THE INTERNET FIX: EASY NARCOTICS

Three doctors and a Texas pharmacist provided prescription narcotics
through the Internet over the last two years to thousands of patients they
never met or examined, according to a federal indictment issued last week
that provides a stark example of what prosecutors say is a growing problem
of computer-assisted drug abuse.

A flood of Cipro and Viagra sales over the Web rang the first alarm bells
about Internet pharmacies, but officials say the increasing availability of
controlled substances such as OxyContin and other narcotics is even more
worrisome. As many as 150 rogue pharmacies offer drugs over the Internet to
people without legitimate prescriptions. This includes 15 to 30 Web sites
that provide easy access to dangerous narcotics, according to the National
Association of Boards of Pharmacy.

A Globe correspondent was able to purchase generic hydrocodone, one of the
most abused prescription painkillers, through the Medical Service Network
with remarkable ease.

In the Texas case, prosecutors say patients, including hundreds from New
England, found the doctors through an Internet Web site called The Pill Box
Pharmacy. After filling out a questionnaire, they had a brief telephone
consultation with a doctor, who received $45 to $50 from the pharmacy for
each prescription. According to the Texas State Board of Medical Examiners,
one doctor even allowed his girlfriend to conduct phone consultations,
although she had no medical credentials.

Investigators say people all over the country have gotten sick as a result
of drugs purchased from The Pill Box. One Illinois patient suffered an
overdose after getting four successive prescriptions for hydrocodone,
according to the medical board, and a San Francisco patient with a history
of addiction developed liver damage after he was prescribed the painkiller
Darvocet.

But as authorities begin to tackle this new front in the war on drugs, they
acknowledge that they are several steps behind the sellers.

"Because we haven't seen a significant prosecution, some of the sites have
become emboldened, and we've seen a growth in the number offering
narcotics," said Carmen Catizone, executive director of the pharmacy
association.

"Because of the highly addictive and dangerous nature of the narcotics,
having these sites operating poses a serious risk to public health. They're
used illicitly on the streets and could get into the hands of children."

Nationally, 20 million people abuse painkillers such as hydrocodone and
OxyContin, according to the Substance Abuse and Mental Health Services
Administration, which has no statistics on how many get their drugs through
the Internet.

Drug abusers have clearly discovered Internet pharmacies. Already, there is
a subculture of patients and addicts who meet on the Web to trade
information on the easiest Internet sources, best prices, and how to tap
into more than one pharmacy at a time without getting caught.

Under federal law, narcotics may not be distributed without a prescription,
and the pharmacist must have the original written prescription in hand for
the most addictive narcotics, such as morphine and OxyContin. Most states,
including Massachusetts, do not consider an Internet questionnaire or a
brief phone consultation legitimate justification for writing a
prescription. As a result, legal online pharmacy sites, such as
Walgreens.com, will fill only prescriptions provided by the patient's
regular doctor.

Many of the online pharmacies that dispense drugs based on questionnaires
and phone consultations are based in the United States, while some that
don't require prescriptions at all are based overseas, where prescribing
laws are looser. That doesn't make the business legal; importing narcotics
through the mail, even for personal medical use, is illegal.

Doctor asks reporter how much, not why

A Globe correspondent demonstrated how easy it is to acquire narcotics over
the Internet, buying hydrocodone with little trouble. The reporter entered
personal information and a brief medical history on an online
questionnaire, faxed in a copy of her driver's license, and paid a $125
"consultation fee" by credit card. Within 48 hours, she was speaking by
phone with Dr. Sean Aldridge.

During the two-minute conversation, she complained of migraine headaches
and said hydrocodone had been helpful in the past. Aldridge never asked for
medical records or questioned her about the possibility of addiction. But
he did want to know whether 90 tablets a month would be enough. He also
authorized two refills.

Two days and an additional $100 later, the pills arrived by a delivery service.

In response to a request for an interview about its practices, Medical
Service Network faxed a handout saying, "We do not 'take orders' for
medication."

Aldridge, a doctor licensed in California, declined to discuss his
arrangement with Medical Service Network. "As far as I know, I am providing
a good-faith examination, and that is legal. If there's anything I'm doing
illegally, that will have to change," he said.

Some Web pharmacies are tightening their procedures. Many that previously
relied on a questionnaire now require a phone consultation, and some are
asking for medical records. At Norco Direct, a site specializing in "strong
pain relief" and named for a brand of hydrocodone, all customers must agree
to language stating they have an emergency medical condition. Officials say
these sites are still operating illegally unless the physician does an exam.

"The folks who remain know they are walking on the edge," said Dale Austin,
deputy executive vice president of the Federation of State Medical Boards.

Norco Direct e-mailed a reporter to "stop badgering us" when asked
questions about the operation. "We are also in the process of arranging
home physical exams ... our doctors ... will not 'dish out' medication on a
whim," e-mailed a company representative who would not identify himself.

Prosecutions of Internet pharmacies for narcotics sales are just beginning,
in part because investigators find it difficult to trace sites to their
sources because of the Internet's anonymity. So the federal Drug
Enforcement Administration, and even some state medical boards, are
assigning staff members to work full time on Internet drug fraud.
Massachusetts is not among them.

In one of the first federal convictions, an Oklahoma jury in January found
Dr. Ricky Joe Nelson guilty of conspiring to distribute controlled
substances over the Internet.

Working through PlanetPills.com, the Oklahoma surgeon wrote as many as 300
prescriptions a day - most for narcotics - to patients all over the country
based on their answers on an Internet questionnaire. One admitted addict
testified at the trial that she used the company because it was easier than
lying to her family doctor, US Attorney Robert McCampbell said.

Patients paid $250 for 100 pain pills, five times the retail price, earning
Nelson $175,000 in just six weeks. According to Nelson's lawyer, the doctor
turned to Internet work after he was traumatized while helping rescue
victims of the Oklahoma City bombing in 1995. Now he's in jail awaiting
sentencing and planning an appeal.

"The doctor never intended to break the law," Paul Antonio Lacy said. "He
was trying to do something on the cutting edge of medicine. Unfortunately,
some of the patients were liars."

"Inventing a new type of medical service"

The federal indictment handed up in Texas last Wednesday alleges that The
Pill Box conspired to distribute hydrocodone and addictive tranquilizers
and made the three doctors, pharmacist, and middleman involved about $14
million in 30 months. Separate cases pending before the New Jersey and
Texas medical and pharmacy boards allege doctors recruited by the Texas
pharmacist, William Stallknecht, issued tens of thousands of prescriptions
to patients across the United States and abroad they never examined.
Stallknecht did not respond to requests for comment.

One doctor he recruited, Ernesto Cantu of San Antonio, allegedly prescribed
570 hydrocodone pills to a New Jersey woman who was in treatment for
addiction to prescription painkillers. He also allegedly prescribed
painkillers to the Illinois patient who suffered an overdose, and to
himself and his girlfriend. Some patients who called him to get
prescriptions were actually interviewed by his girlfriend, who was
masquerading as "Dr. Cantu," officials allege. Cantu's lawyer declined to
comment on the allegations.

Dr. David Bryson is also facing charges in The Pill Box case. He defends
his role as "inventing a new type of medical service" that didn't harm
anyone. Bryson, who was unemployed and facing bankruptcy when he started
working with Stallknecht in 1999, says he made as much as $9,000 a week
writing narcotic and tranquilizer prescriptions. He says most of his
patients, including about 100 in Boston and a lobsterman from Maine, needed
the drugs for chronic pain and couldn't get them from their local doctors.

"I didn't need or want any drug abusers in the practice," he said. "That
would have been suicidal."

But officials say that without doing a physical examination Bryson and
other doctors have little means of ferreting out addicts.

"Locally, pharmacists know who they are and doctors recognize the
drug-seeking behavior," said Paul Nasca, an Internet investigator for the
California medical board. "Over the Internet, there's no safety net."