The first anthrax case was reported by the Centers for Disease Control and Prevention on Oct. 4th. Americans were then bombarded with information not only about the deadly bacterium but also about the one drug approved to treat it: ciprofloxacin, sold by Bayer as Cipro. Within about a month, thousands of people potentially exposed to anthrax were taking Cipro to prevent infection. (Many also took the generic drug doxycycline after officials said it also could help fight the disease.)
Despite the cautions of health officials, many Americans began stockpiling supplies of Cipro in the event of future outbreaks or contact with the germ. Some obtained the drug through their doctor, but some turned to the Internet.
Online drug sales from reputable merchants are wholly legitimate, and a billion-dollar-a-year business. But a new study in this month's issue of the American Journal of Medicine reveals the extent to which sketchy, fly-by-night, and often illegal vendors tried to capitalize on the Cipro mania.
Alexander Tsai, a medical student at Case Western Reserve University, helped conduct the study. He and his colleagues identified 59 Web sites that were selling Cipro without a prescription in the last week of October. Of those, 23 (or 39 percent) were set up in the two-week period following Oct. 4 and none was certified by the National Association of Boards of Pharmacy's Verified Internet Pharmacy Practice Sites program.
More than 80 percent of the sites were registered in the United States, with the rest based in Mexico, New Zealand, Brazil, and other countries in Europe and Asia.
Within two weeks, half the Web sites had stopped advertising Cipro (many continued to sell other popular drugs, like Viagra). The researchers said that suggests the window for cracking down on these vendors is small, and that consumers who bought from them might be left dangling if they had questions or problems.
Nearly 30 percent of the sites provided no information to potential customers about the side effects of Cipro, and 27 percent didn't state that the drug isn't recommended for people with a history of bad reactions to its class of antibiotics, called the quinolones.
Only eight of the sites had false or misleading medical information. However, many didn't offer the full 60-day recommended course of Cipro to prevent anthrax disease, selling instead small supplies of the drug with questionable clinical value. The average cost of the drug on the 59 sites was $6.95 a tablet, 50 percent more than wholesale price of $4.67.
Most sites asked visitors to fill out a medical questionnaire, though 11 did not. Tsai said these surveys may be read by doctors working with the Web site, who use the information to justify a prescription. In that way, Tsai added, the sites may fall under the umbrella of legality.
Still, both the American Medical Association and the Food and Drug Administration have said that prescription-by-questionnaire, while not technically illegal, is a dangerous breach of good medical practice. They warn people who obtain drugs this way that doing so puts them at risk of harm.
Sites that don't gather any meaningful medical information certainly violate medical ethics and quite possibly the law, Tsai said.
Compounding the problem, Tsai said, is that "there really is no centralized way of dealing with these Web sites." States have a variety of laws regulating what can and can't be sold over the Internet, and what constitutes a legitimate sale of medication.
Within two weeks of the first anthrax case, states were warning their residents about the hazards of buying Cipro online. In early November, Illinois sued three Internet sites for selling Cipro without a proper license. The three sites were based in the United States.
At the same time, the FDA sent letters to 11 foreign-based Internet sites advertising Cipro (including three covered in Tsai's study) warning that their business practices might be illegal in the United States. The agency also sent letters to five other overseas merchants with sites it had contacted previously about their illicit sales of the drug.
"We are taking action" against the spurious drug sites, said an FDA official who spoke under the condition of anonymity. But, the official added, "it's a problem that's very difficult to control."
The FDA said it has issued 200 "cyberletters" in recent years to what it considers rogue pharmacies that operate online. The vast majority of these are based overseas and are thus beyond the reach of American law.
Crystal Wright, a spokeswoman for the National Association of Chain Drug Stores, said her group urges consumers to stay away from Internet drug sites. "There are a lot of hack sites out there," she said, making it hard to trust the quality of the medication being sold. In addition, many sites don't have a licensed pharmacist dispensing the drugs, Wright said.
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