Attempts to stop U.S. doctors and pharmacies from issuing prescriptions online without physical examinations often have amounted to tortuous, low-speed chases through cyberspace after elusive targets.
Now, California regulators are stepping up their efforts. Last month, they revoked the license of a cyber doctor accused of issuing 11,000 illicit prescriptions, and last week they levied $48 million in fines against six out-of-state prescribers.
But this state, along with others, faces daunting obstacles in the shadow world of online prescribing. Not the least among them are the growing popularity of no-fuss prescriptions, the difficulty of prosecuting doctors across state lines, the limited resources of state medical and pharmacy boards and spotty or antiquated state regulations.
Even though the national Federation of State Medical Boards adamantly opposes online prescribing without proper examination, only 22 individual boards in the U.S., including California's, have specifically prohibited it. A few states have passed legislation against online prescribing or have tried to prosecute doctors, with mixed success, under existing consumer protection or criminal laws.
One barrier is the apparent belief among some doctors that there is nothing wrong with writing a prescription without actually seeing the patient.
"I did not do anything wrong in treating these patients," Dr. Jon Opsahl of Colton said last month, after he became the first physician in California whose license was revoked for improper online prescribing. "There was no physical exam that could have been done on these patients that would have altered the treatment."
Opsahl, who prescribed to 1,500 people a range of medications from Viagra to Vicodin, insisted that he had reviewed extensive medical records sent by his patients.
Regulators argue, however, that there is no consistency in screening from one online pharmacy to another, and that patients are more likely to suffer reactions or complications if not examined thoroughly. Most pharmacies ask patients to fill out questionnaires, but incomplete, implausible or apparently disqualifying answers are sometimes overlooked.
In one case in Kansas, a state investigator's son -- who acknowledged he was 16 -- was prescribed Viagra even though he had not filled out sections of an online questionnaire and was under the site's required age of 21, regulators there said. In the same case, a female investigator who ordered Viagra under her own name was advised to refile her order under a male name.
In another case, an Ohio regulator said he ordered medication using the name of his cat.
There are thousands of U.S. Web sites offering Viagra, the weight-loss drug phentermine and other popular drugs without exams, but all are operated by only 100 or so pharmacies, according to the National Assn. of Boards of Pharmacy. The difficulty for regulators is that these suppliers create and disband Web sites faster than officials can track them.
Because of that problem, it's nearly impossible to quantify how much money the online prescribers raise or how many Web sites there are, said Elizabeth Boehm, an analyst with Forrester Research, a technology research firm based in Cambridge, Mass. But she said her e-mail inbox is "inundated with offers" -- as are those of other computer users nationwide.
Doctors, who collect a consultation fee for each patient, may or may not be in the state where the patient lives. That's a problem because the practice of medicine is not regulated nationally; it is regulated by states.
"We just have to face up to the fact that the old rules -- where everything stops at the state lines -- may no longer be applicable," said Stuart Biegel, a UCLA professor who wrote a book about how the Internet affects the legal system.
Oversight is haphazard, and sanctions vary. In the last four years, state medical regulators have levied millions of dollars in fines, revoked six physicians' licenses and dragged dozens of doctors into court. Pharmacy regulators, who oversee drugstores, have issued letters of reprimand or other sanctions against nearly 50 online operators in 20 states.
But many states have yet to penalize a single doctor or pharmacy. And the efforts by others to stem the illicit trade appear to have had little effect.
Carmen Catizone, executive director of the National Assn. of Boards of Pharmacy, said pharmacy boards are hampered by medical boards that won't discipline the doctors.
"If there's a physician involved who is ghost-signing these prescriptions, it goes to the medical boards," he said. "In some states, they don't have clear-cut language to say this is illegal or below the standard of practice."
California is trying to take a strong stand. In 2000, it specifically prohibited doctors from prescribing drugs or devices without exams. Its fines are the stiffest in the nation -- as much as $25,000 per infraction.