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Digital Social Media, Youth, and Nonmedical Use of Prescription Drugs: The Need for Reform

J Med Internet Res. 2013 Jul; 15(7): e143. Published online 2013 Jul 26. doi: 10.2196/jmir.2464

PMCID: PMC3742396 PMID: 23892156


Monitoring Editor: Gunther Eysenbach

Reviewed by Robert Forman and Isaac Montoya

Tim K Mackey, MAS, PhD,1,23 Bryan A Liang, MD, JD, PhD,1,2,3 and Steffanie A Strathdee, PhD41Institute of Health Law Studies, California Western School of Law, San Diego, CA, United States

2School of Medicine, Department of Anesthesiology, University of California, San Diego, La Jolla, CA, United States

3San Diego Center for Patient Safety - School of Medicine, Department of Anesthesiology, University of California, San Diego, San Diego, CA, United States

4Division of Global Public Health, Department of Medicine, University of California, San Diego, San Diego, CA, United States

Tim K Mackey, School of Medicine, Department of Anesthesiology, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0629, United States, Phone: 1 951 491 4161, Fax: 1 619 515 1599, Email: ude.dscu@yekcamt.



Abstract

The tragic death of 18-year-old Ryan Haight highlighted the ethical, public health, and youth patient safety concerns posed by illicit online nonmedical use of prescription drugs (NUPM) sourcing, leading to a federal law in an effort to address this concern. Yet despite the tragedy and resulting law, the NUPM epidemic in the United States has continued to escalate and represents a dangerous and growing trend among youth and adolescents. A critical point of access associated with youth NUPM is the Internet. Internet use among this vulnerable patient group is ubiquitous and includes new, emerging, and rapidly developing technologies—particularly social media networking (eg, Facebook and Twitter). These unregulated technologies may pose a potential risk for enabling youth NUPM behavior. In order to address limitations of current regulations and promote online safety, we advocate for legislative reform to specifically address NUPM promotion via social media and other new online platforms. Using more comprehensive and modernized federal legislation that anticipates future online developments is critical in substantively addressing youth NUPM behavior occurring through the Internet.


Keywords: non-medical use of prescription medications (NUPM), eHealth, Internet, social media, youth and adolescents, drug abuse, substance abuse


Introduction

On February 12, 2001, Ryan Haight, an 18-year-old honors student and varsity athlete from California, USA, died from an overdose of the opioid prescription drug Vicodin (hydrocodone/acetaminophen) bought from an online pharmacy without a prescription [1]. His death highlighted the immediate patient safety and public health risks of nonmedical use of prescription medicines (NUPM) by youth (ie, children and adolescents) obtained from the illicit online environment. This tragic event led to passage of the 2008 US federal legislation, the Ryan Haight Online Pharmacy Consumer Protection Act (RHA), which established regulatory provisions and tools for the Drug Enforcement Agency (DEA) of the United States to control the sale and dispensing of controlled substances over the Internet [2].


However, the effectiveness of the RHA on NUPM online sourcing and regulation of online pharmacies has not been well established or studied. Consequently, the problem of illicit online sourcing of controlled substances and other medications without a prescription has yet to be adequately resolved [1,3]. Despite RHA passage, new forms of unregulated digital media and information technology platforms continue to be developed and are rapidly becoming associated with illicit online prescription drug sourcing in digital environments highly populated by youth.


In order to inform policy efforts to address youth NUPM and current regulatory limitations, we explore the potential public health and patient safety implications of promotion of youth-based NUPM in social media. To do so, we first review current national trends in youth NUPM behavior and Internet and social media utilization. We then examine the use of social media by illicit online pharmacies in promoting NUPM and analyze current policy instruments, including the RHA. We then recommend policy solutions and advocate for additional research to better inform the public and ensure safe Internet access to prevent youth NUPM


Nonmedical Use of Prescription Drugs

National Trends in NUPM Since Ryan Haight’s death, prescription drug abuse among youth has become part of a larger national trend of morbidity and mortality associated with drug overdose, diversion, and polydrug abuse [4-7]. The US Centers for Disease Control and Prevention (CDC) reported in 2010 that more than 12 million people engaged in nonmedical use of prescription painkillers alone; misuse/abuse of this drug class was responsible for approximately 475,000 emergency room admissions in 2009 [6,8]. Indeed, misuse has led to a marked increase in US public and private health care expenditures, estimated up to $72.5 billion in direct costs annually [8-10]. Prescription drug abuse also disproportionately impacts vulnerable populations, including rural groups, low-income groups, those subject to sexual victimization or dating violence, those with a history of mental illness, and those with a history of substance abuse disorders [5,6,11-13].


Youth NUPM Crucially, a key high-risk group for NUPM is youth (children and adolescents, aged 12-17). Estimated prevalence of NUPM among this age group is high, with the CDC reporting in 2011 that 20.7% of high school students had engaged in NUPM (OxyContin, Percocet, Vicodin, Adderall, Ritalin or Xanax) [14]. A 2010 National Survey on Drug Use and Health similarly reported at least 3.0% of all youths (and 5.9% of 18-25 year olds) reported psychotherapeutic NUPM in the past month in 2010 [4,15]. Other studies report even higher prevalence of abuse [12,16]. More recently, the Monitoring the Future 2011 national survey reported that after marijuana, prescription and over-the-counter medications represented the most commonly abused drugs for either licit or illicit drugs among 12th graders [17]. Most troubling, NUPM use among youth may also lead to other forms of substance and illicit drug abuse [4,7,18-20].

Youth narcotic and controlled substance NUPM, which includes commonly abused pain medications such as OxyContin and Vicodin, is perhaps the most deeply concerning risk to youth health development and has even been associated with illicit heroin drug abuse [1,21]. NUPM in these drug classes can result in severe adverse clinical interactions and side effects, drug dependency, and increased emergency room admissions [2,10,16,22]. NUPM is also associated with other high-risk health behavior including alcohol consumption and marijuana use, resulting in poor school performance—yet may be perceived as a lower risk behavior by youth compared to other forms of illicit drug abuse [1,3,12,15,17]. Additionally, increases in NUPM associated with Attention Deficit Hyperactivity Disorder drugs (ADHD), such as Ritalin and Adderall, have become a serious concern [22-25]. Importantly, virtually all these drugs have been detected as marketed by illicit “no prescription” online pharmacies and have been subject to counterfeiting [1,2,25-28].


Traditional NUPM Sourcing Traditional methods of drug diversion, including person-to-person purchasing, trading, loaning, sharing, stealing and theft, family member and friend access, street drug purchases, prescription forgeries and fraud, and “doctor/prescription shopping”, have traditionally enabled NUPM [1,12,16]. In order to address these vulnerabilities, some US states have implemented “Prescription Drug Monitoring Programs” (PDMPs) to track prescribing and dispensing of controlled substances in order to detect suspected abuse and diversion [4-7,16]. Although these programs may provide controls to stem diversion of high-risk prescription drugs to youth populations [6,8,16], they are highly uneven in enforcement and state resource commitment [29]. Consequently, they may be ineffective for broader identification and intercession in youth NUPM sourcing. But further, uneven PDMPs may not be responsive to the changing nature of health information seeking and online behavior associated with youth NUPM. Indeed, PDMPs may miss the mark in terms of where youth NUPM sourcing is starting to occur and do not address online sourcing of prescription drugs, which may be familiar to youth yet difficult to trace for illicit activity [22,30-32]. To date, this specific risk factor has not been adequately assessed in youth-related NUPM research.


Potential Online Risks for NUPM Behavior

Internet and Social Media Utilization Trends Exacerbating risks of NUPM access is unregulated content on the Internet, the use of which is now ubiquitous among both youth and adults. Indeed, survey data from the Pew Research Center’s Internet and American Life Project (Pew Internet) indicate that some 72% of US adult Internet users search for health and medical information online and that more than one third engage in health care self-diagnosing [33,34]. In addition, the US Food and Drug Administration (FDA) reports 23% of adult Internet consumers have admitted to purchasing a prescription medicine online, of whom 15% acknowledged the risky nature of purchasing from an online pharmacy located outside the United States [35].

As might be expected, Internet use by the youth demographic is almost universal. Pew Internet reports that an estimated 95% of teens (ages 12-17) [36] currently use the Internet and are the most likely age groups to have an online presence [37]. In addition, there has been a rapid rise in utilization of social networking reflected by a majority (80%) of online teens using popular social media sites including Facebook (93%), and use of other social media platforms including Myspace (24%), Twitter (12%), and YouTube (6%) [36]. Indeed, youth respondents have reported that the Internet is their primary source of general information, even if the credibility of such information is difficult to determine [38].

Although this population group has widespread adoption of the Internet and social media, they may not engage in safe online behavior. For example, at least 44% of teens admitted they lie about their age to access websites or to set up an online account [36]. Indeed, those using social media sites report being twice as likely as nonusers to misrepresent their age [36]. At the same time, teens are reporting that they use online sources for looking up health, dieting, and physical fitness information (31%) and that 17% of them go online for information on difficult topics including drug use and sexual health [37].

Within this already vulnerable population, there is also a disproportionate income effect. Teens from lowest-income families are twice as likely (23% vs 11%) to seek health information online compared to teens from higher income households [37]. Further, almost half (48%) of teens report purchasing items online, indicating that teens may be comfortable and have access to make potentially illicit purchases if appropriate controls are absent [37].


NUPM and Illicit Online Pharmacies

Youth online behavior trends indicate that this population is adopting digital technology for consumption of health information and may be engaged in risky online behavior, which can increase risk for Internet-enabled NUPM [37,39]. Several studies have identified the public health risks of sourcing from “no prescription” illicit online pharmacies that enable NUPM, including among youth and adolescents [9,22,26,27,30,32,40,41].


Importantly, any online pharmacy purportedly marketing the sale of a prescription medication without the need of a prescription is both violating applicable US laws and regulations, as well as promoting NUPM behavior given that adequate controls to ensure patient safety are lacking. This promotion of NUPM is often facilitated by false and misleading marketing used in online direct-to-consumer advertising (DTCA) [42,43], which has yet to be adequately regulated by FDA and others [42,43]. These illicit forms of DTCA may be difficult for consumers, particularly youth, to accurately identify as legitimate (or not), despite public service announcements attempting to inform consumers that online purchasing can be dangerous [44].


Despite its illegality, the spectrum of drugs available for online NUPM sourcing is virtually unlimited [1]. This includes a host of therapeutic drug classes marketed without sufficient controls, including drugs for weight loss, ADHD, steroids, inhalants, contraception drugs and devices, opioids, a variety of narcotics, and drugs in critical shortage promoted across various Internet mediums, including social media [9,22,24,26,30,32,40,41,43,45,46].


Collectively, these studies illustrate that illicit online sourcing represents a potential risk factor for youth NUPM. Illicit NUPM promotion through Internet pharmacies engenders a completely unregulated system of parallel access for youth. This can lead to self-prescribing of virtually any medicine, resulting in drug abuse and dependence, as well as use of drug forms that are of questionable quality, authenticity, and safety, all without medical or parental oversight [1,28]. Tragically, this form of NUPM sourcing has been directly linked to patient deaths, including Ryan Haight, as well as others [1,28].


Lack of Sufficient Research on Social Media and NUPM

Recognition and needed research on the convergence of social media and youth NUPM is highly uneven. Despite growing evidence of online sourcing risks, a recent systematic review of NUPM behavior among adolescents failed to mention online information seeking/sourcing or social media usage as a specific risk factor [12]. Conversely, organizations such as the National Center on Addiction and Substance Abuse have specifically identified increased risks associated with substance abuse for youth who use social media [39]. The United Nations International Narcotics Control Board also warns that illicit Internet pharmacies have started using social media to target young audiences [47].


Some studies have also attempted to assess this area of risk. Previous research has identified increasing use of popular social media platforms by illicit “no prescription” online pharmacies marketing the sale of several high-risk drug products [24,43,46,48]. This includes a recent study that found that illegal DTCA marketing of a fictitious illicit online pharmacy using social media sites Facebook, Myspace, and Twitter was easily accessible and could be done at low cost [48].


Another published study examined the use of Twitter to discuss Adderall NUPM behavior among college students [49]. It found that 8.9% of Adderall-related tweets analyzed mentioned another substance (including illicit drugs), indicating the dangerous possibility of promotion of polydrug abuse via social media [49]. Another unpublished study analyzed Adderall-related Twitter traffic and found that the highest volume of Twitter content (roughly 7 out of 10) originated from illicit online pharmacies advertising the sale of medications with no prescription required [50].


Though an evidence base supporting the association between social media and NUPM is beginning to emerge, there is an urgent need for additional research specifically examining in detail NUPM-related risk factors enabled by social media. This should be pursued in conjunction with policy analysis to determine if current law and legislation can effectively regulate this digital medium to ensure youth and patient safety.


Ineffective Enforcement/Coverage of Existing Regulations More than 10 years after Ryan Haight’s unintentional death, youth online-enabled NUPM access remains relatively unabated despite legislative and law enforcement efforts. Global action (such as Interpol’s Operation Pangea) have led to the closure of some illicit online pharmacies [51]. Yet despite these operations, organizations such as the National Association of Boards of Pharmacy (NABP) continue to report that the vast majority (97%) of existing online pharmacies are “not recommended” and present potential patient safety risks [52]. This includes 87% of recent NABP-reviewed online pharmacies not requiring a valid prescription for dispensing [52].

The specific mechanisms of the RHA to stem controlled substance online NUPM focus on registration, licensure, disclosure, and reporting requirements for online pharmacies offering controlled substances as well as requiring valid prescriptions for dispensing (including at least one in-person examination) [2]. It also imposes increased penalties for illicit actors in an attempt to deter such criminal activity [2]. Yet, the RHA primarily focuses on domestic online pharmacies, which is problematic given that surveys have identified up to 23% having a physical addresses outside the United States and most do not provide any address at all [1,52]. Hence, online pharmacies selling controlled substances that operate outside of the United States may not be subject to the jurisdiction of the Act or the DEA, limiting enforceability.

Additional gaps in the RHA in effectively dealing with the illicit online sale of controlled substances have also been reported. This includes websites “unlocking” hidden content that provides access to controlled substances and using affiliate networks and portal sites to avoid law enforcement detection [3]. Further, other illicit actors may simply sell the “prescription” to the patient for an additional fee, allowing for re-use and may not be subject to the RHA (1). Criminals operating online pharmacies have also gone as far as impersonating DEA agents and defrauding consumers by threatening law enforcement and prosecution for illegal purchase of a drug after a consumer has purchased online [53].

Further highlighting the limitations of the RHA in effectively regulating controlled substance NUPM, a 2011 report by online monitoring company LegitScript, published a sample list of 1000 illicit online pharmacies actively offering the sale of controlled substances without a valid prescription (including over half with domain name or server presence in the United States)—an activity in direct violation of the RHA [3].


Yet, despite these clear legal violations and claims by DEA of RHA effective deterrence, there appears to be little enforcement with no successful prosecutions under the RHA against these or other criminal violations of the law [3,54]. Hence, there is a clear need to reexamine the scope and coverage of the RHA and enable additional tools of enforcement to meet changing online trends and current regulatory gaps.

Reform

Amending the Ryan Haight Act Associated risks of NUPM to patient safety and public health are high, but in n