaint; b) a medical history is obtained; c) a physical examination is performed; and d) some logical connection exists between the medical complaint, the medical history, the physical examination, and the drug prescribed. Prescriptions based on telephone interviews or online questionnaires are not considered valid. In support of these guidelines, the American Medical Association subsequently issued guidance for physicians on Internet prescribing that largely parallels the DEA’s position (American Medical Association Policy (Policy H-120.949)).
Since 2001, the sale of controlled substances over the Internet has been cited in U.S. Justice Department reports (National Drug Intelligence Center 2001, 2002; DEA 2002) and has led to criminal investigations for Internet sales of non-prescription drugs such as ecstasy, gamma hydroxyl butyrate (GHB) and methamphetamines, (Drug Enforcement Administration News Release 2002, 2003; National Drug Intelligence Center 2003) and the illicit sale of prescription drugs online (NDAS 2001, National Drug Intelligence Center 2003, U.S. Department of Justice 2002, Hutchinson 2002). Similarly, the U.S. Food and Drug Administration (FDA) has provided testimony (Hubbard 2003), and reports (Henney 2000, FDA 2003, Center for Drug Evaluation and Research 2003) on the risks of online prescription practices. In conjunction with U.S. Customs, the FDA participated in an investigation of illicit prescription drug sales originating overseas (FDA 2003). On March 1, 2004, the White House Office of National Drug Control Policy (ONDCP) issued the 2004 National Drug Control Strategy Update (White House 2004) which for the first time described plans to monitor illicit Internet drug offers (p. 28). Concurrent with the issuance of this strategy update, ONDCP issued a press release (ONDCP 2004) entitled “U.S. Drug Prevention, Treatment, Enforcement Agencies Take on ‘Doctor Shoppers,’ ‘Pill Mills’” and a fact sheet entitled “Reducing Prescription Drug Abuse” (ONDCP 2004) which announced initiatives to stop illicit online prescription drug sales. There were four potential “choke points” for NPW enforcement efforts: a) search engines that list NPWs when searches are conducted; b) credit card companies with which NPWs and their customers have accounts; c) package delivery companies; and d) Internet service providers (ISPs) where NPWs files are hosted (Forman and Block In press).
The existing regulation of Internet prescription drug sales was very clear on paper, but quite murky in practice. At its most basic, the purchase of any prescription drug must be done through a properly accredited Internet site, which requires a valid prescription. To oversee this regime, the National Association of Boards of Pharmacy (NABP) established a certification program to enable the approved sales of prescription medications over the Internet. The program, known as Verified Internet Pharmacy Practice Sites (VIPPS) certification, allowed merchants in the United States to sell prescription medications over the Internet. To achieve VIPPS accreditation, a pharmacy site must comply with the licensing and inspection requirements of the state in which it does business, and must demonstrate to the NABP compliance with certain specified criteria, including patient rights to privacy, authentication and security of prescription orders, maintenance of quality assurance and improvement program, and provision of meaningful consultation between patients and pharmacists.
Even with certification, there are limits on what a pharmacy can sell based on Federal regulation. These rules apply equally to physical and virtual pharmacies. Physicians can prescribe and pharmacies can dispense drugs listed in the Controlled Substances Act Schedules II through V, which are defined as drugs with a legitimate medical purpose, but dangerous if not properly controlled. Drugs listed in Schedule I are considered to have no legitimate medical purpose and are illegal to sell under any circumstance, such as heroin. The powerful drugs currently most prone to abuse are Oxycontin (Schedule II) and Vicodin (Schedule III). Schedule II drugs cannot be provided legally over the Internet, while Schedule III drugs can prescribed through a VIPPS Internet pharmacy.
Despite this regulatory regime and the fact that purchasing controlled substances overseas is illegal, traditional enforcement efforts towards illicit purchases have generally been lax. This is because of the overwhelming volume of pharmaceuticals entering the United States and the political controversy around individuals attempting to purchase cheaper prescription drugs for legitimate medical problems overseas. As a result, despite a clear regulatory regime, the actual flow of prescription drugs (legal and illegal) into the United States continues to accelerate.
9. Increasing Awareness of Drug Availability Online.
Beginning in the fall of 2003, the popular press began reporting on the availability of prescription opioids over the Internet without prescription (Forman et al 2006). The earliest newspaper report on NPWs was published on October 18, 2003, in the New York Times (Harris 2003) in an article describing a joint DEA/FDA taskforce targeting “rogue online pharmacies” that sold prescription drugs without a prescription. Two days later the Washington Post released a five-part series detailing the results of a one-year investigation into the availability of prescription drugs without a prescription (Gaul and Flaherty 2003a, b, c, d, e, f). A month after the Washington Post series, USA Today (Rubin 2003) reported on the “uncontrolled sale of controlled substances” over the Internet and then, in December 2003, news coverage about NPWs became widespread with the Los Angeles Times, Philadelphia Daily News, Boston Herald, Miami Herald, Denver Post, San Jose Mercury News, and the Chicago Tribune publishing stories about the online availability of controlled substances without a prescription (Anderson 2003, Caywood 2003, DeWolf 2003, Frates 2003, Gaul 2003, Healy 2003, Higgins 2003). Since then, press and broadcast coverage of this phenomenon has accelerated. A recent example is the front-page story in USA TODAY on June 13, 2006, “Prescription Drugs Find Place in Teen Culture.” The press reported that the term “pharm party”, where youth swallow fistfuls of prescription drugs, is now widespread.
Building A Comprehensive Strategy
I. Conduct Research Designed to Obtain.
A. Accurate Information regarding the Extent of Controlled Substances Availability without Prescription over the Internet.
In contrast with the many reports in the law enforcement literature and popular press, there are few publications in the public health or medical literature concerning the availability of prescription opioids without prescription over the Internet. In a Medline search using combinations of terms including “online,” “opioids,” “Internet,” and “narcotics” only one publication addressing the availability of prescription opioids over the Internet was found: the principal investigator’s preliminary research report (Forman 2003). This, and other searches conducted using Medline and PsychINFO, identified general articles about topics such as online pharmacy prescribing practices, the Internet as a source of drug information, and the online sale of sexual performance enhancement drugs, but no articles were found about websites selling prescription opioids without a prescription.
The European Union funded the Psychonaut 2002 Project, which searched the Internet for drug-related websites using a controlled search methodology (psychonaut2002.org). Its primary aim was to collect and analyze the information available on these websites, and to develop an Early Warning System for professionals providing information and suggestions concerning emerging drug markets, new drugs and new trends in drug use. This was a multi-site research project involving 15 centers from nine European countries and analyzed more than 4,000 sites in 8 languages. Investigators in this project have published articles about the availability of controlled substances on the Internet (Schifano et al 2003).
B. Data on Internet Role in Supplying Prescription Drug Abusers.
There is an overall lack of information about who is using the Internet to obtain psychoactive prescription drugs without a prescription. The original impetus for TRI’s research on NPW websites came from reports in AA meetings and to clinicians that advertisements for drugs on the Internet were becoming an important contributor to relapse. To explore this carefully, a study was undertaken in 2004 in a collaborating private adult residential treatment program outside Philadelphia (Gordon, Forman and Siatkowski 2006). One hundred consecutive adult patients were interviewed concerning how they had obtained the drugs they had used 30 days prior to entering treatment. Nine percent reported having purchased their drugs online and an additional 2 percent stated they had found their dealer online. In addition, 29 percent indicated that they knew they could purchase drugs over the Internet without prescription and 11percent reported they had used the Internet either to buy drugs or locate a drug dealer. Among the respondents who knew the Internet was a drug source, reasons given for not using it were: it was too expensive; the desired drug could not be obtained (e.g. cocaine); and fear of being identified by authorities or other family members using the same computer. The results of this preliminary study suggest that the Internet has become a source of controlled substances for some addicted individuals (Gordon et al 2006).
Although we have extensive anecdotal evidence of the Internet’s role in illicit drug distribution, we still do not have solid information about the amounts of controlled substances that are being purchased without a prescription over the Internet, both by adults and adolescents. Neither of the two annual national drug use surveys, MTF and NSDUH, contain questions asking non-prescription drug users where they obtain their drugs (e.g., friends, internet, doctors, dealers, family medicine cabinets), although they could do so in the future.
Relatively little is known about how socioeconomic factors and demographics, such as race, gender and ethnicity, relate to adolescent non-medical prescription drug use. In terms of location, it has been observed that drug use patterns among adolescents from rural areas may be different from those of non-rural youth (Gordon and Caltabiano 1996, Warner and Leukefeld 2001) However, some publications show rural youth exceed urban youth in their drug use and some find the contrary (Ruiz et al 2005). The role of the Internet as a source of drugs for these groups has not been explored. For example, could the Internet be a more important source for rural youth than for urban youth who have more immediate access to dealers? Would female adolescents (who already show greater non-medical use of prescription drugs) be more likely than males to use the Internet to purchase these drugs, since the Internet does not involve direct contact with dealers and purchases can be made in privacy rather than on the street?
II. Develop New Treatment and Prevention Strategies to Respond to Emerging Role of Internet as Drug Supplier.
Most adults do not realize that many adolescents and even younger children may find it easier to buy drugs online than on street corners. Even at very young ages, they can navigate easily among websites, which offer information, entertainment, and consumer goods. Websites aggressively advertise controlled substances, so that a seventh-grader researching a paper for health class might enter the term “Vicodin” in any major search engine and see sites that sell these narcotics, without a prescription, on a majority of the listings provided. Even websites that claim they require prescriptions often allow users to generate a “prescription” by simply checking off a series of quick questions; no direct interaction with a physician is required.
Although media coverage of the misuse of pharmaceutical drugs by adolescents is increasing, many parents and youth do not believe that these drugs are a threat. A national survey by the Partnership for a Drug Free America (2005) reported that almost half of teens said they believe that prescription drugs, even if not prescribed by a doctor, are much safer than street drugs and almost a third said that prescription pain killers, even if not prescribed, are not addictive. The survey also reported that adults and youth do not view controlled substances such as Vicodin as equally “dangerous” as narcotics that can be bought from street dealers or classmates, especially since these drugs are widely prescribed by doctors for legitimate medical purposes. The ease with which these drugs are obtained over the Internet, their packaging, and their appearance of legitimacy can contribute to the belief that such drugs are relatively safe when in fact these drugs can be lethal when taken in high doses or in combination with alcohol. The Partnership for a Drug Free America has recently undertaken a major national campaign to educate parents and adolescents about the dangers of non-medical use of controlled substances, specifically Vicodin and other narcotic analgesics.
There are some indications from treatment centers that Internet drug availability may play a role both in developing drug dependence and in relapse. For both adolescents and adults who purchase drugs over the Internet, the computer could become a relapse trigger, which may need to be avoided until a stable recovery has been secured. More research is needed regarding the effect that Internet access has on relapse, both in terms of the client being confronted with unsolicited offers for prescription drugs via email, and the role of NPW’s in facilitating access that can lead to relapse.
The powerful addictive properties of some of these drugs further complicate treatment and prevention. Treatment for adolescents purchasing prescription narcotics over the Internet may require unique interventions when compared to traditional treatment approaches for abuse of illicit street drugs. This is a pressing concern because of the substantial risk for overdose and death resulting from the use of prescription opioids and sedatives particularly in combination with alcohol.
Treatment, intervention and prevention efforts face new challenges related to the emergence of the Internet as a drug source. Current drug education and prevention programs, designed largely for classroom use, may not have the same impact on the emerging phenomenon of Internet drug sales to youth, since evidence suggests that parents, teachers, and the students themselves do not view drugs obtained over the Internet as equally “dangerous” as those bought from street pushers or even classmates. The skills taught in most school drug education curricula may not prove relevant in the very context of the Internet, where children can buy drugs without physical contact with sellers or peers. Over the Internet, a 14-year old can access a tremendous amount of information about dangerous drugs, including how to purchase them without a prescription. New prevention strategies may be required to deal with this new reality, including ways to use Internet technology to teach prevention.
III. Encourage Public and Private Collaboration to Curtail Internet Sales of Controlled Substances without Prescription.
As is the case with any drug epidemic, if we wait too long, the problem will become far more difficult to control. Based on our extensive research, particularly our contacts with treatment professionals in the field, we are convinced that now is the time to develop a comprehensive approach to combating the illicit sale and shipment of these drugs to youth. The private sector has a powerful role to play. We believe that all parties involved in Internet commerce, from advertising, to ISPs, to the financial institutions that make electronic payments possible, to the common carriers that ship merchandise, need to embrace the problem of internet sales of controlled substances without prescription as a top priority. Each sector has a different interaction with the eco-system that drives this commerce. Each sector will have different strategies to employ. Some of the strategies discussed in the “Keep Internet Neighborhoods Safe” public-private collaboration include:
A. Work with Internet Service Providers (ISPs) to offer their customers managed service that can be configured to block access to websites offering to sell controlled substances without prescription.
Parents are deeply concerned about the safety of their children where they live and go to school. Parents should be able to limit their children’s access to drugs in the virtual neighborhood of the Internet, whether the parents are technically savvy or not. ISPs can offer their customers the opportunity to implement technology that will block access to websites offering to sell controlled substances without prescription. The technology should be easy for customers to install and use and could be made available directly by the ISPs or through third party providers. The largest of the ISPs already offer parental controls which could be adapted to serve this valuable function. Earlier efforts by federal and state governments to mandate filtering systems in the area of pornography have failed because of spillovers to legitimate areas. These approaches have most often faltered by permitting or requiring ISPs to use Internet Protocol (“IP”) based filtering. Where a filtering system is based on an ISP blocking designated IP addresses, the filter can block numerous lawful sites that share the same IP address.
We propose empowering parents and other customers to decide whether to implement filtering as part of their ISP service. It would give the ISP the option of providing a software or hardware filtering system implemented on the ISP end or on the customer’s computer. Even when a filtering system is URL or content based, if the ISP can effect the filtering only by applying it to all of its customers and not just the ones requesting it, the spillover effect could harm valued First Amendment interests of otherwise lawful Internet users. If the ISP’s network configuration does not permit customer specific, URL-based filtering, or if it is simply more economical for the ISP, the ISP could provide the filtering system through software on the customer’s computer, just as many ISPs presently implement anti-virus and anti-spam filters. For example, since its Vista operating system, Microsoft has implemented parental controls that enable customers to request filtering of drug sites.
ISPs alternatively may want to make a simpler option available to their customers. There is no reason why parents who do not want to be able to purchase controlled substances over the Internet need to have access to websites selling them in their home. An ISP could, directly or through a third party provider such as Look Smart’s Net Nanny, offer its customers a system that blocks access to all websites selling prescription drugs over the Internet, whether lawfully or unlawfully.
B. Prevent Misuse of Financial Institutions to Facilitate Illegal Sales of Controlled Substances over the Internet.
The financial sector can play a pivotal role in combating the trafficking of illicit drugs on the Internet, since most of the purchases of controlled substances without prescription rely on payment by credit cards or PayPal. All financial institutions already have extensive legal obligations to ensure the integrity of the financial system. Responsibilities for monitoring the international financial system for abuse and preventing such abuse should include explicit requirements to monitor illicit drug sales. The obligations to “know your customer” and conduct due diligence have been reinforced by both anti-money laundering legislation and the USA Patriot Act. The combination provides a powerful framework that is fully applicable to sales of controlled substances without prescription over the Internet. Most major financial institutions already include prohibitions on the use of their financial networks for any illicit purchase or sale of drugs. This practice should be adopted throughout the industry. Financial institutions could also include a contractual due diligence requirement for any organization, including merchant banks, third party acquirers and other payment processors, including credit card companies, to monitor their networks for any use of the financial network for illicit drug sales. This information about offending accounts could then be shared with other financial institutions as well as law enforcement agencies for appropriate action to protect the credit network from illegal sales of substances.
C. Develop national education campaigns about the dangers of non- medical use of controlled substances which are increasingly available over the Internet as well as technological means of protecting home computers from these websites.
The Partnership for a Drug Free America undertook a major educational campaign targeted at parents and adolescents to inform them of the dangers of non-medical use of controlled substances obtained over the Internet as well as the dangers posed by excessive use of over the counter medications, such as cold remedies. This effort was critically important in shaping public understanding and attitudes about these problems. In addition, government agencies, such as NIDA and SAMHSA, launched national educational initiatives about non-prescription drug use by adolescents.
Internet Service Providers (ISPs) can also play a critical role in educating their customers about the dangers presented by illicit internet drug sales in the information they regularly provide to their subscribers. They can also educate their customers about technological safeguards such as firewalls and parental control software that can prevent the use of computers for the illegal purchase of addictive controlled substances. Moreover, ISPs can make these technological safeguards widely available to their customers and update the technology as needed.
D. Whenever Internet users request a search for any controlled substance, encourage all major Internet search engines to display prominent warnings that it is illegal to purchase controlled substances without a valid prescription in the United States.
To buy controlled substances without prescription over the Internet, adolescents must first find websites that are offering to sell these drugs. Many young people use the Internet to find everything from music downloads to movie tickets. Through search engines such as Google and Yahoo!, easily constructed searches readily lead to hundreds of websites offering to sell controlled substances without prescription. Internet search engines can play a deterrent role by placing forceful warnings at the top of search results for controlled substances without prescription. They can also help educate Internet users about the dangers of non-prescription use of controlled substances by providing automatic links to drug education websites whenever these search requests are made. These links would take users to easily accessible websites, including those sponsored by Federal government agencies as well as those operated by private organizations, such as the Partnership for a Drug Free America which provide information about the dangers of non-medical use of powerful prescription drugs, such as Vicodin or Oxycontin. A list of some of these online educational resources is attached as Appendix B.
“Keep Internet Neighborhoods Safe” was a collaborative effort of Drug Strategies, the Center for International Criminal Justice and the Berkman Center for Internet and Society at Harvard Law School, the Weill Medical Center of Cornell University and the Treatment Research Institute at the University of Pennsylvania. For additional information, please contact Mathea Falco, President, Drug Strategies at 415-638-6600 or email@example.com.
This project was made possible by support from the Miriam and Peter Haas Fund, Dr. Laurie Michaels, the Center for International Criminal Justice at Harvard Law School and Carolyn S. Brody. The background research was supported in part by the National Institute on Drug Abuse and the Center for Substance Abuse Treatment.
American Medical Association Policy (Policy H-120.956 – 3).
American Medical Association Policy (Policy H-120.949).
Anderson, Curt. (2003, December 4). Web Sites Charged In Internet Drug Case: Feds Say Diet Pill, Viagra Sales Illegal. San Jose Mercury, p. 2C.
Attorney General’s Office, U.S. Justice Department. (2002, March). The Electronic Frontier: The Challenge Of Unlawful Conduct Involving The Use Of The Internet A Report Of The President’s Working Group On Unlawful Conduct On The Internet.
Boyd, Carol J., McCabe, Sean E., and Christian J. Teter. (2006). Medical and nonmedical use of prescription pain medication by youth in a Detroit-area public school district. Drug and Alcohol Dependence, 81(1), 37-45.
Caywood, Thomas. (2003, December 14). Online Drug Buying Can Turn Into Nasty Habit: Deals Are Illegal, Dangerous. Boston Herald, p. 4.
Center for Drug Evaluation and Research, Cyber Letters. (2003). Contact Us by Email if You Suspect Illegal Online Drug Sales. Retrieved October 25, 2006, from fda.gov/Cder/warn/cyber/cyber2003.htm.
Clickz Network Statistics. (2006). Retrieved January, 26 2006, from clickz.com/stats/web_worldwide/.
DeWolf, Rose. (2003, December 4). Conn. A.G.’s OxyContin Hunt Leads To Us. Philadelphia Daily News, p. 15.
Domestic Strategic Intelligence Unit (NDAS) of the Office of Domestic Intelligence. (2001). Drug Trafficking in the United States.
Drug Enforcement Administration, U.S. Department of Justice. (2002). State Factsheets.
Drug Enforcement Administration. (2002, September 19). News Release. Operation Webslinger.
Drug Enforcement Administration. (2002, December 20). News Release, DEA suspends online drug activity.
Drug Enforcement Administration. (2003, May 1). News Release, DEA Brings ‘Operation X-OUT’ to Ohio.
Fong, Ivan. (1999, July 30). Statement Of Ivan Fong, Deputy Associate Attorney General Department Of Justice, Before The Subcommittee On Oversight And Investigations, Committee On Commerce, United States House Of Representatives Concerning Sale Of Prescription Drugs Over The Internet.
Forman, Robert F. (2003). Availability of Opioids on the Internet. Journal of the American Medical Association, 290(7), 889.
Forman, Robert F. (2006). Narcotics on the Net: The Availability of Websites Selling Controlled Substances. Psychiatric Services, 57(1), 24-26.
Forman, R. and Block, L. (2006) Marketing of opioid medications without prescription over the internet. Journal of Marketing and Public Policy, 25: 133-146.
Forman, Robert F., Woody, George E., McLellan, Thomas A., and Kevin Lynch. (2006). Availability Of Websites Offering To Sell Opioid-Containing Medications Without A Prescription.American Journal of Psychiatry, 163(7), 1233-1238.
Forman, R., Marlowe and McLellan. The Internet as a Source of Drugs of Abuse. Current Psychiatry Report, 8: 377-382, 2006.
Fox, Susannah and Mary Madden. (2005) “Generations Online.” Pew Internet & American Life Project. December, 2005. pewinternet.org/PPF/r/170/report_display.asp
Frates, Chris. (2003, August 25). AG Targets Importing Of Drugs Through Unlicensed Pharmacies. The Denver Post, p. B-04.
Gaul, Gilbert M. (2003, December 28). Net Doctor Racks Up Business. The Miami Herald.
Gaul, Gilbert M. and Mary Pat Flaherty. (2003a, October 20). Internet Trafficking in Narcotics Has Surged. Washington Post, p. A1.
Gaul, Gilbert M. and Mary Pat Flaherty. (2003b, October 21). Web Physician Says He Did No Harm; Thousands of Patients Received Painkillers Without Being Examined. Washington Post, p. A14.
Gaul, Gilbert M. and Mary Pat Flaherty. (2003c, October 22). Lax System Allows Criminals to Invade the Supply Chain. Washington Post, p. A1.
Gaul, Gilbert M. and Mary Pat Flaherty. (2003d, October 23). Canada is a Discount Pharmacy for Americans; FDA Doing Little to Stop Cross-Border Trade in Drugs. Washington Post, p. A17.
Gaul, Gilbert M. and Mary Pat Flaherty. (2003e, October 24). Warnings Target Rogue Drug Sites; Drugstore.com Campaign Aimed at Illegal Pharmacies. Washington Post, p. A7.
Gaul, Gilbert M. and Mary Pat Flaherty. (2003f, December 1). Google To Limit Some Drug Ads: Giants Asked To Help Discourage Illicit Online Pharmacies. Washington Post, p. A1.
Gordon, Susan M., Forman, Robert F. and Siatkowski, Candis. (2006). Knowledge and Use of the Internet as a Source of Controlled Substances. Journal of Substance Abuse Treatment, 30(3), 271-4.
Harris, Gardiner. (2003, October 18). Two Agencies to Fight Online Narcotics Sales. New York Times.
Healy, Mary. (2003, December 1). A Web of Drugs; Online ‘Rogue Pharmacies’ Offer Quick Access to Prescription Drugs, Many of Them Addictive and Dangerous. Los Angeles Times, p. F1.
Henney, Jane E. (2000, September 29). E-Regulation and Public Health. Leonard Davis Institute of Health Economics, University of Pennsylvania Health Policy Seminar Series, Philadelphia, PA.
Higgins, Michael. (2003, December 6). Lawmakers Target Rogue e-pharmacies.Chicago Tribune, p. 1.
Hubbard, William K. (2003, March 27). Statement of William K. Hubbard Associate Commissioner For Policy, Planning, And Legislation Before The Committee On Government Reform. U.S. House Of Representatives.
Hutchinson, A. (2002, October 10). DEA Congressional Testimony before the House Judiciary Subcommittee on Crime, Terrorism, and Homeland Security.
Johnston, L. D., O’Malley, P. M., Bachman, J. G., and J.E. Schulenberg. (2005). Monitoring the Future: national results on adolescent drug use: Overview of key findings, 2005. Bethesda, MD: National Institute on Drug Abuse.
Kissinger, Meg. (2004, May 3). Internet becoming lax pharmacist: Addicts easily obtain drugs without prescriptions. Milwaukee Journal Sentinel Online Edition.
Lenhart, A. (2004, June 18). Teens, Students, Parents and Internet Technology: The Findings of the Pew Internet & American Life Project. Presented at the Lawlor Group Summer Seminar. Minneapolis, MN.
Littlejohn, C., Baldacchino, A., Schifano, F., & Deluca, P. (2004). Internet pharmacies and online prescription drug sales: A cross-sectional study. Paper submitted for publication.
Marriott, Michael. (2006, March 31). Digital Divide Closing as Blacks Turn to Internet. New York Times.
McCabe SE, Teter CJ and C.J. Boyd. (2006). Medical use, illicit use, and diversion of abusable prescription drugs. Journal of American College Health, 54(5), 269-278.
National Association Board Pharmacy. Retrieved June 23, 2003, from nabp.net/vipps/intro.asp.
National Center on Addiction and Substance Abuse at Columbia University (CASA). (2004). “You’ve got drugs!” Prescription drug pushers on the internet: A CASA white paper. New York, NY.
National Center on Addiction and Substance Abuse at Columbia University (CASA). (2006).“You’ve got drugs!” Prescription drug pushers on the internet: 2006 Update: A CASA white paper. New York, NY.
National Drug Intelligence Center. (2001). National Threat Assessment 2002.
National Drug Intelligence Center. (2002). Information Bulletin: Drugs, Youth and the Internet.
National Drug Intelligence Center. (2003, September). Hyphophorous acid in methamphetamine production, reprinted in Drug Enforcement Administration Microgram, (36)9.
National Drug Intelligence Center. (2003). National Threat Assessment 2003. Washington, DC: U.S. Department of Justice.
Office of National Drug Control Policy (2004). Reducing Prescription Drug Abuse. Retrieved March 4, 2004, from whitehousedrugpolicy.gov/news/press04/030104.html.
Office of National Drug Control Policy. (2004, March 1). U.S. Drug Prevention, Treatment, Enforcement Agencies Take on “Doctor Shoppers,” “Pill Mills.” Retrieved March 4, 2004, from whitehousedrugpolicy.gov/news/press04/030104.html.
Partnership for a Drug-Free America. (2005, April 1). Generation Rx: National Study Reveals New Category of Substance Abuse Emerging. New York, NY: Author.
Salman, R. & Schifano, F. (2000). The Internet, children, young people and substance misuse: Co-ordinated approaches are needed to minimise the use of E-commerce to obtain drugs and prevent substance misuse. Public Health Medicine, 2 (3), 96.
Schifano, F., Leoni, M., Martinotti, G., Rawaf, S., and Rovetto, F. (2003). Importance of Cyberspace for the Assessment of the Drug Abuse Market: Preliminary Results from the Psychonaut 2002 Project. CyberPsychology, 6(4), 405-410.
Schifano, F., Leoni, M., Deluca, P., & Rovetto, F. (2003, July 23-25). Surfing the net whilst wandering around for drugs: The Psychonaut 2002 preliminary results. Paper presented at the European Association for Behaviour Analysis Conference, Parma, Italy.
Schifano, F., P. Deluca, L. Agosti, G. Martinotti and the Psychonaut 2002 research group. (2005). Hallucinogenic phenethylamines on the web; the case of 2C-T-7 (“Blue Mystic”). Journal of psychopharmacology, 19(6), 675-9.
Schifano, F., & Deluca, P. (2003, October 23-25). The quest for drugs: New tools, old habit. Paper presented at the 2nd PrevNet Conference of Telematics in Addiction Prevention, Dublin, Ireland.
Schifano, F., Deluca, P., & Baldacchino, A. (2004). Online prescription drugs’ availability; the case of dextropropoxyphene. Paper submitted for publication.
Substance Abuse and Mental Health Services Administration. (2006). Results from the 2005 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-28, DHHS Publication No. SMA 05-4062). Rockville, MD: Author.
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2003). The DAWN Report: Trends in Drug Related Emergency Visits, 1994-2002. Rockville, MD: Author.
U.S. Department of Justice, Drug Enforcement Administration. (1970). Controlled Substances Act. Retrieved October 25, 2006, from usdoj.gov/dea/pubs/csa.html.
U.S. Department of Justice, Drug Enforcement Administration. (2001, April 27). Dispensing and Purchasing Controlled Substances over the Internet, Federal Register, 66(82). Notices p. 21181-21184.
U.S. Department of Justice. (2002, June 18). Press Release: Defendants Sentenced for Selling Prescription Drugs on Norfolk Men’s Clinic Web Site.
U.S. Department of Justice. (2002, May 29). Press Release: Internet Doctor Sentenced to Over 4 Years in Prison.
U.S. Food and Drug Administration. Buying Medicines and Medical Products Online. Retrieved August 4, 2003, from fda.gov/oc/buyonline/default.htm.
U.S. Food and Drug Administration. (2003, September 29). Press Release: FDA/U.S. Customs Import Blitz Exams Reveal Hundreds of Potentially Dangerous Imported Drug Shipments.
U.S. General Accounting Office. (2004, June 17). “Internet Pharmacies: Hydrocodone, An Addictive Narcotic Pain Medication Is Available Without A Prescription Through The Internet,” testimony before the Permanent Subcommittee on Investigations, Committee on Governmental Affairs, U.S. Senate.
Volkow, Nora. (2004, June 12). Keynote address to the College on Problems in Drug Dependence Annual Conference, San Juan, Puerto Rico.
Warner, BD, and Leukefeld, CG. (2001). Rural-urban differences in substance use and treatment utilization among prisoners. American Journal of Drug and Alcohol Abuse. 27(2), 265-80.
The White House. (1999, August 5). Executive Order 13133 Working Group on Unlawful Conduct on the Internet.
The White House. (2004, March). National Drug Control Strategy Update.
Zickler, Patrick. (2004, July). Early Nicotine Initiation Increases Severity of Addiction, Vulnerability to Some Effects of Cocaine. NIDA Notes, 19(2).