Viagra Prescriptions on the Internet: Is this Telemedicine?

By Ronald L. Scott

Viagra was recently released as an oral therapy for impotence or ("erectile dysfunction"). The FDA data sheet issued for Viagra advises that before the drug is prescribed, a thorough medical history and physical examination should be undertaken to diagnose erectile dysfunction, determine potential underlying causes and identify appropriate treatment. The data sheet also notes that there is a degree of cardiac risk associated with sexual activity, and physicians may need to consider the cardiovascular status of their patients prior to initiating treatment for erectile dysfunction. Like many medicines, Viagra has several potential side effects in a small percentage of patients, including headache, abnormal vision, and dizziness. The data sheet also advises that agents for the treatment of erectile dysfunction should be used with caution in patients with anatomical deformities of the penis or in patients with sickle cell anemia, multiple myeloma, or leukemia. Further, Viagra is not intended for "recreational" use to improve sexual performance of those not suffering from erectile dysfunction.

Some web sites are now offering prescriptions to Viagra on the Internet. Some sites are essentially acting as mail-order pharmacies, requiring the patient to furnish a prescription by his doctor. More troubling are the sites offering a "package deal" of both prescriptions and drugs. Certainly, the marketplace has shown creativity in this instance. For example, to minimally comply with the FDA data sheetís recommendation of a physical examination, one web site asks whether potential customers have had a recent physical examination showing general good health. The site then takes a history over the Internet, and has a licensed physician review the history at a charge of $110.00. However, if the physician denies to issue the prescription, there is no charge for the "review." The site also advises patients that impotence can be a symptom of other medical problems such as diabetes, prostate cancer, or vascular problems, and suggest that patients should see their physician to ensure they do not suffer from such conditions. Conveniently, the site suggests that in the interim Viagra will treat any erectile dysfunction. The site also says that at least one doctor quit prescribing on the Internet because of "traditional" views of a State Board of Medicine.

Prescribing Viagra over the Internet may indeed be objectionable to many statesí medical boards. A face-to-face medical examination may reveal more medically; even the history portion of the examination may be more accurate where there is an opportunity for the patient or physician to ask follow-up questions. Telemedicine holds great promise in some situation, such as the ability of an urban specialist to consult with a rural patient (or the rural patientís general practice physician). Advanced technology used in telemedicine may permit a physician at a distant location to transmit or receive high quality radiography or other images. Most telemedicine allows two way conversations by audio, and may use video as well. However, it is not the lack of technology used in Internet prescribing that presents the most problematic issues. Rather, the idea essentially promises more than it provides. If men are too embarrassed to discuss erectile dysfunction with their personal physician, they are not likely to return to the physician for a post-prescription diagnosis, and admit they obtained a prescription via the Internet. The misuse of the Internet for diagnosis could have unfortunate consequences. Some state medical boards may feel forced to regulate internet prescribing, redefine what constitutes the "practice of medicine" requiring a license within a given state, and generally lessen the freedom of physicians to practice medicine using advanced technology.

05/20/98