David versus Goliath Revisited:
The Great Cross Border Internet Pharmacy Debacle

By Louise Binder, Chair, CTAC
Spring 2007

Well, it is déjà vu all over again. The American government has returned to its favourite neo-colonial strategy to solve its high domestic drug pricing problems: purchasing Canadian drug supplies for a steal, so to speak.

You may recall that this was a serious problem just before the last U.S. election. Internet pharmacies had set up shop in Canada and were filling and shipping to U.S. patients brand name prescription drugs designated for Canadian patients. They were doing this using prescriptions faxed by U.S. doctors to Canadian doctors for co-signing.

No one involved in these ongoing transactions has clean hands. The U.S. doctors know that the pharmacists filling the prescriptions are not seeing the patients. The Canadian doctors know nothing about the patients nor their conditions other than what is on the prescriptions. The internet pharmacies know that they are not filling a prescription properly signed by the patient’s doctor, and that the doctor and the pharmacist should see the patient to provide advice and counselling before handing the drug over.

They also know that manufacturers do not give Canadians unlimited supplies of drugs, but rather allocate an amount based on an analysis of reasonable Canadian use. Drugs sent across the border mean fewer available for Canadian patients.

Why do American patients want to take potential risks and import Canadian drugs? Because their drug prices are too high. Why are they so high? Because the U.S. government does not regulate brand name drug pricing and lets the free market system prevail.

In Canada, we created the Patented Medicine Prices Review Board (PMPRB) to monitor and regulate drug prices. This is a trade off for the patent protection (presently 20 years) afforded brand name drug companies to recoup the cost of research and development of new drugs. Removing this system of regulation would drive Canadian prices up, putting even more drugs out of the reach of Canadians who badly need them.

Americans like the result of our drug regulation: lower prices for brand name drugs. In fact, it is the only part of the Canadian system many Americans seem to like – as long as it stays in Canada. They want to cherry pick the benefits of this part of our system without recognizing that it is only one part of the fabric of our healthcare system. To start pulling out this thread causes the entire fabric to unravel. Or maybe that is too charitable, maybe they understand perfectly well, but in true neo-colonial fashion, they just do not care. And many American politicians go along with this band-aid solution to avoid facing the real issue – their unregulated, expensive drug market.

The controversy over cross border internet pharmacies seemed to take a back seat for awhile as the Americans had bigger issues to resolve and many Canadian internet pharmacy companies moved offshore.

Now it is back, with a vengeance. It started in September with a deal struck in Congress and signed by the President to reopen the so-called “foot traffic” personal importation of prescription drugs by American patients. This is practical, however, only for people living in border states.

Then came a series of events that effectively reopened all channels of prescription drug importation to all U.S. patients. First, in October, the Department of Homeland Security announced it would cease confiscation by customs agents of prescription drugs mailed from Canada. The Food and Drug Administration (FDA) was given back this enforcement task, and the FDA admits it lacks the capacity to effectively carry it out. Thus, via internet and mail order sales, drugs from Canada are available to all Americans.

On January 10, 2007, these changes were consolidated into a new legislative proposal in the new Democrat-controlled Congress. A bipartisan Bill, the Pharmaceutical Market Access and Drug Safety Act of 2007, has been introduced in both the Senate and the House of Representatives. This Bill legalizes the importation of prescription drugs from Canada by American patients, pharmacists and drug wholesalers. That means the legalization of not only personal importation by individual patients, but also the bulk importation by health maintenance organizations, state drug plans and other entities such as high volume retail chains. The Bill is predicted to pass because congressional leaders claim to have enough support in Congress to override a presidential veto.

It has serious and dangerous ramifications for both U.S. and Canadian patients. We have not warned American patients of the problems of counterfeit drugs, of improper prescribing by doctors and pharmacists who have never seen the patients, of no counselling on the use of the drugs nor contraindications. They tell us to mind our own business. To be charitable, I understand that when you either take these risks or forego lifesaving and life-enhancing drugs, you take the risks. Even when we explain that we are allocated a supply of drugs for Canada from drug manufacturers that cannot meet more than one month’s supply for the U.S. market, they are unmoved because of their dire need.

What are the dangers for Canadian patients? They are grave. Manufacturers will not supply unlimited amounts of drugs to Canada. If it is clear that drugs allocated for the Canadian market are being diverted to the higher-priced U.S. market, the tap will be shut off. We could very quickly find drug shortages for Canadians across the country. For some, it is quite simply a question of life and death. For others, it will mean a profoundly reduced quality of life. This is simply intolerable.

In the longer run, there could be a strong pressure on Canada to deregulate drug prices and to create a North American drug price, namely the high U.S. price. American governments and the pharmaceutical industry have long hoped for this result. It is simply unacceptable.

Cross border trade in Canadian prescription drugs to the U.S. has the potential to be have a devastating effect on access to badly needed medications for Canadians. This would most hurt those of us most in need, including people with HIV and coinfections.

What can you do about this? Well, we cannot stop the Americans from doing whatever it is they will do to avoid taking responsibility for this domestic problem. We can, however, demand that our politicians at both the federal and provincial levels use their legislative powers to ban internet pharmacies. Write to them to demand immediate action, so they are not scrambling to react once the horses are out of the barn.

We can also demand that provincial medical associations severely punish doctors who sign prescriptions for patients that are not their own.

And we can demand that pharmaceutical companies commit to ensure that no Canadian patient is forced to go without needed medication because of this practice. After all, it is not our fault that the U.S. is treating Canada as its personal medicine cabinet.

Act now. Your health is at stake.