The vast size and ever-changing content of the Internet precludes continuous monitoring of drug-related websites. In Japan, multiple psychoactive substances, known as ‘dap’ or ‘ibo drugs’ are easily procurable online 71,105. Specific and actionable information on how to obtain a vast range of hallucinogens has been available online for over a decade 82. In 2005-6,‘salvia divinorum’ employed as a search term yielded websites offering sale, distribution, or links to sites that did so 58% of the time 103.

The burgeoning demand for ‘legal highs’ resulted in an enormous increase in psychoactive substance online transactions 74. By removing the requirement for personal interactions with drug dealers, the Internet emerged and succeeded as an alternative avenue for NPS acquisition 1,2,51. The DEA currently recognises Internet substance purchases for non-medical indications as an entrenched drug consumer practice 97. The medical office participating in CAP no longer purchases the drugs and seeks payment from Medicare and beneficiaries.

The CAP program takes the physician out of the purchase and acquisition chain for these Part B drugs. Under the old AWP system, payment for prescription drugs under Medicare Part B was equal to the lower of billed charges or 95% of the AWP as reported by drug manufacturers to clearinghouses such as Red Book or Medspan. The pharmacy collects and keeps the customer’s insurance co-payment, while the PBM bills its client—usually, an employer or health plan—for the remaining charge of the drug.

For example, when a person covered by a PBM fills a prescription at a retail pharmacy, the PBM has already negotiated the price at which it will purchase the drug from the pharmacy. PBMs then distribute the prescriptions with their own network of mail-order pharmacies or through retail pharmacies. PBMs play an ever-increasing major role in the distribution of prescription medication in the United States, especially with the establishment of the Medicare Part D program.

Situations where drugs are outdated, contaminated, too potent or not potent enough, improperly manufactured and handled or counterfeit are mentioned regularly in the news (FDA, 2005). Nor are the drugs they offer always safe or genuine. Many certified e-pharmacies are currently available on the Internet but an important number of illegal drug sellers are also operating on the web.

Internet has revolutionized the sale of medicines so that consumers can self-select and buy medicines, often delivered across national and state boundaries, without face-to-face interaction (Bessel et al., 2003). Finally, the growing development of alternative medicines leads to an increase in the trade of herbal products whose use and production remain largely unregulated. Moreover, many consumers believe that online pharmacies are more convenient than traditional pharmacies and offer cost savings.

When prices of medicines are high and price differentials between identical products exist, there is a greater incentive for the consumer to seek medicines outside the normal supply system.