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Click, click: the internet and prescription drugs |
Summary
The internet exposes doctors and consumers to advertisements for prescription drugs. The commercial nature of a web site may not be obvious, and key pieces of information may be missed amidst the multiple pages on a web site. Developing standards to deal with internet advertising will be difficult because web sites can be based and accessed from anywhere in the world. Drugs can even be ordered over the internet without any contact with a doctor and before the drug is approved by regulatory authorities. The creation of virtual pharmacies may be helpful to some people, but they will also not be able to duplicate some of the traditionally important functions of the person-to-person interaction.
Key words: advertising, consumer information, drug industry, regulation.
(Aust Prescr 2000;23:73-4)
There is a comment for consumers on this article
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 CafÃĮš© HerpÃĮš© web site set up by SmithKline 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?
References
1. http://www.cafeherpe.com Accessed July 2000.
2. Australian Pharmaceutical Manufacturers Association. Code of Conduct. 13th ed. Sydney: Australian Pharmaceutical Manufacturers Association; 2000.
3. U.S. Food and Drug Administration. FDA and the Internet. Advertising and promotion of medical products. Geneva: World Health Organization; 1999 http://www.fda.gov/opacom/morechoices/transcript1096/fdainet.html
4. World Health Organization. Cross-border advertising, promotion and sale of medical products using the Internet. WHA Resolution 50.4. Geneva: World Health Organization; 1997.
5. World Health Organization. Ethical criteria for medicinal drug promotion. Geneva: World Health Organization; 1988.
6. World Health Organization. Cross-border advertising, promotion and sale of medical products using the Internet. The report of the ad hoc working group on cross-border promotion, advertising and sales of medical products using the Internet. Geneva: World Health Organization; September 1997.
7. World Health Organization. Medical products and the Internet. Geneva: World Health Organization; 1999.
8. Armstrong K, Schwartz JS, Asch DA. Direct sale of sildenafil (Viagra) to consumers over the Internet. N Engl J Med 1999;341:1389-92.
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