How to Verify Internet Pharmacies with NABP’s Melissa Madigan
Hillary B: 00:18 So today we have a special guest on to talk to your pharmacist podcast. Our Guest Melissa Madigan is a PharmD, JD and is the policy and communications director for the National Association of Boards of pharmacy or NABP. Melissa started with NABP in 1995 is professional affairs manager after graduating from Depaul University College of law. Previously she practiced pharmacy in a variety of settings including, yeah, the University of Illinois Hospital, Loyola University hospitals cancer center and Dominic’s stores unlisted. Graduated from the University of Illinois at Chicago College of Pharmacy. And she’s recently spent five Years as Pharmacy Law Instructor at Midwestern University College of pharmacy. She is also a past president of the American Society for Pharmacy Law. Melissa, welcome to you to talk to your pharmacist podcast.
Melissa Madigan: 01:47 Oh, thank you for having me.
Hillary B: 01:48 Well, thank you for joining us. And now that our listeners have heard a little bit about your background, maybe you can fill in any gaps from that intro or share a little bit about your personal life.
Hillary B: 02:01 Um, I don’t think there’s really anything else to mention about my work with NABP, but I guess personally I have two daughters and I have a husband who is a doctor and my daughter just got admitted to medical school, so that’s exciting. And I have another daughter who’s at Colorado State University. Oh. And I have four dogs and two cats.
Hillary B: 02:26 You stay busy and have a full family of fur babies and other babies that are all seem to be in health care, which is fine. And, yeah, and you’re just, so our listeners now, you’re located just outside of Chicago, uh, so they can kind of get a feel for where that is. So Austin’s,
Melissa Madigan: 02:46 we’re right by O’hare airport, so it’s an easy drive if anyone is commuting in.
Hillary B: 02:51 Yeah. Awesome. So, Melissa, we’ll go ahead and get started with just refresh for everyone. What is NABP?
Melissa Madigan: 03:00 Well I’m sure that most of your audience knows that any VP is the producer of the NAM plex, the licensure exam for pharmacists in all 50 states as well as the MPJ e, which is used I believe right now in 48 states. Um, I guess as background, our members are the boards of pharmacy, uh, in all 50 states as well as four jurisdictions, 10 Canadian provinces, The Bahamas and Australia. So we are an international organization. The basis for any BP is to support its members in their efforts to protect the public health. So that’s really our mission is to do that. And all of our programs and all of our services are intended to be that type of support for the boards of pharmacy. So as I mentioned, you know we’ve got the licensure exams for pharmacists. We also have a foreign pharmacist exam, but what we also have is a series of accreditation programs for pharmacies and wholesalers. One of our first accreditation programs was called Vips. It’s was the verified Internet pharmacy practice sites program. And we launched that in 1999 after we heard about really internet pharmacies being out there that weren’t licensed. It was really the wild wild west and it was very confusing for patients because they didn’t know that maybe it was important to have a pharmacy that’s licensed not only in your state, but in your country. People were ordering drugs from all over the world that they were getting shipped in and it was a very dangerous situation for patients. So that came, came about and the late nineties to deal with that.
Hillary B: 05:25 Yeah. And it’s still a very relevant topic today. Yes. Say Melissa, we hear about drug prices and that certainly on the news a lot and people are looking at uh, how do they get their medicines and some people are still turning to the Internet. Could you tell us a little bit more about what are some of the dangers for patients related to purchasing prescription medications online?
Melissa Madigan: 05:51 Yes, definitely. So at any one time, there’s probably about 30,000 websites selling prescription drugs. We have gotten information that says there are probably tens of millions of people going online in the u s to buy drugs. Completely understandable. The prices are high, they’re looking for lower prices, they’re looking for convenience, they’re looking for a quick delivery. Unfortunately though it is still in a way the wild, wild west. In fact, the online sale of unregulated drugs is now considered a global public health threat and is being looked at all over the world in terms of the safety for patients. One of the things that we’ve done is that we have staff here in our office that actually go online, look at the websites and determine whether or not they’re operating illegally, dangerously, that kind of thing. We have looked at almost 12,000 websites and what we have found is that approximately 95% of them are operating illegally, which means there’s only about 5% out there that are safe for patients to be using. So the odds of somebody stumbling across a legally operating website other than maybe when they would know, like one of the big chains, the odds are pretty high. So what we did is that we created a program similar to VIPPs program, but it’s more tailored towards patients. It uses a domain name as a way to identify that the website is legal and safely operating in their jurisdiction. And that is our .Pharmacy programs. So what a patient would do is they would go online, maybe Google or bing or Yahoo site of pharmacy, what they should be looking for as a pharmacy, whose domain name ends in the word pharmacy. And the reason we did that is that a domain name is impossible to fake our VIPs program, which is a great program, very thorough, uses a seal of approval to show that it is a legitimate pharmacy. Unfortunately, we have found many illegal operators have copied and pasted our seal of approval onto their website, which really negates everything that we’ve done. So now VIPs, pharmacies by our standards are required to use a.pharmacy domain. And again, that .pharmacy domain makes it easy for patients to find a legitimately operating pharmacy.
Hillary B: 08:32 Wow. So I’ve been familiar with the VIPPS program and yeah, I’m just thinking about all of the online TV ads and, and just other where places that are advertising for people, consumers, patients to get medications online. They’re talking about how easy it is. You can get a doctor to write for get it delivered to your door like Roman or even birth control, etcetera, but you’re saying that unless these pharmacies have the.pharmacy domain, then consumers should just be aware that they are not necessarily an accredited pharmacy through an ABP that’s guaranteed is safe and secure.
Melissa Madigan: 09:19 Yeah, so that would be an easy way for them to identify a safe legally operating pharmacy. Even it doesn’t have a.pharmacy. It still might be perfectly legal. What we look for when we prove a dot from domain is we make sure that the pharmacy is only filling prescriptions based on a legitimately issued prescription that they’re licensed in all the jurisdictions where they are shipping to that they have some privacy information on the website that shows patients that their privacy is protected. Those kinds of things. There’s 10 standards of the pharmacies have to demonstrate in order to get our domain name. If there is a pharmacy that they find that is not a debt pharmacy approved websites, it could still be illegal. They just would need to check it out with the state board of pharmacy where they’re located or if they’re outside the u s the board of pharmacy of their nation.
Hillary B: 10:13 Got It. Okay. Very interesting. So how has NABP, kind of alerting patients about this new program that you guys have with the pharmacy or how should pharmacist be able to help tell patients about this?
Melissa Madigan: 10:30 Well, we put forth a three year effort, if not longer, to educate patients about this problem in about the debt pharmacy domain. And so we developed three different public service announcements that have been playing on donated airtime. We are a nonprofit, so we’ve been very fortunate that we’ve gotten quite a bit of radio and television time. I’ve even seen a commercial while I was getting my oil changed a dealership. So it does explain to patients the problem and to look for a, from RMC domain and to go to our website, which is safe at pharmacy. And there they can find a list of the approved pharmacies that we have. I should mention that the list of approved pharmacies is also used by several important stakeholders in their efforts to protect patients as well. Google, bing and Yahoo all require a. Dot. Pharmacy domain for a pharmacy that or pharmacy related company that is advertising on their platform. Also visa requires pharmacy merchants to have a .pharmacy approval if they are conducting card, not present transactions, which would be a transaction over the internet. We also have snapchat and Pinterest that include our .Pharmacy in their policies, so they do recognize our program. Mastercard also recognizes our program as well, so we’ve been very fortunate to have some of these really big players recognize that our program is very important and that patients really need some safety outside of just buyer beware. Another project that we’re working on with being is a popup project, so in addition to our list of approved pharmacies, we also have a really, really long list and I mentioned it earlier of rogue pharmacies. The list of about 12,000 domain names that are dangerous for patients and one thing has done is very admirable. They have taken that list and within their organic search results. So search results that are not for the advertisements. They have incorporated a warning for any of the organic search results that appear on our list. So say a patient goes into bang and types in buy online prescription drugs and a pharmacy pops up in their, again, their organic search results, not the advertisements and they hover over their about to click on it and if it’s one of the bad guys up warning will pop up so that the patient will know that we have looked at it and we consider it to be problematic and can still click through to it if they would like. But at least that warning is there. And from our conversations with thing, a lot of patients do not go further with that. So one of the things that we’re doing is we’re really working harder to beef up that list. So although it has 12,000 pharmacies, bad guys on it, we really want to add to that and make sure that as many of the bad domain names are covered.
Hillary B: 13:41 Awesome. So still talking about patient safety and other important topic is around the importation of drugs. I saw somewhere the US government estimates that nearly 1 million people in California alone across to Mexico for health care including buying prescription drugs and then I saw it somewhere else where even the state of Utah included a voluntary pharmacy tourism program and for certain employees within their public employee health plan who use a number of their 13 costly prescription meds. The insurer is paying to fly the patient and a companion to San Diego and then drive them to a hospital in Tijuana to pick up a 90 day supply and it was part of their right to shop bill champion by their health care economist, one of the Utah representatives. They’re saying there’s not enough data to know how much the savings are, so that’s great. I think that we’re looking a lot about how do we reel in those costs, but safety is also really important concern. Yeah. First and foremost, we want to make sure that we’re doing what’s safe and right for the patient. Tell us a little bit more about what an ABP and other organizations are working on first. Like what are some concerns about importation and then what are some of the things that an ABP is working on about importation of non FDA drugs.
Melissa Madigan: 15:14 So I have heard about those programs. I would be interested once they get up and running to see how many patients actually take them up on that. And if there are any problems associated with it, at least the patients are going there and they know where they’re going and they’re going into a building and buying whatever it is they want to buy and then coming back so they know what they’re getting because they’re going to the actual physical location, which may or may not be dangerous. It’s hard to tell. But in order to counter this excess problem, I mean, normally NABP doesn’t get involved with pricing. Right? Um, in this instance, it affects patient safety and it affects access to life saving medications, which is very important to us. Right? So, that’s one of, that’s the reason we’ve become involved in it. So what we’ve seen is that state and federal legislators are proposing legislation to allow importation of prescription medications either at the retail level or at the wholesale level.
Melissa Madigan: 16:17 These proposals really don’t have so much detail that we can tell really how they would do that. At least for the retail importation use a website or it doesn’t sound like the proposals are to drive someone to Canada and then get them back. It seems as if many, if not all of these proposals are long distance, which is a concern for us. What we have heard from the Congressional Budget Office is that the savings with regards to at least Canadian imports will be negligible. The implementation of the program along with the fact that not all Canadian medications are less expensive. My understanding is that many generic products are more expensive than they are here, so as a result, our own federal government says that the savings may not be worth the effort or the risk. The other really, really important thing is that Canada doesn’t have enough drugs to supply the u s so they are actually considering proposals to prohibit exporting their health. Canada approved drugs to the u s based on these proposals. Again, that pretty much counters all the efforts that states and federal regulators are attempting to accomplish. What we have done, and we’ve done this in partnership with the Alliance for safe online pharmacies, which is a not for profit organization that is located in the DC area is we have visited congressional offices to educate the staff of legislators about these problems. They don’t realize that many of these websites, although they say they’re from Canada, they look Canadian. They have the big maple leaf that they’re really not located in Canada and they probably don’t have health Canada approved drugs. We’ve also found that even if there is a pharmacy that is located in Canada and they are exporting prescription drugs here, they’re not necessarily using health Canada imported approved drugs, but they are outsourcing the actual dispensing to pharmacies that are located in other countries where there is a high level of counterfeit drugs. We have come across counterfeit drugs or heard reports of counterfeit drugs that have paint in them, rat poison, chalk, drywall material, all sorts of things that we would never want in our own drugs. So it’s just very risky for to expect patients to purchase these drugs and possibly get not only counterfeit drugs but maybe super potent drugs or drugs with no active ingredients at all, which is of course very dangerous. So we have determined that this is a high priority for us and we’ve spent quite a bit of time and effort on it.
Hillary B: 19:10 Yeah, I’m glad that you all are able to provide some education and there’s definitely a lot of things to consider as we’re looking at all of these different solutions right now. Another thing that that I thought was kind of interesting too is even in regards to the latest recalls over Valsartan, that was due to at carcinogen, that was found as part of the raw materials for the Valsartan because of drugs that were actually manufactured overseas. But one of the, as you were saying countermeasures is that the FDA is increasing those inspections of overseas plants to make sure that they’re at the same frequency is domestic manufacturing plant. So yeah, just a lot of importance on making sure that there’s a good balance of chain regulation and helping to make sure that patients still get access and safety. So threading that needle. Yes.
Melissa Madigan: 20:10 And if I could just jump in real quick, what we would love is if pharmacists come across patients whose medications aren’t working or who have questions about online pharmacies, if they could try to find out where the patients are getting their meds, if they’re not getting it from the pharmacy where they’re at, it would be really helpful I think for pharmacists to start educating patients about that. The alliance were safe online pharmacies had a pilot project, I believe it was in Indiana, where they were educating physicians about this issue and making sure that physicians were where, because oftentimes the physician will say, Oh, you can’t afford the medication. You might want to try this Canadian pharmacy. And it turns out that it’s one of the rogue pharmacies that we have identified as dangerous. We really need to step it up when it comes to letting other professionals know because they are also in contact with patients and might know more than we do. So
Hillary B: 21:03 yeah, no, that is such a great point, Melissa, is that we as pharmacists need to be aware of these issues and to be aware of the resources. So I’m thankful that you were able to share about what an ABP is doing and some things that pharmacists can look out for in the community and just some of the concerns so that they’ve got some talking points and have some good references. So I’m very appreciative, uh, to be able to share about this topic. So Melissa is kind of our final question. I ask all of our guests, what is some advice that you would tell your younger self or for other pharmacists who are just getting started in their career?
Melissa Madigan: 21:45 Oh my gosh. I would say to try to identify what it is you really love to do. What I really loved when I graduated from Pharmacy School. I remember really going back in my head about pharmacy school and really, really enjoying my law class. After working for a couple of years, I thought, well maybe I will go on and do something in addition to be a pharmacist and looked into law school and it was a really good fit for me. Not everyone would want to go to law school or go onto another degree program, but there are certainly practice sites and residencies and and just different things that pharmacists can volunteer to do that really, really make you feel like you’re happy every day. You want to just not have to feel like you’re going to work, quote unquote everyday. You want to be happy. I’ve been so fortunate to be able to do that, so that’s what I would recommend. Just find what makes you so happy so you can get up every day and look forward to your day.
Hillary B: 22:47 That is such great advice, Melissa. And Yeah, you don’t see a lot of pharmacists who are also attorneys that you’ve, you use that pharmacy school and background and I’m thankful to have people who go on and get other degrees so that they can provide expertise in important topics of pharmacy law are people that go on and get their MBAs or have other degree programs or just other skillsets because there are so many different career paths within pharmacy. Just a lot of opportunity to get up and do what you love every day.
Melissa Madigan: 23:24 that’s right. That’s right.
Hillary B: 23:26 Yeah. Well thank you Melissa, for being a guest on the talk to your pharmacist podcast. It was great to hear a little bit more about what NABP is doing and for all the listeners out there, it’s also very important, not only are you taking the MPJE law tests to get licensed, but they also maintain CE. So you’ve got your NABP number. Yes, yes. So every, every state that you’re taking, you’ve got to use that in NABP number and they’ve got the CPE monitor that you can go on and check to make sure you’ve gotten all your CEs for every state that you’re licensed in it because it is very important to make sure because, all of the boards of pharmacy do check on that. So they have access to the portal and can do audits and things. And so one of my favorite resources to keep track, because I am licensed in multiple states it’s actually the pharmacist’s letter has it all very well organized with what the requirements are for each state. I’m not sure if there’s any other resources out there that others have found that pharmacist’s letter has worked well for me for knowing what is needed for each state.
Melissa Madigan: 24:41 I should mention that CPE monitors now available as an app or go to either our website or what did the APP stores and make should be appropriate.
Hillary B: 24:51 Wonderful. Well thank you so much Melissa. It was pleasure to have you as a guest
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