How online prescriptions increase the risk of medication misuse

Contents

There are now numerous telemedicine platforms that make it possible to prescribe medication remotely, among other things. Various laws, such as the one lifting the ban on remote treatment, have paved the way for patients to have easy access to medical services. This is particularly helpful for people in rural areas or with limited mobility.

However, many platforms now aggressively advertise the fast and uncomplicated access to prescription drugs without personal contact with a doctor. Many people will be familiar with DocMorris and Shopapotheke from advertising. DocMorris in particular has been running various advertising campaigns for the purchase of prescription medicines (also known as Rx medicines) since 2012. Only recently, the North Rhine Chamber of Pharmacists was able to bring about an end to DocMorris discount campaigns for vouchers in connection with e-prescriptions.

Easy access to potentially dangerous medicines

Often, access to prescriptions for drugs that are not entirely harmless is only possible after filling out a questionnaire. The customer has the choice of having a prescription issued or having it filled directly. If a prescription is received, the medication can be collected from the pharmacy. Pharmacist Stefan Schwenzer says: "In fact, we only supply certain types of medication after intensive testing. This applies, for example, to medicines with addictive potential such as benzodiazepines." When in doubt, he tries to contact the prescribing online doctor, but this is often difficult. However, if patients choose to have their medication sent online, it is not just a control instance that is eliminated.

Prohibition of referral and medical duty of care

The German Pharmacy Act (Section 11 ApoG) stipulates that pharmacies may not enter into any agreements aimed at the referral of patients or the allocation of prescriptions. At the same time, the German Civil Code (§ 630a BGB) stipulates that medical treatment, including the prescription of medication, must be carried out in accordance with recognized professional standards. The doctor's duty of care is a key element in ensuring that the patient's health is paramount.

It is problematic if there is no separation between the telemedicine platform and the mail-order pharmacy – In some cases, the pharmacies associated with the platforms are not based in Germany. It is unclear whether all platforms adhere to the prohibition on referrals, according to which prescriptions may not be sent directly to a pharmacy. Prescriptions are typically sent to selected mail-order pharmacies after a telemedical consultation. If there is no option to select a pharmacy, which is the case with some platforms, this could lead to false incentives and the prohibition on referrals is not complied with.

Linking telemedicine and online pharmacy "critical"

Schwenzer considers "the increasing linking of such 'prescription platforms' with the direct shipment of medicines by a shipper, usually based abroad" to be "particularly critical", whereby "the prescription obligation applicable in Germany is systematically undermined" and "the current ban on direct cooperation between doctors and pharmacists regarding the allocation of prescriptions or patients is cleverly circumvented". It is worrying that this kind of approach can now also be observed in the prescription of medicinal cannabis."

heise online also managed to obtain prescription potency medication and Tramadol, an addictive narcotic, by filling out a questionnaire during several test purchases from three different platforms. The drugs were sent by online pharmacies that are not listed in the mail-order register for online pharmacies of the Federal Institute for Drugs and Medical Devices. The main locations are in the Netherlands, close to the German border. The medicines were sent using letterbox addresses in Germany. The prescribing or treating doctors came from Ireland or Munich. In the case of two platforms, the medication was dispatched directly after the order was placed, without the prescription being viewed beforehand.

In an answer from the German government to a small question at the beginning of the year, it was not clear to what extent "international platforms such as doktorabc.com, which are based in non-EU countries but arrange medical treatment and the dispatch of medicines from assigned mail-order pharmacies within the EU" see a need for legislative action, as first reported by the Deutsche Apotheker Zeitung. "The Federal Ministry of Health does not currently see any need for further legislative action", the Federal Government stated in February.

Significant risks due to unrestricted access

"Legislators must no longer turn a blind eye to the fact that platforms with all-inclusive offers consisting of the brokerage of electronic prescriptions and the corresponding medicines are in fact overriding the tried and tested system of pharmaceutical supply and thus creating considerable risks for consumers through de facto unrestricted access to prescription medicines," Morton Douglas, lawyer at the North Rhine Chamber of Pharmacists (Apothekerkammer Nordrhrein, AKNR), explained to heise online.

With the support of specialist lawyers, the AKNR is focusing both on legal action against mail-order pharmacies and on raising public awareness of the risks of digital medicines. "We already consider it a success that this discussion is being held today," says AKNR Managing Director Bettina Mecking, who spoke about the topic in the Pharmazeutische Zeitung podcast together with Dr. Anne Bongers-Gehlert, a lawyer specializing in healthcare law.

From sexual enhancers and antibiotics to narcotics

"Many prescription medicines, such as antibiotics, can simply be ordered," says Mecking. She had recently been able to order zopiclone "just like that" during a test purchase without identifying herself, and the questionnaire was also short. According to Bongers-Gehlert, the whole thing started with potency pills from DrEd, which now operates under the name Zava. "In the meantime, however, we have had to realize that this has continued to develop and now [...] completely different indications are also affected, such as these famous weight loss injections or medical cannabis and so on".

The AKNR has been consistently taking action against questionable online offers in the pharmacy environment for years and was recently successful against the Dr. Ansay platform. As a result, the platform is no longer allowed to advertise telemedical treatments aimed at prescribing medicinal cannabis, but also offers various other services. The responsibility of platforms such as Google is also increasingly coming into focus. The AKNR is also examining whether search engines can be held liable if they support advertising for questionable medicinal products.

Easier access to medicinal cannabis

Following the entry into force of the Cannabis Act (CanG), cannabis is no longer classified as a narcotic but as a prescription-only medicine. Access to cannabis is facilitated by platforms such as Dr. Ansay, as a prescription is only possible after an online consultation with a doctor. In February, ZDF reported that imports of medicinal cannabis increased by almost 40 percent (to 8.1 tons) in the second quarter of 2024 compared to the first. According to the Ministry of Health in Baden-Württemberg, this indicates that "medicinal cannabis may also be prescribed for consumption purposes, thereby circumventing the legal provisions."

Authorities should monitor regulations

Monitoring compliance with pharmacy regulations is the responsibility of the relevant state authorities. The medical associations are responsible for monitoring professional ethical obligations and are subject to the supervision of the respective state authorities. This structure is intended to ensure that violations can be identified and sanctioned. If there is a suspicion that "medical cannabis is not being prescribed for therapeutic reasons, an attempt could be made [...] to inform the respective state medical association and initiate a review under professional law. This is also [possible] for doctors who work in Germany from other European countries," according to the Baden-Württemberg Ministry of Health. Pharmacies should also take action against recognizable abuse and refuse to dispense if necessary.

Cannabis legalization a "serious mistake"

"The legalization of cannabis is and remains a serious mistake by the federal government," said a spokesperson for the Bavarian Ministry of Health at the request of heise online. "Media reports suggest that consumers are covering their consumption of cannabis for recreational purposes with a medical (online) prescription to obtain cannabis of high pharmaceutical quality without cultivation associations or self-cultivation. There are also more and more (medical) providers offering to prescribe medicinal cannabis online via platforms," said the spokesperson.

In some cases, prescriptions are also prescribed without prior doctor-patient consultations. This endangers people's health "massively" and is also not suitable for "curbing the black market and organized crime". According to the Bavarian Ministry of Health, cannabis legalization "has created considerably more problems than it has solved. We will therefore continue to control the existing cannabis regulations in Bavaria as strictly as possible". The ministry has therefore already submitted corresponding proposals for "changes to the federal regulations on medicinal cannabis".

BMG and BfArM are monitoring developments

Access to potentially dangerous drugs such as the painkiller tramadol is particularly critical. In addition to its pain-relieving effect, it also harbors risks such as dizziness, nausea, confusion and, above all, the potential for dependence and abuse. In cooperation with the Federal Institute for Drugs and Medical Devices (BfArM), the BMG is monitoring the risks and experiences with tramadol: "The BMG, in close cooperation with the Federal Institute for Drugs and Medical Devices (BfArM), is closely monitoring developments and experiences regarding drugs approved in Germany, such as tramadol. This monitoring also includes looking at the risks of active ingredients and side effects associated with misuse."

According to the (model) professional code of conduct for doctors, exclusive advice via communication media is only permitted if it is medically justifiable and the necessary care is maintained, as the Federal Ministry of Health (BMG) explained to heise online. The BMG is closely monitoring developments in the field of telemedicine and is considering legal adjustments to tighten up and effectively enforce compliance with professional standards and the ban on collusion.

"Not on the way to an opioid crisis"

According to the Federal Institute for Drugs and Medical Devices (BfArM), Germany is not yet on the path to an opioid crisis. Between 2005 and 2020, the prescription of opioid analgesics actually fell by 19 percent. This is based on billing data from four statutory health insurance funds covering a total of 25 million people. "The beginning of the so-called 'opioid crisis' in the USA, on the other hand, was characterized by a sharp increase in prescriptions for opioid analgesics. Overall, these results confirm and extend the findings from earlier studies that there is no evidence of a so-called opioid crisis in Germany", the current Bulletin on Drug Safety from the BfArM and Paul Ehrlich Institute says.

Conclusion

The increasing shift of drug prescriptions to the Internet harbors considerable risks. The AKNR and other experts urgently warn of the dangers of uncontrolled access to prescription drugs, which is promoted by online prescriptions and non-transparent structures. One possible solution called for by the AKNR is the introduction of an Rx mail-order ban, whereby prescription drugs may no longer be shipped. Furthermore, existing laws and regulations must be monitored and enforced more consistently to prevent abuse and increase the responsibility of platform operators.

(mack)