Health Information on the Internet—A Double-Edged Sword?

Abstract

See Related Article p. 458 See Related Article p. 458 A study by Schepis and colleagues [[1]Schepis T.S. Marlowe D.B. Forman R.F. The availability and portrayal of stimulants over the Internet.J Adolesc Health. 2008; 42: 458-465Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar] in this issue of the Journal describes the online availability and portrayal of amphetamine-class prescription stimulants. They found that a range of prescription-only stimulants was available to buy without any involvement from a health provider. The Internet has previously been described as a “double-edged sword” for adolescents [[2]Sun P. Unger J.B. Palmer P.H. et al.Internet accessibility and usage among urban adolescents in Southern California: implications for Web-based health research.Cyberpsychol Behav. 2005; 8: 441-453Crossref PubMed Scopus (75) Google Scholar], with the potential to both help and harm them. Adolescents need ready access to health information: how does this fit? This study shows that there is potential for adolescents to acquire powerful stimulants in much the same way that they might order a new DVD or that “must-have” accessory. Schepis and colleagues provide one part of the context, and warn us of the potential public health threat, but what do we know about how adolescents are likely to behave? Interestingly, McCabe et al [[3]McCabe S.E. Teter C.J. Boyd C.J. Medical use, illicit use and diversion of prescription stimulant medication.J Psychoactive Drugs. 2006; 38: 43-56Crossref PubMed Scopus (226) Google Scholar] commented, with surprise, in their study of prescription stimulant misuse by adolescents that the Internet was never mentioned as a source of these drugs [[3]McCabe S.E. Teter C.J. Boyd C.J. Medical use, illicit use and diversion of prescription stimulant medication.J Psychoactive Drugs. 2006; 38: 43-56Crossref PubMed Scopus (226) Google Scholar]: primary sources were friends and peers. Schepis et al cite adolescent endorsement of online sources in the 2005 National Survey on Drug Use and Health [[4]Substance Abuse and Mental Health Services AdministrationResults from the 2005 National Survey on Drug Use and Health: National Findings. Office of Applied Studies, NSDUH Series H-30, DHHS Publication No. SMA 06-4194, Rockville, MD2006Google Scholar]. These data imply that adolescents may actually use the internet as a source for purchasing prescription drugs. Are adolescents going to be able to do this? There are challenges for adolescents when using the Internet for health information. Many of these might relate to underlying health literacy skills [[5]Gray N.J. Klein J.D. Noyce P.R. et al.The Internet: a window on adolescent health literacy.J Adolesc Health. 2005; 37: 243.e1-243.e7Scopus (123) Google Scholar]. We should accept that the starting point for most Web searches is a search engine, and Google is the usual choice [[6]Nettleton S. Burrows R. O'Malley L. The mundane realities of the everyday lay use of the internet for health, and their consequences for media convergence.Sociol Health Illn. 2005; 27: 972-992Crossref PubMed Scopus (165) Google Scholar]. First, then, they need to spell a useful term that will generate a meaningful set of results. Reviewing the list of search terms used by Schepis et al, from “Adderall” to “phendimetrazine,” the complexity is challenging for adolescents who might only have heard these names in passing from others, or—and this is arguably more likely—the street names (not used in the present study). Regular Google users will recall that if a term could have an alternate spelling, the results page starts with “Did you mean …?” Inspired by the Schepis et al article, I conducted my own ad hoc experiment. I misspelt Adderall as “aderal” and phendimetrazine as “fendimetzeen.” Google suggested the correct term in both cases. The first result for the “aderal” attempt was an article authored by a pediatrician, aimed at parents, who helpfully listed all the common misspellings [[7]Iannelli V. Aderol, Aderall or Aderal for ADHD.http://pediatrics.about.com/cs/adhd/a/msp_adderall.htmGoogle Scholar]. This demonstrates the two sides to this dilemma, because such spelling error prompts are invaluable for regular health queries. One of the recommendations of Schepis and colleagues was to monitor adolescent Internet activity, including software blocking certain searches. This issue highlights yet another double-edged challenge. Many Internet terminals in public places, such as schools and libraries, use software content filters, and this could limit access to information about terms like “penis,” an example of a word that we know adolescents use frequently in their own e-mail health questions [[8]Gray N.J. Harvey K. McPherson A. Macfarlane A. Help! Adolescent health language in email messages.J Adolesc Health. 2008; 42: S5-S6Abstract Full Text Full Text PDF Google Scholar]. The “digital divide” is perpetuated for health queries if adolescents without home access are limited in the search terms that they can use in public facilities. Using nontechnical strategies—being interested in adolescents' Internet experiences, and discussing searches that went wrong—could improve their skills in avoiding exposure to unwanted material in the long term, and parents and providers can play a vital role. Schepis et al felt that sites aimed at adolescents were best characterized as “antimisuse.” On the face of it, this sounds admirable. Reflecting, however, on what we know about the effect of the sophisticated marketing surrounding antitobacco messages for children, would this “Don't do it, kids!” exhortation simply attract them to adult-focused sites? Another recommendation in this article was for parents to keep and monitor their adolescent's stimulant medications. Parents and adolescents must work together to ensure that they get the best from their medications. It is vital, however, that transition occurs during adolescence to promote independent and responsible medication use. Quarantining these medications and limiting autonomy should be avoided, but the risks should be discussed in the context of a trusting relationship between parent, provider, and adolescent [[9]Hack S. Chow B. Pediatric psychotropic medication compliance: a literature review and research-based suggestions for improving treatment compliance.J Child Adolesc Psychopharmacol. 2001; 11: 59-67Crossref PubMed Scopus (101) Google Scholar]. McCabe et al [[3]McCabe S.E. Teter C.J. Boyd C.J. Medical use, illicit use and diversion of prescription stimulant medication.J Psychoactive Drugs. 2006; 38: 43-56Crossref PubMed Scopus (226) Google Scholar] found in their survey that 54% of adolescents prescribed such medications had been approached to sell, give, or trade their drugs: these young people are at risk of unwanted attention, and should be supported by their family, not policed. The obvious follow-up research to this article would be to talk to adolescents about the availability and portrayal of these drugs on the Internet. Critical health literacy is very relevant here. Adolescents can be overwhelmed by the amount of information available online, and they express—with varying sophistication—levels of mistrust of different online product sources [[5]Gray N.J. Klein J.D. Noyce P.R. et al.The Internet: a window on adolescent health literacy.J Adolesc Health. 2005; 37: 243.e1-243.e7Scopus (123) Google Scholar]. Adolescents in the United Kingdom revealed a general reluctance to buy even legitimate medications online [[10]Gray N.J. Klein J.D. Cantrill J.A. Noyce P.R. Buying medicines on the internet: young consumers' perceptions.J Am Pharm Assoc. 2002; 42: 313Google Scholar]. Their concerns divided into two categories: receiving medications that were harmless but ineffective, or receiving adulterated medications that might do harm. They felt that buying from a trusted retailer (such as a pharmacy also known “offline”) might reduce, but not eliminate, these risks. If a minority of adolescents is going to use this supply route, harm reduction measures are needed. Support for adolescents to critically appraise sites will lessen the risk of tragic consequences. Schepis and his colleagues have provided a thought-provoking article for those of us who support the premise that the Internet helps to address adolescents' unmet health information needs. As barriers to care and information persist for young people, we must work with adolescents so that they understand the positive power and danger of the medium [[11]Cohall A. Rickert V. E-health Adolescent Medicine: State of the Art Reviews, Vol. 18, no 2. AAP, Chicago, IL2007Google Scholar]. We have to accept that there will always be some threat to our young people's welfare from any new technology: we have to develop trusting relationships with them to increase their self-efficacy. In this way, we will help them to develop strategies for maximizing the benefit and minimizing the harm therein. The Availability and Portrayal of Stimulants Over the InternetJournal of Adolescent HealthVol. 42Issue 5PreviewTo quantify the online availability and portrayal of amphetamine-class prescription stimulants with a focus on those medications commonly prescribed to and abused by adolescents. Full-Text PDF