Coumadin from Canada: the dark side of internet medicine

Like 4 million Americans, I take an anticoagulant drug, also known as a ‘blood thinner’. Anticoagulants are used to treat and prevent blood clots in patients with thromboembolic disorders, such as atrial fibrillation and venous thromboembolism (VTE).

They’re also very dangerous drugs.  Anticoagulants are the most common medication to cause adverse drug events, with bleeding being the most common side-effect.(Ref 1)  Ten percent of all drug-related adverse outcomes are from anticoagulants and they are the most frequently implicated drug in adverse events resulting in emergency room visits and hospitalization with the resulting costs running into the hundreds of millions of dollars.(2)  Anticoagulants are not a drug to be dispensed without thought and oversight.

I started anticoagulation therapy 13 years ago, when I was 34 years old, following an episode of deep vein thrombosis and pulmonary embolism.  I’m a rarity however…the majority of anticoagulant patients are over age 65. (Ref 3)  While I’m fortunate to have prescription drug insurance, many do not. Even with prescription drug coverage, medications can still be unaffordable. Approximately 1 in 5 people don’t take a medication a doctor has prescribed because they can’t afford to pay for it. (4)  So it’s no wonder that patients, especially older patients on fixed incomes, are tempted to seek out cheaper sources of prescription drugs. It is a question I’m often asked…how do I afford my medication?  I did some research to see what resources were available to patients like myself on anticoagulants.  What I found was alarming.

A search quickly led me to the account of Dr. Frank Evans (@frankevans111) who has over 109,000 Twitter followers.  Dr Evans promotes many drugs, all linking to a Canadian pharmacy. One of the drugs he promotes is Coumadin (warfarin), a prescription anticoagulant.

CanPharm

The Canadian pharmacy

When I followed the link to the Canadian website, I was easily able to place an order for Coumadin.  No prescription required to be presented.  No medical questions of any kind asked.

I was even offered a bonus FREE medication to go with my Coumadin purchase…my choice of 4 pills of Viagra or Cialis.  How thoughtful, freebies. Screenshot of my cart:

CanPharmCart

But don’t worry…being a savvy consumer, I see this is clearly a legitimate pharmacy as none other than the US Department of Health and Human Services and Better Business Bureau logos are featured along the bottom of each page:

canpharmlogos

When I click on the HHS logo, this ‘official’ HHS certificate pops up to reassure me:

canpharmseal

 

There is even a handy link to their Canadian pharmacy license:

canpharmcert

Of course, none of these documents are legitimate.  HHS does not issue such certificates.  Even the license number isn’t found in the Ontario College of Pharmacists registry.

Yet it certainly looks impressive.  Least you laugh and think ‘who on earth would think such a site is legitimate?’, keep in mind only 12% of US adults have proficient health literacy. Many patients lack the skills needed to vet health information, making them easier health scam targets.

A doctor promoting online drugs?  Maybe, maybe not.

canpharmdoc1I found myself wondering…what kind of medical doctor encourages people to get a dangerous drug online from a clearly questionable pharmacy?  It is near-to-impossible to determine the true identity of a Twitter account or their true location, NSA types not-withstanding perhaps.  Dr. Evans Twitter profile lists his location as Los Angeles, California, which may or may not be accurate. I checked theMedical Board of California database and found that indeed, a Frank Evans is currently licensed to practice by the state of California.  And that this licensed Frank Evans is from Canada and he once held a fellowship in addiction medicine at Loma Linda University, which it not too far from Los Angeles.  But there is absolutely no evidence beyond these coincidences to suggest that they are one and the same person. Because this internet pharmacy is utilizing the same name of a real, licensed physician,  any basic online verification of credentials by a patient may lead to the false assumption that they are connecting with a reputable clinician.

Is there a real Dr. Evans behind this twitter account? Probably not. Surely someone would not be so naive as to use his or her real name when perpetrating a scam.  The headshot photo of Dr. Evans on the Twitter feed appears to be a generic stock photo; it shows up as in marketing uses on multiple websites, across a range of medical products.

All that glitters

canpharmbill

My receipt for coumadin from internet pharmacy

The question remains:  Why would a patient buy Coumadin (wafarin) over the internet?

Cost?   It can’t be cost.   While there is the perception that Canadian drugs are cheaper than in the United States, this is not always the case. Generic Coumain, warfarin, is actually cheaper if purchased from your corner pharmacy in the US than from this Canadian pharmacy.

2 mg warfarin 30 tabs at Wal-Mart = $4.

2 mg warfarin 30 tabs from Canadian Pharmacy = $38.55

Convenience?  It can’t be convenience.  If you are a patient on Coumadin (warfarin), obtaining a prescription is easy. This is a medication which requires very close management…necessitating an office visit to check optimal blood thinning levels (INR), on average, once per month with more frequent visits sometimes required.  The clinician managing a patient’s INR is also likely the one writing the scripts.  There should never be a time in which a patient is not under the care of a clinician to be able to access a new script.

Illicit use?  When you order online and a prescription is not required to be presented, it leaves the door wide open for people who don’t really need a drug to gain access.  What is the benefit of this for Coumadin?  To my knowledge there is no reason for anyone to take an anticoagulant if they don’t need to.  You can’t get high from it.  There is no resale value. This is such a dangerous drug that there is only potential harm from taking it…and therein is a disturbing possibility, that it could be utilized for self-harm. On websites which provide guidance for those contemplating suicide, Coumadin is mentioned by name with suggested dosing to ensure a fatal result. (I will not link to this material)

While I can’t fathom why patients would order anticoagulants over the internet, it surely must be happening by enough people;  if there wasn’t a profitable market, then online pharmacies would not do it.

Beyond one pharmacy and Coumadin

xareltoMultiple anticoagulants can be purchased on the internet, not just Coumadin (warfarin).  I found multiple internet pharmacies willing to sell the newer (and far more expensive) anticoagulants where no generic is yet available–Pradaxa, Xarelto, Eliquis, Savaysa.  In some cases, an internet pharmacy will advertise one of the newer drugs and then redirect the consumer to a ‘better, cheaper alternative’ to purchase warfarin.  One can only hope that patients understand that anticoagulant drugs have very different dosing and management and are not self-interchangable. You cannot sub out 10mg of one Xarelto for 10mg of warfarin and all will be fine!pradaxa

The lesson

My takeaway from this research:

  1. It pays to do your homework.  Something advertised as ‘cheaper’ isn’t always. Nor is it equally safe and effective..you have no way of knowing what you’re truly getting in the mail from a source you don’t know personally. If at all possible, deal with your local pharmacy where you can talk to someone with known expertise, face-to-face. If you can’t afford your medications, talk to your pharmacist and physician who can help identify appropriate cheaper alternatives, coupons, and patient assistance programs.
  2. Just because someone has ‘MD’ behind their name, it unfortunately doesn’t mean they are a reputable source of information. Nor does it mean they actual possess the credentials they claim.  Be skeptical.  Give special scrutiny to anyone online using their credentials as a method of trying to sell you something.
  3.  Despite efforts. the ability of regulators to close down illegal pharmacies is limited. The ‘Frank Evans MD’ Twitter account first began sending people to this particular Canadian pharmacy in March 2015, so I presume this domain/pharmacy has been in business at least since that time…long enough that its surprising its still operating. Regulation can only do so much; the best protection is to be an informed consumer and take the advice of the FDA:  “Don’t order medicines from web sites that claim to be Canadian pharmacies. Most are not legitimate pharmacies, and the drugs they supply are illegal and potentially dangerous.”

 

REFERENCES

  1. Piazza G, Nguyen TN, Cios D, et al. Anticoagulation-associated adverse drug events. The American journal of medicine. 2011;124(12):1136-1142.
  2. HHS National Action Plan for Adverse Drug Events, 2014 http://health.gov/hcq/pdfs/ADE-Action-Plan-508c.pdf
  3. Kirley et al National Trends in Oral Anticoagulant Use in the United States, 2007 to 2011 Circulation: Cardiovascular Quality and Outcomes. 2012; 5: 615-621
  4. Mazer, M., Bisgaier, J., Dailey, E., Srivastava, K., McDermoth, M., Datner, E. and Rhodes, K. V. (2011), Risk for Cost-related Medication Nonadherence Among Emergency Department Patients. Academic Emergency Medicine, 18: 267–272.

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