We just added over 300 online pharmacy websites to our “unapproved” list. All of these are part of the infamous Nurhul Chee Network. These websites don’t disclose their dispensing pharmacy and don’t require a valid prescription preceded by an in-person doctor’s exam. Additionally, we’ve had complaints about websites affiliated with this network sending out “spam faxes.”

We don’t really know if there is actually named “Nurhul Chee” in the first place, but in exposing this network, the World Internet Property Organization is a pretty good place to start. Last year, legitimate online pharmacy drugstore.com filed a complaint against one of Chee’s affiliate websites, drugstoreTM.com, for trademark violation. The Administrative Panel identified Chee as one of two Respondents, but it’s not clear that they ever identified that he actually exists. (In fact, one “Robert Murry” of “Evergreen Technologies” asked to be considered the only respondent.)

Assuming that Chee is a real person (even if not a real name), where is he or she? It looks to us like Singapore. If so, where are the drugs coming from, within the US or outside of the country? If the latter, that’s a violation of Federal law. If the former, why don’t the websites disclose the location and identity of the dispensing pharmacy?

The answer, of course, is that websites that offer prescription drugs without adhering to the law or sound medical or pharmacy practices thrive in the shadows, and hate the sunlight. If these businesses are completely legitimate and not worried about the legality of their actions, it is important for them to clearly state where the prescription drugs are coming from, which pharmacy fills the orders, and so forth.

LegitScript is pleased to welcome several new online pharmacies over the next few weeks. Today, we’re glad to announce that TriangleCompounding.com has been reviewed and approved. Welcome, Triangle!

Triangle Compounding is located in Cary, North Carolina, and is licensed or otherwise permitted to dispense prescription drugs in ten states. Something else we’re glad to note: Triangle Compounding is accredited by the Pharmacy Compounding Accreditation Board (PCAB).

The topic of compounding pharmacies highlights an important issue regarding prescription drug compounding: given some of the tension between the Food and Drug Administration (FDA) and compounding pharmacies, how should an organization like LegitScript, which is focused on verifying online pharmacies, deal with online pharmacies engaged in prescription drug compounding? A complete answer will be the subject of a future blog, but generally, we like to see pharmacies that are engaged exclusively or primarily in the business of compounding get accredited by PCAB. Of course, pharmacies have traditionally engaged in some amount of compounding (as the FDA has noted), and we don’t necessarily look for PCAB accreditation if a pharmacy engages in some limited amount of extemporaneous compounding.

The folks over at KnujOn have released a troubling report about the Directi Group, PrivacyProtect.org, and how rogue online pharmacies rely (unsurprisingly) on rogue domain name registrars (DNR). The report indicates that the Directi group controls 48 “phantom” DNRs that, in turn, are supporting rogue online pharmacy networks.

Last month, LegitScript and KnujOn reported on the role that DNRs play in supporting websites selling illicit steroids. This report is a natural follow-up to that, looking at the 48 phantom DNRs that, in fact, appear to be controlled by the Directi Group, which also appears to control PrivacyProtect.org, the service that enables website owners to hide their identity.

LegitScript will take a closer look at the report with an eye to an important follow-up question: which affiliate networks are these websites part of? And what’s the extent of the relationship between the rogue online pharmacies and the Directi Group?

Update: Directi disclaims all allegations in the knujon / hostexploit reports as baseless and factually incorrect. The full text of Directi’s press release is here.

Should online pharmacy website owners (“registrants”) be allowed to register the online pharmacy anonymously? Generally, LegitScript won’t approve a online pharmacy if the registration is anonymous, as we explain below.

To back up a bit, when you buy a domain name (e.g., “www.bestpharmacy.com”) you have to provide a name, address, telephone number, email, and so forth, as contact information of the person who controls the website. However, you can make that information anonymous, so that a person checking out who owns the website just sees a generic name and address, or “Privacy Protected.”

This is fine for most websites. But when it comes to pharmacies, one of the first protections offered by brick-and-mortar pharmacies is the ability to walk in the door, know who the pharmacist is, and see that there’s a real, live pharmacy doing a bona fide business. Legitimate Internet pharmacies should offer the same to their customers: the ability to know who really controls the website, and who is accountable if there is a problem with the medication.

As an example, when we verified KidsRx.com, a pediatric online pharmacy, we saw that the website was registered to the actual owner and Pharmacist-in-Charge. That’s great! That helps us, and consumers, know who actually controls the website. And it means that websites like KidsRx.com don’t have anything to hide. By contrast, slyfoxpharmacy.com, which offers prescription drugs without a prescription, is registered anonymously. Could it be…because they don’t want anybody to know who they are?

There are valid reasons for registering some websites anonymously. But not for online pharmacies: in this sector, with your health at stake, accountability is too important. And that’s why LegitScript won’t approve an online pharmacy unless its registration information is complete and accurate.

MarkMonitor released a study yesterday suggesting that visits to rogue online drug sites have tripled over the last year. One third of the 2,986 websites the study reviewed saw nearly 100,000 visits daily. The company concedes that this isn’t a precise number, but used the Alexa website visitor ranking system to estimate traffic to sites selling six major pharmaceuticals.

The study estimated that sales of those six pharmaceutical drugs (illicit sales, that is) was about $12 billion. That’s a three-fold increase from the $4 billion MarkMonitor estimated last year. And the study found:

Marketers for these pharmacies and sites are becoming increasingly aggressive. MarkMonitor estimates brandjackers spend $26 million annually for search advertising using only those six (pharmaceutical) keywords.

One dynamic that MarkMonitor’s study may not have addressed is the structure of the rogue online pharmacy networks, which can result in 1,000 websites linking back to one main website where orders are processed and payments are conducted. Looking at individual website visits is a pretty good proxy for that (after all, individual website visitors don’t know that there are another 999 identical websites out there).

Another disturbing finding:

49 percent of the 2,986 pharmacies were hosted in the U.S., followed by the U.K., which hosted 12 percent, and Germany, which hosted 9 percent.

See LegitScript’s and KnujOn’s report on rogue websites selling steroids for a discussion of that issue.

Benjamin Gluck of the Bird Marella law firm launched a blog back in May that’s a welcome addition to serious discourse on the Internet related to online pharmacies.

Those concerned with online pharmacies might disagree with Mr. Gluck’s approach, as he defends (often successfully, we might add!) online pharmacy operators and associates accused of violating the law. However, he’s a serious thinker about the lack of legal clarity as to what’s legal, and what’s not, regarding some aspects of online pharmacy operations.

Yesterday, Kansas Attorney General Steve Six announced an indictment against Hogan’s Pharmacy owners Jolane and Mark Poindexter, and against pharmacist Rick Kloxin, for purchases from medhaven.net, for “distributing prescription-only drugs to people throughout the United States based upon questionnaires customers completed via the Internet.”

LegitScript thinks that there may be more to the story.

Medhaven.net is, as of this morning, still an operational website. And it’s linked to an even larger network of rogue Internet pharmacies (at least 230) that appear to be based in Singapore.

Follow the connections:

• MedHaven.net is registered to an “Amirul Lee” in Singapore. However, the registration service is provided by Nurhul Chee, who uses the email jethsam@yahoo.com.
• Nurhul Chee, with a Singapore address and the same email as listed above, is the registered owner of more than 200 other online pharmacies, like WatsonsPro.net, which does not require a valid prescription for prescription drugs.
• And wait! WatsonsPro.net says, in their terms of service, that they fill their order with Hogan’s Pharmacy, and that “Kansas law” controls any dispute.

Meanwhile, these other sites, such as WatsonsPro.com (or .net), are still up and running. Several of these sites have names like HoganRx.com, HoganPharma.com, and so forth.

How large is this network, which is called “Alliance Healthcare Group”? We’ve uncovered over 230 websites that are still up and running, and providing prescription drugs without requiring a valid prescription.

The precise relationship between the owners of Hogan’s pharmacy and Nurhul Chee in Singapore is unclear, but three questions remain:

1. Why would medhaven.com, HoganRx.com, and websites like WatsonsPro.com, which claimed to fill orders with Hogan’s Pharmacy in Kansas, be registered to somebody in Singapore?
2. Were Hogan’s Pharmacy’s owners controlling the Singapore-based network, or just filling orders for it?
3. Were any of the drugs counterfeit, and/or relabeled to appear as if they were US drugs, when in fact they were from China, India, or elsewhere?

One possible answer: some of the prescription drugs dispensed without a prescription came from the US, and others came from or through Singapore or other international locations. That, of course, is a violation of Federal law, according to the FDA.

A study released by CasaColumbia indicates that US youth perceive prescription drugs as easier to obtain (without a prescription) than beer.

As reported by the Washington Post,

Nineteen percent of teenagers found it easier to purchase prescription drugs than cigarettes, beer or marijuana, compared with 13 percent a year ago. A quarter of the teens said it is easiest to buy marijuana, with 43 percent of 17-year-olds saying they could buy the drug in less than an hour.

What has long been less than clear is the extent that the Internet plays in prescription drug abuse among youth. Clearly, it is part of the problem, but studies like the National Survey on Drug Use and Health indicate that “family and friends” are the main source of the problem — hence the campaign to encourage people to empty their medicine chests of unused prescription drugs. All the same, CASA Columbia’s study reinforces the need for parents to watch their kids’ Internet use.

A survey by the Pew Internet Project indicates that 75% of the US public uses the Internet as a resource for health information.

The report also indicates that as much as 10% of the American public uses the Internet to find health information each day.

The report’s author also said something that hints, we think, at an ongoing debate:

What do these numbers have to do with participatory medicine? I have seen our data used over and over to convince policy makers, medical professionals, investors, and even patients themselves that the internet is an important source of health information and a force for change in health care (whether for good or for ill). I’m like an ammunition dealer in the internet wars — all sides use our data since the Pew Internet Project does not endorse technologies, industry sectors, or outcomes.

The debate will be about telemedicine, the transfer of medical information via the phone or Internet (a valid practice if it adheres to certain standards) versus “online consultations,” a prescription provided via website by a doctor who never physically examines a patient (which is not considered a valid basis for a prescription).