E-DRUG: Mail-order drug delivery (contd)

[Kirsten Myhr <myhr@online.no>]

E-DRUG: Mail order drug delivery (contd)
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Dear E-druggers,

Norway (and the other Nordic countries I think) has today a delivery 
system where pharmacies are allowed to receive prescriptions by mail 
and send the drugs to the patient. This system was instituted because 
of the long distances and people living in places too small to have a 
pharmacy - and we do not want dispensing doctors! The drugs are sent 
by mail or by bus. No extra precautions are taken to prevent theft, 
but this is not a problem here either. The government will refund the 
pharmacy for the freight cost to ensure equal prices regardless of where 
you live. As you see this system is controlled by the government. And 
because of the small scale and the control by the nearest pharmacy, we 
don't need to worry about storage conditions (would only apply to a few 
drugs anyway). The local pharmacy will also ensure written information 
for the patient etc.

Our laws and regulations do not prevent pharmacies from operating a
nationwide mail order system, but until now pharmacies have only served
their neighborhood. The present system does not allow wholesalers or
manufacturers to start mail order pharmacies. And, due to the 
regulations on advertising, it will be illegal to issue a catalogue of 
products.

Last year, a report on the future organisation of pharmaceutical services
in Norway listed the following factors in favour of mail-order (I don't
necessarily agree):

- It may be economic for the society to bypass the pharmacy (cheaper 
drugs)
- it is "easy" for the patient
- it opens up the possibility of working actively with negative/positive
drug lists. Makes it possible to do generic or parallel substitution
- will maintain availability in small places
- mail order systems that are based in access to patient data, may check
that the patient is given correct quantities (according to directions for
use), and could therefore contribute to rational drug use.

Factors against mail-order:
- lack of direct contact between the customer and the pharmacy, making it
difficult to give necessary information and disclose wrong use and/or
misunderstandings
- to rationalise and to keep freight cost low, large quantities are often 
issued
- issuing of large quantities increases the danger of overstocking, thus
increasing risk of overdosing, a safety risk in itself
- long delivery time may cause delays and discontinuation of therapy. This
is of particular concern in wrong deliveries (wrong drugs or wrong 
address)
- if access to patient data are permitted, it raises questions of 
principle concerning protection of patient data.

In Sweden, a report on the future organisation of pharmaceutical services 
has been published. On mail-order the summary says it should be legal to
establish such a system if it is done without any risk of damage to 
humans, animals or the environment.  

European Union has opened up our borders due to the goal of free flow of 
goods and some of us are quite worried about that. Today there is a lot 
of discussion on mail-order and ordering drugs via Internet which is also a 
form of mail-order. WHO issued a statement on the issues in May last year 
and a working group is due to report soon. In Norway, we know about such 
companies having operated from e.g. the Netherlands (closed down when the 
authorities were made aware) and Sweden. Companies in the UK have 
advertised in Norwegian newspapers.

I don't think many countries operate mail-order pharmacies yet. It's been 
in the U.S. for years and is e.g. owned by health maintenance 
organisations, drug companies or insurance companies. It is mainly used 
for expensive drugs for chronic diseases. A note in Scrip in March last 
year said the US National Community Pharmacists Association had renewed 
its call for tighter regulation of mail-order pharmacies following the 
hospitalisation of 14 teenagers suffering from overdose of baclofen; 
stolen outside a house when an agent tried to deliver it. That's one weak 
point.

According to Scrip 7 October last year, Germany has banned mail-order
provision of medicine, but the national insurance is expected to challenge
that as they think it will save money.

In the UK, again according to Scrip, a case had been raised against a
pharmacist who dispensed contraceptives to women in Germany by mail order
(contraceptives are cheaper in the UK). The pharmacist worked for a 
company in London which has been supplying Prescription Only medicines to 
Germany. The case was dismissed, the mail-order delivery was called an 
"indefensible activity". The UK Medicines Control Agency has said it will 
look at mail-order supply on a case-by-case basis to see if it complies 
with the Medicines Act.

This describes the situation briefly in some European countries. 
 
Ms Kirsten Myhr, MScPharm, MPH
Bygdoy Alle 58B
0265 Oslo
Norway
Tel: +47 22 56 05 85 (h)
Fax: +47 22 24 90 17 (w) Tel: +47 22 24 88 55 (w)
E-mail: myhr@online.no
or (w): kirsten.myhr@helsetilsynet.dep.telemax.no

Note from the co-moderator: 
---------------------------
Thanks Kirsten for an excellent review. Syed Rizwanuddin Ahmad

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