EU loophole that means dangerous painkillers are doled out at the click of a mouse
The death of an Irish man from an overdose has sparked calls for tighter online regulation
AS A young man, Richard Breatnach seemed to have it all. The son of an eminent Dublin radiologist, with his family home an elegant Victorian mansion on a leafy street in an exclusive part of the city, he attended the elite Jesuit school, Gonzaga College, where he is remembered as a keen and talented actor.
His death at just 31, in Brighton two years ago was, by complete contrast, a tragically squalid affair.
He had become dependent on opiates and was killed by an overdose of the powerful painkiller dihydrocodeine, usually prescription-only, that he had bought online.
This drug is twice as strong as the codeine contained in over-the-counter painkillers and it is highly addictive.
Richard’s GP had refused to prescribe opiates, having seen through his claim to need them for chronic pain. Richard discovered another way to obtain dihydrocodeine — in lethally huge amounts, and without even leaving his home. What’s more, it is entirely legal.
Richard found a website run by Bolton-based company HR Healthcare that sold prescribed drugs online. He had only to fill in a questionnaire, which took just 15 minutes to complete, to obtain prescription-strength dihydrocodeine. In it, he claimed he needed the drug for migraines.
This was signed off by a European Unionqualified GP working for the website — without ever meeting Richard or reading his medical notes. The tablets were posted to him within days.
At his inquest in August 2016, coroner Victoria Hamilton-Deeley heard expert evidence that dihydrocodeine should not be prescribed for migraine, not least because of its addiction risk.
She also heard that Richard had been sent an astonishing total of 126 high-strength tablets in one batch. Patients are normally told to take a maximum of four a day. It was on this batch that Richard overdosed.
The coroner noted that no effort had been made to contact Richard’s GP or to doublecheck the information he’d given.
Following the inquest, Miss Hamilton-Deeley was moved to write to the medical director of NHS England, Bruce Keogh, highlighting the perils of this legal conduit to powerful prescription drugs. She also wrote to HR Healthcare, demanding that it take action to safeguard customers in future.
The coroner is not the only authority to be disturbed by the fact that anyone can fill in an online prescription form, have it signed off by a doctor anywhere in the EU — without ever being physically examined by them — and then receive large amounts of addictive and potentially lethal prescription drugs such as opioid painkillers and benzodiazepines (given for anxiety and sleep).
It may sound frighteningly dubious, but it is perfectly above board, thanks to a loophole in EU regulations.
ONLINE prescribing sites are allowed to sell drugs such as dihydrocodeine in Britain on the principle that EU-qualified GPs and pharmacies should be able to prescribe to any EU citizen, explains medicines policy adviser Lynda Scammell.
‘We normally find that these doctors who are supposed to monitor people’s online questionnaires are registered in countries such as Romania and Bulgaria,’ she told Good Health.
In Ireland, the requirements for prescriptions of controlled drugs means the address of the practitioner must be within Ireland and for the likes of opiates and benzodiazepines, a handwritten GP signature is required.
But for medicines that fall outside this, like the addictive codeine-based painkillers you can buy over the counter, the concern is that some countries’ regulatory systems for medics and prescribing may not be operated as rigorously as Ireland’s.
While there are no official figures on how many people are using these services, David Grieve, a former mental health nurse who runs Over-
Count, a charity that supports people dependent on prescription drugs, says online prescriptions are the most popular purchasing option for people dependent on codeine-based drugs, and he knows of hundreds who do this.
A similar issue is the ease with which patients can buy antibiotics online: the problem with opioids is that they’re seriously addictive and patients can easily overdose.
Experts at Britain’s official regulator, the General Pharmaceutical Council (GPhC), have become so alarmed by this burgeoning legal online trade in painkillers, antibiotics and mood-altering psychiatric medications, that they are proposing legal changes to try to curb it. The GPhC’s chief executive, Duncan Rudkin, says: ‘We are concerned that patients may be able to access medicines that are not clinically appropriate for them from online services.
‘Medicines are not ordinary items of commerce and must not be treated as such.’
Here, as in Britain, there are as yet no inspection or regulation plans for online medical services, outside of existing legislation on the registration of doctors.
But moves are being made to change this. At the recent AGM of the Irish Medical Organisation, members voted for an examination into the safety of online GP services.
The IMO has called for regulation of this industry over fears of incorrect diagnoses or non-compliance with clinical guidelines.
And the calls have been welcomed by the legitimate online doctor services who want standards raised in the industry to protect all patients.
Dr Brian McManus, medical director of VideoDoc, is against any questionnaire-style prescribing and would be loathe to think the services they offer could be mistakenly lumped in with that.
‘We would reject that kind of medicine — it is very poor and very dangerous.
‘From VideoDoc’s perspective I have written up the scope of service and the clinical guidelines and we don’t prescribe opiates at all.
‘We don’t prescribe benzodiazepines, Tramadol, Lyrica or any other drugs that are prone to abuse as our feeling is in general we don’t know the patients and those kinds of drugs would be best prescribed by their GP who knows them and sees them regularly and can monitor their prescribing.’
With the VideoDoc service, every patient has a video one to one with a GP via the internet and all the GPs employed by VideoDoc are working in Ireland and registered with the Irish Medical Organisation.
But Dr McManus is against the questionnaire-style sites where prescriptions are filled without speaking to the patient at all.
‘I think it is appalling medical practice to issue prescriptions online without actually speaking to the patient, without talking to them, and without knowing their past medical history,’ he told Good Health.
‘I don’t think those kind of services should be allowed.
‘We don’t offer that service and would totally reject it. Our service means you have to have a face-toface consultation with the doctor who will go through your history.
‘Even with that we still don’t prescribe controlled drugs and we would welcome any regulation around telemedicine and online prescribing.’
After Richard Breatnach’s inquest, Britain’s Care Quality Commission (CQC), which inspects the companies that run medication-selling websites found that HR Healthcare, the online service that sent Richard Breatnach the consignment of 126 highstrength dihydrocodeine tablets that brought about his death, was a serious risk.
It was inspected by the CQC in January 2017 and a website it ran was closed down for six months ‘to protect patients’.
INSPECTORS found unsafe care, with national guidance ignored and patients at risk due to poor record-keeping — and a failure to share information with patients’ GPs, such as the doctor who would have warned that Richard should not be prescribed opiates.
This website was subsequently shut down, although HR Healthcare now operates another online service with a different name.
A spokesman told Good Health that in the wake of Richard’s inquest: ‘HR Healthcare reviewed its safety procedures and continues to do so regularly, and has since ceased dispensing privately issued prescriptions for dihydrocodeine and all other opioid medications.
‘As part of its ongoing safety review, HR Healthcare has also since implemented stricter controls on medications dispensed through the pharmacy.’
It is a consolation to know that our regulators may properly ensure that Irish-based services using Irish doctors must operate safely. But what of the others?
Cutting costs of their medicines is one of the reasons people turn to the internet to try and buy prescribed drugs at a cheaper price.
But they could be buying a products in from legally permitted sellers operating in distant parts of the EU, where regulation may be perilously looser.
In France, Spain and Italy, they have decided that online pharmacies which use doctors outside their borders should not send drugs to people who merely fill in questionnaires online.
Wouldn’t it make sense to copy our continental counterparts and ban this dangerous trade?