7. Some Websites offer to prescribe medication based only on a questionnaire. Is this a safe practice? Is it legal?

Unlike the traditional relationship between a patient and the patient's health care professional, some online practitioners issue prescriptions in the absence of a physical examination or direct medical supervision. According to the American Medical Association, a health care professional who offers a prescription for a patient the practitioner has never seen before and based solely on an online questionnaire generally has not met the appropriate medical standard of care. As a result, patients may receive a drug that is inappropriate for them to use and may sacrifice the opportunity for a correct diagnosis or the identification of an underlying medical condition for which use of the prescription drug may be dangerous.

It is a violation of the Federal Food, Drug, and Cosmetic Act to dispense prescription drugs without a valid prescription. FDA will work with the states to determine the validity of online prescriptions and to bring enforcement actions under state law, federal law, or both, as appropriate. In addition, several state boards of medicine have ruled that such practice is medical misconduct and have fined and suspended the licenses of health care practitioners who have prescribed drugs in this manner.

Can an individual order drugs using the Internet without seeing a doctor?

Federal law requires that "A prescription for a controlled substance to be effective must be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice" (21 CFR 1306.04(a)). Every state separately imposes the same requirement under its laws. Under Federal and state law, for a doctor to be acting in the usual course of professional practice, there must be a bona fide doctor/ patient relationship.

For purposes of state law, many state authorities, with the endorsement of medical societies, consider the existence of the following four elements as an indication that a legitimate doctor/patient relationship has been established:


* A patient has a medical complaint;
* A medical history has been taken;
* A physical examination has been performed; and
* Some logical connection exists between the medical complaint, the medical history, the physical examination and the drug prescribed.

A patient completing a questionnaire that is then reviewed by a physician hired by or working on behalf of an Internet pharmacy does not establish a doctor/patient relationship. A consumer can more easily provide false information in a questionnaire than in a face-to-face meeting with the physician. It is illegal to receive a prescription for a controlled substance without the establishment of a legitimate doctor/patient relationship, and it is unlikely for such a relationship to be formed through Internet correspondence alone. However, this is not intended to limit the ability of practitioners to engage in telemedicine. For purposes of this guidance document, telemedicine refers to the provision of health care using telecommunication networks to transmit and receive information including voice communications, images and patient records.

Some Internet sites recommend to the patient that they not take a new drug before they have a complete physical performed by a doctor. These sites then ask the patient to waive the requirement for a physical and to agree to have a physical before taking the drug they purchase via the Internet. An after the fact physical does not take the place of establishing a doctor/patient relationship. The physical exam should take place before the prescription is written. These types of activities by Internet pharmacies can subject the operators of the Internet site and any pharmacies or doctors who participate in the activity to criminal, civil, or administrative actions. For DEA registrants, administrative action may include the loss of their DEA registration. Additionally, providing false material information to obtain controlled substances could be considered obtaining a controlled substance by fraud and deceit, which is subject to Federal and State penalties.