NOEL KING, HOST:
It's become pretty common to order drugs through the mail, and Amazon has jumped into the game, so that market could get even bigger. But there are still some big questions about safety. Alex Smith is with member station KCUR.
ALEX SMITH, BYLINE: The weather in Park Hills in eastern Missouri can be all over the map, according to resident Loretta Boesing.
LORETTA BOESING: We experience temperatures like they would feel in Arizona. You know, sometimes we experience the temperatures like they feel up north.
SMITH: Boesing thinks those extreme temperatures played a part in a health scare involving her son Wesley. In 2012, when Wesley was 2, he got so sick from the flu that he needed a liver transplant. The surgery went well, but just a few months later, lab tests showed Wesley's body appeared to be rejecting the organ. Boesing felt devastated and guilty.
BOESING: I feel the extra duty of not just protecting his life, but the life that lives on inside him.
SMITH: In the end, Wesley rallied and kept his new liver. But Loretta kept wondering what might have gone wrong. Then she remembered that when his transplant medications were last delivered, they had been left outside by the garage, where they sat for hours. Temperatures that day were in the hundreds, far higher than the safe range listed on the drug's guidelines. At the time, she hadn't worried about it.
BOESING: Even though I see plainly on the bottle, you know, that it says store at room temperature, I still thought, ah, someone's making sure it was safe.
SMITH: But after Wesley's setback, Boesing swore off mail order altogether. And this year, she started a Facebook group for patients who are worried about mail-order drugs. She thinks all insurers should give their customers easy access to retail pharmacies unless mail-order companies can prove that drugs are getting to patients at the right temperatures. There are three big mail-order companies - Express Scripts, CVS Caremark and OptumRx. All three insist they've got the shipping down to a science.
At a warehouse in Kansas City, OptumRx workers pack specialty medications with ice packs and insulated containers. Lead pharmacist Alysia Heller explains that this warehouse ships up to 100,000 prescriptions a day, and it includes a system to account for weather.
ALYSIA HELLER: If there's an extreme heat situation, the system will tell the technician to add an extra ice pack because we've monitored the zip code and the weather in that area.
SMITH: But at OptumRx and across the industry, room-temperature medications, like most blood pressure or cholesterol drugs, are just dropped in bubble mailers. Stephen Eckel, a pharmacy professor at the University of North Carolina, thinks that this can lead to some drugs being damaged.
STEPHEN ECKEL: A lot of people enjoy the convenience of mail order, but there are some risks, as we've discussed, that they have to understand.
SMITH: Eckel says it's possible that medications in oral suspension, like Wesley was taking, could be affected by extreme heat or cold. Eckel thinks it's just a matter of time before mail-order pharmacies start using temperature-controlled packaging for nonspecialty drugs as well and include a temperature monitor in each package so customers know their drugs never got too hot or too cold during shipping. But pharmacy consultant Adam Fein says that approach would just drive up costs. And he points out that many states already guarantee customers the right to use retail pharmacies if they prefer. He thinks the temperature concerns are overblown.
ADAM FEIN: We have literally billions and billions of prescriptions that have been dispensed by mail over many, many years without evidence of widespread harm.
SMITH: Some room-temperature drugs are OK to spend up to 24 hours in temperatures as low as the upper 50s to as high as 104. But scientists just don't know what happens to many medications in more extreme temperatures. In fact, a few studies suggest that some inhalers or drugs like antibiotics can lose potency.
Boesing has gotten a waiver that lets her get Wesley's medication at a specialty pharmacy in St. Louis, but she's continued to advocate on the issue.
BOESING: I don't want my son to receive special treatment. I want everyone to have access to safe medications.
SMITH: In Missouri, the Board of Pharmacy will review its mail-order prescription policies and has invited Boesing to testify later this week. For NPR News, I'm Alex Smith in Park Hills, Mo.
(SOUNDBITE OF DARREN KORB'S "FORECAST")
KING: And that story is part of a partnership with NPR, KCUR and Kaiser Health News.