Order Code RS21711
Updated January 29, 2007
Legal Issues Related to Prescription Drug
Sales on the Internet
Vanessa Burrows
Legislative Attorney
American Law Division
Summary
This report provides a legal analysis of issues related to prescription drug sales on
the Internet, including issues involving online pharmacies and physicians who prescribe
medications over the Internet. Specifically, this report provides an overview of the
various federal and state laws that regulate this field, including laws and regulations
covering prescription drugs, controlled substances, doctors, and pharmacies. Legislators
have introduced the following bills in the 110th Congress: H.R. 194, H.R. 380, S. 242,
and S. 251.
Introduction
Many individuals have turned to online pharmacies to purchase prescription drugs,
and an increasing number of physicians have incorporated the Internet and email into their
medical practice. Use of this technology has many advantages for both the doctor and the
patient, including cost savings, convenience, accessibility, and improved privacy and
communication.1 Although many online pharmacies are legitimate businesses that offer
safe and convenient services similar to those provided by traditional neighborhood
pharmacies and large chain drugstores, other online pharmacies — often referred to as
“rogue sites” — engage in practices that are illegal, such as selling unapproved or
counterfeit drugs or dispensing drugs without a prescription.2 Some rogue sites operate
in a legal gray area in which the online pharmacy, as mandated by federal law, requires
a prescription before dispensing prescription drugs, but allows patients to secure a
prescription by completing an online questionnaire that is reviewed by a doctor who never
examines or speaks to the patient. This practice, though potentially unsafe for patients
who may be diagnosed incorrectly, is not necessarily illegal.
1 Food and Drug Administration, U.S. Department of Agriculture, Buying Drugs Online: It’s
Convenient and Private, But Beware of ‘Rogue Sites’ (2001), [http://www.fda.gov/fdac/features/
2000/100_online.html].
2 Id.

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The regulation of online pharmacies and doctors consists of a patchwork of federal
and state laws in an array of areas.3 At the federal level, the Food and Drug
Administration (FDA) regulates prescription drugs under the Federal Food, Drug, and
Cosmetic Act (FDCA), which governs, among other things, the safety and efficacy of
prescription medications, including the approval, manufacturing, and distribution of such
drugs.4 It is the FDCA that requires that prescription drugs may be dispensed only with
a valid prescription.5 The Drug Enforcement Agency (DEA) enforces the Controlled
Substances Act (CSA), which is a federal statute that establishes criminal and civil
sanctions for the unlawful possession, manufacturing, distribution, or importation of
controlled substances.6 State boards of pharmacy regulate pharmacy practice, and state
medical boards oversee the practice of medicine.7 Thus, some laws that govern online
pharmacies and doctors vary by state. Laws governing each of these areas are described
below.
Federal Oversight
As noted above, the CSA is a federal statute that establishes criminal and civil
sanctions for the unlawful possession, manufacturing, distribution, or importation of
controlled substances.8 The primary purpose of the CSA is to facilitate the legal
distribution of controlled substances for legitimate medical purposes while preventing
their diversion for illegal uses. Although the CSA is generally known for prohibiting
illegal drugs that have a high potential for abuse and no accepted medical use, such as
heroin or cocaine, the statute also covers a range of other drugs that have a lesser potential
for abuse and an accepted medical use, including certain prescription drugs. Although
most prescription drugs are not controlled substances and therefore are not regulated
under the CSA, some prescription drugs, such as narcotics and opiates that are often used
in the treatment of pain, are regulated under the CSA because they have a greater potential
for abuse than other prescription drugs and may lead to physical dependence.
It is the latter category of prescription painkillers that appear to be among the drugs
most heavily dispensed by certain Internet pharmacies in accordance with prescriptions
that are issued based on online questionnaires.9 This practice has sometimes been abused
by rogue sites that dispense large quantities of addictive substances to customers
apparently seeking access to prescription painkillers, and it has lead to instances of
addiction, overdose, and death. In response to cases in which online doctors have written
3 For additional information, see GAO Report GAO-01-69, Internet Pharmacies: Adding
Disclosure Requirements Would Aid State and Federal Oversight.
4 21 U.S.C. §§ 301 et seq.
5 Id. at § 353(b).
6 Id. at § 801 et seq. For more information on the Controlled Substances Act, see CRS Report 97-
141A, Drug Smuggling, Drug Dealing and Drug Abuse: Background and Overview of the
Sanctions Under the Federal Controlled Substances Act and Related Statutes, by Charles Doyle.
7 The FDCA excludes the practice of medicine from its jurisdiction. 21 U.S.C. § 396.
8 Id. at §§ 801 et seq.
9 See, e.g., Gilbert M. Gaul and Mary Pat Flaherty, Doctors Medicate Strangers on Web, WASH.
POST, Oct. 21, 2003, at A1.

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thousands of prescriptions for controlled substances without examining their patients, the
federal government has begun prosecuting certain doctors under the CSA by charging
them with the illegal distribution of controlled substances.10 Penalties under the CSA vary
depending on the amount and type of substance involved but generally include monetary
fines, forfeiture, and imprisonment.11
As noted above, prescription drugs are also regulated by the FDA under the FDCA.12
Although state law also governs the prescribing of drugs, the FDCA covers certain aspects
of the prescribing process, including the requirement that prescription drugs may not be
dispensed without a valid prescription.13 The FDCA, however, does not define the
meaning of “prescription.” Rather, each state defines what constitutes a valid prescription
under its pharmacy laws. Because such definitions differ from state to state, there is no
uniform, national definition of the term “prescription.”14 Thus, certain activities, such as
prescribing drugs without performing an in-person examination, may be explicitly illegal
in one state but of ambiguous legal status in another.
Concerned about reports of rogue online pharmacies, Congress has considered
legislation to establish a federal definition of what constitutes a valid prescription.15 For
example, such legislation has included proposals to establish a single federal standard for
prescriptions or to require online pharmacies to disclose information about themselves
and about the doctors approving prescriptions on their sites.16 Congress has also explored
the possibility of limiting the means by which allegedly rogue sites do business, namely
by restricting their ability to advertise on search engines, make credit card sales, and ship
prescription drugs,17 and some companies have responded with their own proposals. For
example, Google, an Internet search engine, no longer accepts advertising from
unlicenced pharmacies and prohibits the use of certain controlled substances as keywords
for search purposes.18 Because federal and state regulators face many legal barriers when
attempting to exercise jurisdiction over rogue pharmacies based in foreign countries,19
10 Id.; see also Editorial, Internet Drug Trafficking, PHILA. INQUIRER, Dec. 2, 2006, at A8.
11 21 U.S.C. §§ 841 et seq.
12 Id. at §§ 301 et seq.
13 Id. at § 353(b).
14 Inside Washington Publishers, FDA May Back Changing Law to Define Internet ‘Prescription’,
FDA WEEK, March 28, 2003.
15 Id.
16 See, e.g., Point, Click, Self-Medicate: A Review of Consumer Safeguards on Internet Pharmacy
Sites: Hearing Before the House Comm. On Government Reform, 108th Cong. (2003).
17 Gilbert M. Gaul and Mary Pat Flaherty, Google to Limit Some Drug Ads, WASH. POST, Dec.
1, 2003, at A1. The Bush Administration has also expressed interest in pursuing such a strategy.
Press Release, Office of National Drug Control Policy, U.S. Drug Prevention, Treatment,
Enforcement Agencies Take on “Doctor Shoppers,” “Pill Mills” (March 1, 2004),
[http://www.whitehousedrugpolicy.gov/news/press04/030104.html].
18 Gaul and Flaherty, supra note 17.
19 “The enforcement of a state action or the initiation of a mutual action by a foreign licensing
(continued...)

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placing limits on the degree to which search engines, credit card companies, and shipping
entities enable rogue sites to sell prescription drug may be one of the only ways to control
illicit sales by foreign online pharmacies.
It is important to note that online prescription drug sales by both U.S.-based and
foreign Internet pharmacies may raise additional legal questions involving drug
importation. The FDCA prohibits anyone other than the U.S. manufacturer from
importing prescription drugs that were originally manufactured in the U.S., and the statute
contains various provisions relating to drug approvals and labeling that make it virtually
impossible for prescription drugs made for foreign markets to comply with the extensive
statutory requirements.20 Thus, online pharmacies that sell imported U.S.-manufactured
drugs or foreign versions of drugs approved for domestic sale appear to violate the FDCA,
as do businesses that facilitate such sales. In addition, the CSA prohibits the unapproved
importation of controlled substances, as well as causing such importation,21 so an
individual or pharmacy that uses the Internet in a way that causes controlled substances
to be mailed or shipped into the U.S. may violate the CSA.22 The legal issues involved in
drug importation are discussed in detail in CRS Report RL32191, Prescription Drug
Importation and Internet Sales: A Legal Overview, by Vanessa Burrows.
State Oversight
As noted above, state boards of pharmacy are primarily responsible for regulating
pharmacy practice,23 although the FDA does provide some federal oversight of
pharmacies. Because virtually all states require a pharmacy that sells drugs in the state to
be licensed with the state, a state board of pharmacy traditionally may exercise regulatory
authority over pharmacies located within the state, as well as those that dispense drugs
across state lines to citizens within the state.24 Since each state board of pharmacy sets its
own policies with regard to both online and traditional pharmacies, state pharmacy laws
differ from state to state. While some state laws specify whether or not prescriptions
19 (...continued)
body is virtually unheard of, making it difficult, if not impossible, for state actions to have any
effect on foreign pharmacies.” National Association of Boards of Pharmacy, Position Paper on
the Importation of Foreign Prescription Drugs 6 (March 2003), [http://www.nabp.net].
20 21 U.S.C. §§ 353(b)(2), 355, 381(d)(1).
21 Id. at §§ 957, 960.
22 See, e.g., Importing Controlled Substances From Canada and Other Foreign Countries, 69 FR
38920 (June 29, 2004).
23 National Association of Boards of Pharmacy, Verified Internet Pharmacy Practice Sites
(VIPPS): Most Frequently Asked Questions (2001), [http://www.nabp.net].
24 Id. “These requirements allow state boards of pharmacy to order non-resident pharmacies to
stop shipping product into the state. Within the US, such orders can be enforced by the board of
pharmacy where the violation took place, or by mutual action by the board of pharmacy in the
state where the pharmacy is located.” National Association of Boards of Pharmacy, Position
Paper on the Importation of Foreign Prescription Drugs 6 (March 2003), [http://www.nabp.net].
Foreign shipments of prescription drugs may also violate state laws if the foreign pharmacy is
not licensed in the state, although states often face legal barriers when attempting to exercise
jurisdiction over foreign pharmacies. See supra note 19 and accompanying text.

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based on online questionnaires are valid, other state laws fail to address the issue, thus
rendering it difficult for some states to prosecute doctors who prescribe drugs without
performing an in-person evaluation. For this reason, some critics of the current system
have proposed establishing a federal definition of what constitutes a valid prescription.25
In addition, some organizations have begun to promote uniform national standards
for the industry. For example, the National Association of Boards of Pharmacy (NABP)
is an organization that helps state boards by developing uniform standards on pharmacy
practice. In response to the proliferation of online pharmacies, NABP established the
Verified Internet Pharmacy Practice Sites (VIPPS) program, a certification program that
“identifies to the public those online pharmacy practice sites that are appropriately
licensed, are legitimately operating via the Internet, and that have successfully completed
a rigorous criteria review and inspection.”26 According to NABP, the VIPPS program was
developed in order to improve the safety of online pharmacy practices and to “provide a
means for the public to distinguish between legitimate and illegitimate online pharmacy
practice sites.”27 Although NABP notes that legitimate online pharmacies outnumber
rogue sites and acknowledges that there are many advantages to ordering drugs online, the
Association specifically warns consumers against buying prescription drugs online
without obtaining an in-person examination and valid prescription from a doctor. Like
U.S. pharmacies, Canadian pharmacies may also be certified under the VIPPS program,
but only if they do not export drugs to the U.S.28 However, NABP has indicated that it
may extend its VIPPS certification program to Canadian pharmacies that sell to U.S.
consumers if Congress approves drug importation or “if HHS does not stop the state and
local governments that already are reimporting drugs.”29
Like pharmacy practice, the practice of medicine has historically been regulated at
the state level by state medical boards. According to the Federation of State Medical
Boards (FSMB) “[t]he primary responsibility and obligation of a state medical board is
to protect consumers of health care through proper licensing and regulation of
physicians.”30 Traditionally, states enact laws that regulate the practice of medicine, and
state medical boards implement and oversee state policies.31 If a doctor violates a state law
or regulation, state medical boards generally have the authority to fine or otherwise
discipline the doctor through modification, suspension, or revocation of the doctor’s
25 Inside Washington Publishers, FDA May Back Changing Law to Define Internet ‘Prescription’,
FDA WEEK, March 28, 2003. See also supra notes 15-16 and accompanying text.
26 National Association of Boards of Pharmacy, Verified Internet Pharmacy Practice Sites
(VIPPS): Most Frequently Asked Questions, [http://www.nabp.net].
27 Id.
28 Inside Washington Publishers, FDA Rebuffs Invitations to Inspect Canadian Pharmacies, FDA
WEEK, May 7, 2004. However, the Canadian International Pharmacy Association maintains a
certification program like VIPPS that allows CIPA-certified members to export drugs to the U.S.
29 Inside Washington Publishers, Canadian Internet Pharmacies Ask NABP to Certify Their
Operations, FDA WEEK, Sept. 17, 2004.
30 Federation of State Medical Boards, What is a State Medical Board?, [http://www.fsmb.org/
pdf/PUB_WhatIs_StateMedicalBoard_Brochure.pdf].
31 Id.

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license to practice medicine in that state. In reality, however, laws regarding medical
practice vary widely in strength and effectiveness from state to state. While some states
have strong laws that explicitly prohibit activities such as prescribing drugs without
conducting an in-person examination, other states have weak laws, lax enforcement, or
both.
Like NABP, FSMB has developed a specific policy with regard to online pharmacies
and doctors that prescribe drugs over the Internet. According to FSMB’s model guidelines
on the subject, electronic technology “should supplement and enhance, but not replace,
crucial interpersonal interactions that create the very basis of the physician-patient
relationship.”32 To that end, FSMB guidelines declare that doctors who use the Internet
as part of their medical practice should conduct a physical evaluation of the patient before
providing treatment. Although FSMB recognizes the benefits of online pharmacies, the
organization warns that “[t]reatment, including issuing a prescription, based solely on an
online questionnaire or consultation does not constitute an acceptable standard of care.”33
FSMB further urges that doctors who prescribe drugs on the Internet should be licensed
in all states in which their patients reside,34 a practice that would subject doctors to the
oversight of the medical boards in each state in which their patients lived.35 These
professional standards, however, are not legally enforceable in the absence of state laws
establishing such requirements.
Conclusion
The current legal framework for regulating online pharmacies and doctors is a
patchwork of federal and state laws regarding controlled substances, prescription drugs,
pharmacies, and the practice of medicine. Although many doctors and pharmacies who
use the Internet prescribe and dispense drugs in a safe and legal fashion, others have
exploited gaps in the current system to prescribe and dispense potentially dangerous
quantities of highly addictive prescription drugs. To combat such abuses, legislators and
interest groups have proposed an array of solutions, including establishing a federal
definition of what constitutes a valid prescription, requiring doctors to conduct in-person
examinations, mandating that online pharmacies disclose identifying information about
themselves and their employees, establishing state prescription drug monitoring programs
to track data regarding the prescription and use of controlled substances, giving state
prosecutors the authority to seek nationwide injunctions against rogue sites, educating
consumers about the potential dangers of buying drugs online, establishing certification
programs to identify legitimate online pharmacies, and regulating search engines and
shipping companies that enable rogue sites to do business.
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32 Id.
33 Federation of State Medical Boards, Model Guidelines for the Appropriate Use of the Internet
in Medical Practice (2002), at 5 [http://www.fsmb.org/pdf/2002_grpol_Use_of_Internet.pdf].
34 Id. at 8.
35 Id. at 9. Other professional medical associations have also established policies regarding the
safe practice of online medicine. See, e.g., American Medical Association, Guidance for
Physicians on Internet Prescribing (H-120.949) (2003), [http://www.ama-assn.org/apps/pf_new/
pf_online?f_n=browse&doc=policyfiles/HnE/H-120.949.HTM].

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