"It’s a slight concern-a little bit less now that Viagra is generic-but, typically, a lot of patients, when they’re trying to save money, order stuff online and can’t necessarily be sure where it’s coming from or whether it’s real.

I warn my patients to get their medications at a pharmacy here in the U.S., but there’s not a whole lot I can do once they have the prescription in hand.

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A lot of this is avoided with EHR because we send a prescription directly to the pharmacy. But sometimes I have a patient who requests the paper script, and I can’t do anything once I give them the prescription except warn them.

Nobody actually has ever told me they’ve gotten something bad, but every once in a while patients ask if I can tell whether what they have is real or not, and I tell them, ‘No, I’m not a chemist; there’s no way I can tell.’ ”

Sophia Ford-Glanton, MD / St. Louis

Next: "Patients certainly can end up with counterfeit medications because of radio/TV advertising that they are available outside the country, so I am concerned.""Patients certainly can end up with counterfeit medications because of radio/TV advertising that they are available outside the country, so I am concerned. Most of those are going to be erectile dysfunction medications, but the likelihood of anybody being hurt by those medications is pretty slim.

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I have some patients who try medicines through health stores to boost their testosterone, and most don’t even know what their testosterone levels are. They just start taking them, not knowing what’s in them. I guess they could be dangerous because of the effects they can have on the liver. With prescription ED meds, counterfeits might not be effective, but patients won’t be hurt by them.

I put most of my people on the generic ED drugs; they’re getting very inexpensive. They vary from $2-$4 a pill for the generic sildenafil instead of $40-$75 a pill for the brand names. That should solve most of the problems of people ordering things online that might not be real.

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I’m not concerned about counterfeit pain medication because I don’t prescribe it unless someone has acute stones; then they get about 3 days’ worth. I’m using more Ultram than I ever did before.”

James Hardin, MD / Greenwood, MS

Next: "It’s probably much more common than we think."

"It’s probably much more common than we think. I have patients who tell me they bought something on the Internet that didn’t work. Certainly there are safety concerns, but it’s kind of an equal concern about the safety of the medication and whether it actually works.

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Patients tell me they bought “Canadian pharmacy Viagra” and it didn’t work. A study a couple years ago looked to see if there was any actual medication in those pills, and something like only one out of 20 had Viagra in it. I’d be more concerned if it were dangerous, but that really doesn’t seem to occur.

Usually I tell my patients the stuff is not FDA regulated, the safety is not understood, and that the study showed how infrequently the medication even contains what they think they’re getting.

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That dissuades most men, especially in the sexual medication world now that there is generic Viagra and Cialis. Now, I can offer them a less expensive actual medication as opposed to counterfeit baloney. Now that the generic has come in, I hope we’ll see less counterfeit.”

Charles Welliver, MD / Albany, NY

Next: "A study showed that up to 50% of mail-order Viagra did not come in as advertised. That’s a concern.""A study showed that up to 50% of mail-order Viagra did not come in as advertised. That’s a concern.

Now that sildenafil has gone generic, it’s less of a problem, but still people tell me they’ll import their medicines from Canada and other countries, and I’m not even sure that’s legal.

I’m as concerned about non-FDA-approved supplements containing ingredients that can be dangerous.

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Saw palmetto is used for BPH around the world; the AUA helped sponsor studies that show it doesn’t work any better than a placebo. But some companies put finasteride in, which shrinks the prostate. So people take a drug that works and don’t realize it’s actually something else which can potentially be dangerous. If you take finasteride and don’t know it, and your PSA is low, you might hide an elevated PSA. We urge our patients to use FDA-approved drugs and pharmacies that are regulated.”

Charles Keoleian, MD / Manistee, MI