Surfing, self-medicating and safety: buying non-prescription and complementary medicines via the internet

Prevalence and predictors of self-medication to prevent or treat COVID-19 among undergraduate students in Southern Brazil

Self-medication (SM) is the practice of consuming medicines without a prescription. Despite being a potentially dangerous action, SM is practiced globally and has been highlighted during the COVID-19 pandemic. The aim of this study was to evaluate SM for the prevention or treatment of COVID-19 and the factors associated with this practice among undergraduate students in Southern Brazil. A cross-sectional study was conducted between July and November 2020 using an electronic questionnaire to collect information about the practice of SM and the associated sociodemographic characteristics, health perception, and lifestyle. We collected 1,553 responses and identified a prevalence of 14.9% for SM. The risk factors for SM were earning between BRL 2,101 and BRL 5,250, studying at a public university, and studying a distance undergraduate course. The protective factors were age above 30 years, female sex, working or participating in internships, occasionally recommending their own medications to other people, and worsening health during the pandemic. The main drugs or products used were ivermectin, vitamins C and D, tea, azithromycin, zinc, and propolis. Our data could help in the development of health education measures to reduce SM among undergraduate students and guide the population regarding the risks of this practice.

The contemporary nexus of medicines security and bioprospecting: a future perspective for prioritizing the patient

Reacting to the challenges presented by the evolving nexus of environmental change, defossilization, and diversified natural product bioprospecting is vitally important for advancing global healthcare and placing patient benefit as the most important consideration. This overview emphasizes the importance of natural and synthetic medicines security and proposes areas for global research action to enhance the quality, safety, and effectiveness of sustainable natural medicines. Following a discussion of some contemporary factors influencing natural products, a rethinking of the paradigms in natural products research is presented in the interwoven contexts of the Fourth and Fifth Industrial Revolutions and based on the optimization of the valuable assets of Earth. Following COP28, bioprospecting is necessary to seek new classes of bioactive metabolites and enzymes for chemoenzymatic synthesis. Focus is placed on those performance and practice modifications which, in a sustainable manner, establish the patient, and the maintenance of their prophylactic and treatment needs, as the priority. Forty initiatives for natural products in healthcare are offered for the patient and the practitioner promoting global action to address issues of sustainability, environmental change, defossilization, quality control, product consistency, and neglected diseases to assure that quality natural medicinal agents will be accessible for future generations.

Risk, Trust, and Emotion in Online Pharmacy Medication Purchases: Multimethod Approach Incorporating Customer Self-Reports, Facial Expressions, and Neural Activation

BACKGROUND

Online pharmacies are used less than other e-commerce sites in Germany. Shopping behavior does not correspond to consumption behavior, as online purchases are predominantly made for over-the-counter (OTC) medications.

OBJECTIVE

The objective of this study was to understand the purchasing experiences of online pharmacy customers in terms of critical factors for online pharmacy adoption.

METHODS

This study examined the perceived risk, perceived trust, and emotions related to purchasing medications online and, consequently, the purchase intention toward online pharmacies. In a within-subjects design (N=37 participants), 2 German online pharmacies with different perceptions of risk and trust were investigated for their main business, namely OTC and prescription drugs. The results of a preliminary study led to 1 online pharmacy with high and 1 with significantly low self-reported risk by the prestudy sample. Emotions were measured with a multimethod approach during and after the purchase situation as follows: (1) neural evaluation processes using functional near-infrared spectroscopy, (2) the automated direct motor response during the use of the online pharmacy via facial expression analysis (FaceReader), and (3) subjective evaluations through self-reports. Following the shopping experiences at both pharmacies for both product types, risk, trust, and purchase intention toward the pharmacies were assessed using self-assessments.

RESULTS

The 2 online pharmacies were rated differently in terms of risk, trust, emotions, and purchase intention. The high-risk pharmacy was also perceived as having lower trust and vice versa. Significantly stronger negative emotional expressions on customers' faces and different neural activations in the ventromedial prefrontal cortex and dorsomedial prefrontal cortex were measured when purchasing prescription drugs from the high-risk pharmacy than from the low-risk pharmacy, combined with OTC medications. In line with this, customers' self-ratings indicated higher negative emotions for the high-risk pharmacy and lower negative emotions for the low-risk pharmacy. Moreover, the ratings showed lower purchase intention for the high-risk pharmacy.

CONCLUSIONS

Using multimethod measurements, we showed that the preceding neural activation and subsequent verbal evaluation of online pharmacies are reflected in the customers' immediate emotional facial expressions. High-risk online pharmacies and prescription drugs lead to stronger negative emotional facial expressions and trigger neural evaluation processes that imply perceived loss. Low-risk online pharmacies and OTC medications lead to weaker negative emotional facial expressions and trigger neural evaluation processes that signify certainty and perceived reward. The results may provide an explanation for why OTC medications are purchased online more frequently than prescription medications.

Insights Into the Relationships Between Health Communication and Doctor-patient Relationship: A Scientometric Analysis Based on CiteSpace and Validation of Questionnaires

In order to understand the research status of the relationship between health communication and doctor-patient relationship, and to explore a new path of the impact of health communication on doctor-patient relationship, this paper adopted qualitative methods to quantize the literature over the past 10 years in the Web of Science database and carried out Co-Authorship Analysis, Co-Citation Analysis and Co-Occurrence Analysis based on CiteSpace. In addition, according to the results of bibliometric research, self-designed questionnaires were used to verify the result. A convenience sampling survey was conducted through the online "Questionnaire Star" platform (https://www.wjx.cn) on May 8, 2022, and a total of 254 questionnaires were collected. Interviewees were asked to use social software to acquire health knowledge. Participants come from 21 provinces, 4 municipalities, and 4 autonomous regions across the country, which is geographically representative. The results show that uncertainty of social media information and the particularity of the epidemic make the research on health communication and doctor-patient relationship in social media become a new hot spot. Social media health information quality (source credibility and content trust perception), information asymmetry perception, doctor-patient communication, doctor-patient consistency, doctor-patient trust, doctor-patient relationship may be the key variables for constructing theoretical models.

Vitamin D Supply of Multivitamins Commercialized Online by Amazon in Western and Southern Europe: A Labeling Analysis

Multivitamins are commonly used by the general population, often without medical prescription. The purpose of this report is to inform on the daily vitamin D supply provided by multivitamins containing vitamin D that are commercialized online by Amazon in Western and Southern Europe. We surveyed multivitamins aimed at adults using the following marketplaces: amazon.es®, amazon.de®, amazon.it®, and amazon.fr®. We identified 199 vitamin D3-containing multivitamins sold by Amazon marketplaces: 77 from amazon.es®, 73 from amazon.de®, 33 from amazon.it®, and 16 from amazon.fr®. No multivitamin contained vitamin D2. The daily vitamin D3 supply ranged from 16 to 2000 IU: it was less than 400 IU daily in 108 (54%), 400−800 IU daily in 53 (27%), and more than 800 IU daily in the remaining 38 (19%) products. The vitamin D3 supply of products sold by amazon.it® was on average higher (p < 0.05) than that of products sold by amazon.de®, amazon.fr®, and amazon.es®. In conclusion, the vitamin D supply of multivitamins sold by Amazon may be insufficient, marginally sufficient, or adequate for subjects at high risk of hypovitaminosis D such as subjects 65 years or more of age, pregnant (or lactating) women, or patients on drug treatment or with an underlying disease, where a vitamin D supplementation is advocated.

The Assessment of TikTok as a Source of Quality Health Information on Varicoceles

OBJECTIVE

To evaluate the quality of varicocele information on TikTok, a popular video platform that adolescent patients are now turning to as a source of medical information before visiting a doctor.

METHODS

Using the key word "varicocele," we retrieved the top 225 videos listed on TikTok in May 2022. We extracted general video and engagement data. Video information was coded and analyzed for the completeness of different types of content (definition, symptoms, evaluation, management, and outcomes). The quality of consumer health information was rated using the DISCERN instrument.

RESULTS

Thirty-six videos met inclusion criteria; 17 were created by general users, 16 by healthcare professionals or systems (2 by urologists), and 3 by scientific communities. Healthcare professionals had more views than non-healthcare (P = .05). The quality of health information using the DISCERN instrument was "poor" from health care professional videos and "very poor" from non-health care professionals. However, the quality of information provided by healthcare professionals was statistically better than that of non-healthcare (P< .05). Video content mainly focused on symptoms: 50% of videos from healthcare providers had some or extensive content and 41% of non-healthcare had some content. 23% of videos had misinformation.

CONCLUSION

The overall quality of information for varicoceles on TikTok is not acceptable and does not meet patient needs. It is imperative that urologists create robust, accurate content, and partner with these platforms to connect users with higher quality information. TikTok users should also be mindful that information may not be medically accurate.

Abuse of Non-opioid Analgesics in Germany: Prevalence and Associations Among Self-Medicated Users

BACKGROUND

Abuse of non-opioid analgesics (NOA) is associated with serious health consequences. However, due to inconsistent definitions of NOA abuse, prevalence estimates for the German population are unclear.

OBJECTIVES

This study aimed to estimate the 12-month prevalence of NOA abuse among self-medicated users of these drugs in the general German population and to identify risk factors.

METHODS

Data are from the 2015 Epidemiological Survey of Substance Abuse, a nationally representative sample with 9,204 individuals aged 18-64 years. Classification of NOA abuse was based on self-reported information according to the definition of the ICD-10-GM diagnosis F55.2 abuse of non-dependence producing substances. Multiple logistic regression was performed to examine associations between NOA abuse and sociodemographic, behavioral, and health-related variables.

RESULTS

The weighted 12-month prevalence of NOA abuse was 14.6% (95%-CI [13.2- 16.0]) among self-medicated users of these drugs. Extrapolation of the proportion of individuals abusing NOA to the German population aged 18 to 64 is 3,243,396 individuals or 6.4% (95%-CI [5.7- 7.1]). Inexplicable physical pain, being underweight, depression, hazardous alcohol use, daily smoking, illegal drug use, and frequent use of NOA (one or more times per week and daily use) were associated with an increased probability of NOA abuse. The use of cannabis was associated with a lower probability of NOA abuse.

CONCLUSION

Abuse of NOA is highly prevalent in the German population. Against the background of increasing self-medication of NOA, healthcare providers need to be aware of potential risk factors of abuse to better identify and prevent this problem.

Quality of complementary and alternative medicine information for type 2 diabetes: a cross-sectional survey and quality assessment of websites

BACKGROUND

The global prevalence of diabetes mellitus is projected to reach approximately 700 million by the year 2045, with roughly 90-95% of all diabetes cases being type 2 in nature. Patients with type 2 diabetes mellitus (T2DM) frequently seek information about complementary and alternative medicine (CAM) online. This study assessed the quality of publicly accessible websites providing consumer health information at the intersection of T2DM and CAM.

METHODS

An online search engine (Google) was searched to identify pertinent websites containing information specific to CAM for T2DM patients, and the relevant websites were then screened with an eligibility criteria. Consumer health information found on eligible websites were then assessed for quality using the DISCERN instrument, a 16-item standardized scoring system.

RESULTS

Across the 480 webpages identified, 94 unique webpages remained following deduplication, and 37 eligible webpages belonged to and were collapsed into 30 unique websites that were each assessed using the DISCERN instrument. The mean overall quality score (question 16) across all 30 assessed websites was 3.55 (SD = 0.86), and the mean summed DISCERN score was 52.40 (SD = 12.11). Eighty percent of websites presented a wide range of CAM treatment options with the associated benefits/risks of each treatment, but in 56.7% of the websites, the sources used to collect information were unreliable.

CONCLUSION

This study identified, assessed, and presents findings on the quality of online CAM information for T2DM. Although there were several high scoring websites, there was variability across most of the individual DISCERN items in the assessed websites. This study highlights the importance of awareness among healthcare providers regarding the reliability of online information about CAM treatment and management options for T2DM. Healthcare providers should be aware of patients' information seeking behaviour, guide them in navigating through the content they encounter online, and provide them with resources containing trustworthy and reliable information.

Online Health Resource Use by Individuals With Inflammatory Bowel Disease: Analysis Using the National Health Interview Survey

Background

The internet has enabled convenient and efficient health information searching which is valuable for individuals with chronic conditions requiring some level of self-management. However, there is little research evaluating what factors may impact the use of the internet for health-related tasks for specific clinical populations, such as individuals with inflammatory bowel diseases.

Objective

Our goal was to investigate the factors that influence internet use in acquiring health information by individuals with inflammatory bowel diseases. Specifically, we identified factors associated with internet searching behavior and using the internet for completing health-related tasks.

Methods

We used 2016 National Health Interview Survey weighted data to develop logistic regression models to predict the likelihood that individuals with inflammatory bowel diseases would use the internet for 2 types of tasks: seeking health information through online searches and using the internet to perform health-related tasks including scheduling appointments and emailing care providers.

Results

2016 National Health Interview Survey weighted data include more than 3 million weighted adult respondents with inflammatory bowel diseases (approximately 1.29% of adults in the weighted data set). Our results suggest that approximately 66.3% of those with inflammatory bowel diseases reported using the internet at least once a day, and approximately 14.7% reported being dissatisfied with their current health care. About 62.3% of those with inflammatory bowel diseases reported that they had looked up health information online, 16.3% of those with inflammatory bowel diseases reported that they had scheduled an appointment with a health care provider online, and 21.6% reported having used a computer to communicate with a health provider by email. We found that women who were self-regulating their care were more likely to look up health information online than others. Both middle-aged and older adults with inflammatory bowel diseases who were unsatisfied with their current health care were less likely to look up health information online. Frequent internet users who were worried about medical costs were more likely to look up health information online. Similarly, the results from our statistical models suggest that individuals with inflammatory bowel diseases who were frequent internet users were more likely to use the internet for specific health-related tasks. Additionally, women with inflammatory bowel diseases who reported being married were less likely to use the internet for specific health-related tasks.

Conclusions

For those with inflammatory bowel diseases, there are additional socioeconomic and behavioral factors that impact the use of the internet for health information and health-related tasks. Future research should evaluate how these factors moderate the use of the internet and identify how online resources can support clinical populations in ways that improve access to information, support health self-management, and subsequently improve health outcomes.

Online Information on Probiotics: Does It Match Scientific Evidence?

Probiotics are over-the-counter products marketed for enhancing human health. Online information has been key in promoting probiotics worldwide. However, only few rigorous clinical studies have met the stringent criteria required to establish the efficacy and safety of probiotics. The present study was undertaken to assess the information quality of webpages referring to probiotics and to compare the recommendations available online with the information collected from trusted scientific sources. We evaluated 150 webpages returned by Google searching “probiotics” in terms of typology of website, health information quality based on the JAMA score and the HONcode certification, as well as completeness of the information based on the presence of four criteria: (1) links to scientific references supporting health claims, (2) cautionary notes about level of evidence for alleged benefits, (3) safety considerations, and (4) regulatory status. We then enumerated the health claims mentioned online and the corresponding clinical trials and reviews registered in the Cochrane library. Finally, the conclusions of Cochrane reviews were used to assess the level of scientific evidence of the information available through Google search. HON-certified websites were significantly more frequent in the top 10 websites than in the remaining websites. In terms of completeness of information, only 10% of webpages met all four criteria, 40% had a cautionary note on benefits, 35% referred to scientific literature, and only 25% mentioned potential side effects. The results of the content analysis led us to conclude that: (1) the most frequent typologies of webpages returned by Google are commercial and news, (2) commercial websites on average provide the least reliable information, and (3) significant numbers of claimed benefits of probiotics are not supported by scientific evidence. This study highlights important biases in the probiotics information available online, underlining the need to improve the quality and objectivity of information provided to the public.

eHealth Search Patterns: A Comparison of Private and Public Health Care Markets Using Online Panel Data

Background

Patient and consumer access to eHealth information is of crucial importance because of its role in patient-centered medicine and to improve knowledge about general aspects of health and medical topics.

Objectives

The objectives were to analyze and compare eHealth search patterns in a private (United States) and a public (United Kingdom) health care market.

Methods

A new taxonomy of eHealth websites is proposed to organize the largest eHealth websites. An online measurement framework is developed that provides a precise and detailed measurement system. Online panel data are used to accurately track and analyze detailed search behavior across 100 of the largest eHealth websites in the US and UK health care markets.

Results

The health, medical, and lifestyle categories account for approximately 90% of online activity, and e-pharmacies, social media, and professional categories account for the remaining 10% of online activity. Overall search penetration of eHealth websites is significantly higher in the private (United States) than the public market (United Kingdom). Almost twice the number of eHealth users in the private market have adopted online search in the health and lifestyle categories and also spend more time per website than those in the public market. The use of medical websites for specific conditions is almost identical in both markets. The allocation of search effort across categories is similar in both the markets. For all categories, the vast majority of eHealth users only access one website within each category. Those that conduct a search of two or more websites display very narrow search patterns. All users spend relatively little time on eHealth, that is, 3-7 minutes per website.

Conclusions

The proposed online measurement framework exploits online panel data to provide a powerful and objective method of analyzing and exploring eHealth behavior. The private health care system does appear to have an influence on eHealth search behavior in terms of search penetration and time spent per website in the health and lifestyle categories. Two explanations are offered: (1) the personal incentive of medical costs in the private market incentivizes users to conduct online search; and (2) health care information is more easily accessible through health care professionals in the United Kingdom compared with the United States. However, the use of medical websites is almost identical, suggesting that patients interested in a specific condition have a motivation to search and evaluate health information, irrespective of the health care market. The relatively low level of search in terms of the number of websites accessed and the average time per website raise important questions about the actual level of patient informedness in both the markets. Areas for future research are outlined.

Internet Health Information Seeking and the Patient-Physician Relationship: A Systematic Review

BACKGROUND

With online health information becoming increasingly popular among patients, concerns have been raised about the impact of patients' Internet health information-seeking behavior on their relationship with physicians. Therefore, it is pertinent to understand the influence of online health information on the patient-physician relationship.

OBJECTIVE

Our objective was to systematically review existing research on patients' Internet health information seeking and its influence on the patient-physician relationship.

METHODS

We systematically searched PubMed and key medical informatics, information systems, and communication science journals covering the period of 2000 to 2015. Empirical articles that were in English were included. We analyzed the content covering themes in 2 broad categories: factors affecting patients' discussion of online findings during consultations and implications for the patient-physician relationship.

RESULTS

We identified 18 articles that met the inclusion criteria and the quality requirement for the review. The articles revealed barriers, facilitators, and demographic factors that influence patients' disclosure of online health information during consultations and the different mechanisms patients use to reveal these findings. Our review also showed the mechanisms in which online information could influence patients' relationship with their physicians.

CONCLUSIONS

Results of this review contribute to the understanding of the patient-physician relationship of Internet-informed patients. Our main findings show that Internet health information seeking can improve the patient-physician relationship depending on whether the patient discusses the information with the physician and on their prior relationship. As patients have better access to health information through the Internet and expect to be more engaged in health decision making, traditional models of the patient-provider relationship and communication strategies must be revisited to adapt to this changing demographic.

Internet Health Information Seeking and the Patient-Physician Relationship: A Systematic Review

Background

With online health information becoming increasingly popular among patients, concerns have been raised about the impact of patients’ Internet health information-seeking behavior on their relationship with physicians. Therefore, it is pertinent to understand the influence of online health information on the patient-physician relationship.

Objective

Our objective was to systematically review existing research on patients’ Internet health information seeking and its influence on the patient-physician relationship.

Methods

We systematically searched PubMed and key medical informatics, information systems, and communication science journals covering the period of 2000 to 2015. Empirical articles that were in English were included. We analyzed the content covering themes in 2 broad categories: factors affecting patients’ discussion of online findings during consultations and implications for the patient-physician relationship.

Results

We identified 18 articles that met the inclusion criteria and the quality requirement for the review. The articles revealed barriers, facilitators, and demographic factors that influence patients’ disclosure of online health information during consultations and the different mechanisms patients use to reveal these findings. Our review also showed the mechanisms in which online information could influence patients’ relationship with their physicians.

Conclusions

Results of this review contribute to the understanding of the patient-physician relationship of Internet-informed patients. Our main findings show that Internet health information seeking can improve the patient-physician relationship depending on whether the patient discusses the information with the physician and on their prior relationship. As patients have better access to health information through the Internet and expect to be more engaged in health decision making, traditional models of the patient-provider relationship and communication strategies must be revisited to adapt to this changing demographic.

“Insight” into Drug Quality: Comparison of Simvastatin Tablets from the US and Canada Obtained via the Internet

Background:

Recently, there has been much debate in the US concerning drug importation from Canadian Internet pharmacies. The Food and Drug Administration and US drug manufacturers assert that drugs obtained from international markets via the Internet present a health risk to consumers from substandard products. The public's perception is that drugs from Canada are as safe as those from the US.

Objective:

To determine whether simvastatin tablets obtained via the Internet from Canadian generic manufacturers are comparable in blend uniformity, a major attribute of tablet quality, with the US innovator product.

Methods:

Generic simvastatin tablets from 4 Canadian Internet pharmacy Web sites and the US innovator product were obtained for pharmaceutical analysis, Tablet samples were analyzed using near-infrared spectroscopic imaging techniques, which are designed to detect formulation defects of drug products during the manufacturing process. Digital images were created, revealing the tablets’ internal structures.

Results:

The blend uniformity of the active pharmaceutical ingredient in the tablet samples from Canada was determined and compared with that of the US innovator product. Results indicated that there is little significant difference in blend uniformity among US innovator and Canadian generic tablets.

Conclusions:

Results of this study suggest comparable quality assurance manufacturing standards for the US innovator product and the Canadian generic drug products tested. These findings have clinical, legal, and economic implications that should be addressed by policy makers to safeguard consumers who choose to purchase Canadian-manufactured drugs via the Internet.

Profiling online recreational/prescription drugs' customers and overview of drug vending virtual marketplaces

OBJECTIVES

Internet and social networking sites play a significant role in the marketing and distribution of recreational/prescription drugs without restrictions. We aimed here at reviewing data relating to the profile of the online drug customer and at describing drug vending websites.

METHODS

The PubMed, Google Scholar, and Scopus databases were searched here in order to elicit data on the socio-demographic characteristics of the recreational marketplaces/online pharmacies' customers and the determinants relating to online drug purchasing activities.

RESULTS

Typical online recreational drugs' customers seem to be Caucasian, men, in their 20s, highly educated, and using the web to impact as minimally as possible on their existing work/professional status. Conversely, people without any health insurance seemed to look at the web as a source of more affordable prescription medicines. Drug vending websites are typically presented here with a "no prescription required" approach, together with aggressive marketing strategies.

CONCLUSIONS

The online availability of recreational/prescriptions drugs remains a public health concern. A more precise understanding of online vending sites' customers may well facilitate the drafting and implementation of proper prevention campaigns aimed at counteracting the increasing levels of online drug acquisition and hence intake activities.

Health care use amongst online buyers of medications and vitamins

BACKGROUND

With increased use of the internet, more people access medications and health supplements online. However little is known about factors associated with using online buying. Given the variable quality of online pharmacies, an important question is whether online consumers also have health care providers with whom they discuss internet information and decisions.

OBJECTIVES

To help address these gaps this study used the Andersen Model to explore (1) the characteristics of internet buyers of medicines and/vitamins, (2) the association between health care use and buying medicines and/vitamins online drawing on the Andersen health care utilization framework, and (3) factors predicting discussion of internet information with health providers.

METHODS

The National Cancer Institute's Health Information National Trends Survey (HINTS) 2007 was analyzed to study online medication buying among a national sample of internet users (N = 5074). The Andersen Model of health care utilization guided the study's variable selection and analyses. Buying online and talking about online information are the two main outcome variables. Separate multivariate logistic regression analyses identified factors associated with online buying and factors predicting discussions with providers about online information.

RESULTS

In 2007, 14.5% (n = 871) of internet users bought a medication or vitamin online. About 85% of online buyers had a regular provider, but only 39% talked to the provider about online information even though most (93.7%) visited the provider ≥1 times/year. Multivariate analyses found internet health product consumers were more likely to be over 50 years old, have insurance and discuss the internet with their provider than non-internet health product consumers. Moreover, discussion of internet information was more likely if consumers had a regular provider and perceived their communication to be at least fair or good in general.

CONCLUSIONS

There is a clear association of online buying with age, frequency of visits and discussing online information with a provider. Although most online buyers visited a provider in the prior year, only a minority discussed the internet with them. This suggests a missed opportunity for providers to help patients navigate internet buying, particularly if they are a patient's regular provider and the patient perceives their communication as good.

“Doctor shopping and pharmacy hopping”: practice innovations relating to codeine

Purpose

– The misuse of pharmaceutical opioid analgesics is identified as a global public health concern. Codeine represents an interesting quandary in terms of its regulated status, with individuals varying in their metabolism of codeine, estimation of safe dosages, risk of adverse health consequences and abuse potential. Efforts to quantify and address hidden non-compliant medical codeine use, overuse and intentional misuse is compromised by availability to the public in prescribed and over the counter forms. The paper aims to discuss these issues.

Design/methodology/approach

– A review of literature on codeine use, misuse and dependence, and associated innovative medical and pharmacy interventions is presented, and was conducted as part of a larger scoping review on codeine.

Findings

– The review highlights the complexities associated with monitoring public health awareness of codeine's abuse potential, and customer/patients trends in non-compliant codeine use for therapeutic and recreational purposes. Aberrant codeine behaviours centre on visiting multiple doctors for prescriptions, repeated lost or stolen prescriptions, forging prescriptions and use of multiple pharmacies. Innovations to monitor misuse of codeine include national prescription databases and recent developments in real-time monitoring of dispensing activity.

Practical implications

– Further development of real-time monitoring processes with process evaluation is advised.

Originality/value

– This viewpoint is intended to demonstrate how efforts to quantify and address codeine use are compromised by its availability. It intends to encourage further policy and practitioner dialogue on how to monitor, support and intervene with consumers misusing codeine.

Toxic phytochemicals and their potential risks for human cancer

Consuming plants for their presumed health benefits has occurred since early civilizations. Phytochemicals are found in various plants that are frequently included in the human diet and are generally thought to be safe for consumption because they are produced naturally. However, this is not always the case and in fact many natural compounds found in several commonly consumed plants are potential carcinogens or tumor promoters and should be avoided.

Evaluating aspects of online medication safety in long-term follow-up of 136 Internet pharmacies: illegal rogue online pharmacies flourish and are long-lived

Background

A growing number of online pharmacies have been established worldwide. Among them are numerous illegal websites selling medicine without valid medical prescriptions or distributing substandard or counterfeit drugs. Only a limited number of studies have been published on Internet pharmacies with regard to patient safety, professionalism, long-term follow-up, and pharmaceutical legitimacy verification.

Objective

In this study, we selected, evaluated, and followed 136 Internet pharmacy websites aiming to identify indicators of professional online pharmacy service and online medication safety.

Methods

An Internet search was performed by simulating the needs of potential customers of online pharmacies. A total of 136 Internet pharmacy websites were assessed and followed for four years. According to the LegitScript database, relevant characteristics such as longevity, time of continuous operation, geographical location, displayed contact information, prescription requirement, medical information exchange, and pharmaceutical legitimacy verification were recorded and evaluated.

Results

The number of active Internet pharmacy websites decreased; 23 of 136 (16.9%) online pharmacies ceased operating within 12 months and only 67 monitored websites (49.3%) were accessible at the end of the four-year observation period. However, not all operated continuously, as about one-fifth (31/136) of all observed online pharmacy websites were inaccessible provisionally. Thus, only 56 (41.2%) Internet-based pharmacies were continuously operational. Thirty-one of the 136 online pharmacies (22.8%) had not provided any contact details, while only 59 (43.4%) displayed all necessary contact information on the website. We found that the declared physical location claims did not correspond to the area of domain registration (according to IP address) for most websites. Although the majority (120/136, 88.2%) of the examined Internet pharmacies distributed various prescription-only medicines, only 9 (6.6%) requested prior medical prescriptions before purchase. Medical information exchange was generally ineffective as 52 sites (38.2%) did not require any medical information from patients. The product information about the medicines was generally (126/136, 92.6%) not displayed adequately, and the contents of the patient information leaflet were incomplete in most cases (104/136, 76.5%). Numerous online operators (60/136, 44.1%) were defined as rogue Internet pharmacies, but no legitimate Internet-based pharmacies were among them. One site (0.7%) was yet unverified, 23 (16.9%) were unapproved, while the remaining (52/136, 38.2%) websites were not available in the LegitScript database. Contrary to our prior assumptions, prescription or medical information requirement, or the indication of contact information on the website, does not seem to correlate with “rogue pharmacy” status using the LegitScript online pharmacy verification standards. Instead, long-term continuous operation strongly correlated (P<.001) with explicit illegal activity.

Conclusions

Most Internet pharmacies in our study sample were illegal sites within the definition of “rogue” Internet pharmacy. These websites violate professional, legal, and ethical standards and endanger patient safety. This work shows evidence that online pharmacies that act illegally appear to have greater longevity than others, presumably because there is no compelling reason for frequent change in order to survive. We also found that one in five websites revived (closed down and reopened again within four years) and no-prescription sites with limited medicine and patient information are flourishing.

'I can't be an addict. I am.' Over-the-counter medicine abuse: a qualitative study

OBJECTIVES

Over-the-counter (OTC) pharmacy medicines are considered relatively safe in contrast to prescribed and illicit substances, but their abuse and addiction potential is increasingly recognised. Those affected represent a hard to reach group, with little known about their experiences. Study objectives were to describe the experiences and views of those self-reporting OTC medicine abuse, and why medicines were taken, how they were obtained and associated treatment and support sought.

DESIGN

Qualitative study using in-depth mainly telephone interviews.

PARTICIPANTS

A purposive sample of 25 adults, aged 20-60s, 13 women.

SETTING

UK, via two internet support groups.

RESULTS

Individuals considered themselves 'addicted', but socially and economically active and different from illicit substance misusers. They blamed themselves for losing control over their medicine use, which usually began for genuine medical reasons and not experimentation and was often linked to the cessation of, or ongoing, medical prescribing. Codeine, in compound analgesics, was the main medicine implicated with three distinct dose ranges emerging with decongestant and sedative antihistamine abuse also being reported. Subsequent use was for the 'buzz' or similar effects of the opiate, which was obtained unproblematically by having lists of pharmacies to visit and occasionally using internet suppliers. Perceived withdrawal symptoms were described for all three dose ranges, and work and health problems were reported with higher doses. Mixed views about different treatment and support options emerged with standard drug treatment services being considered inappropriate for OTC medicines and concerns that this 'hidden addiction' was recorded in medical notes. Most supported the continued availability of OTC medicines with appropriate addiction warnings.

CONCLUSIONS

Greater awareness of the addiction potential of OTC medicines is needed for the public, pharmacists and medical prescribers, along with appropriate communication about, and reviews of, treatment and support options, for this distinct group.

Surveillance and uncertainty: community pharmacy responses to over the counter medicine abuse

The sale of over-the-counter (OTC) medicines from community pharmacies offers important opportunities for members of the public to access medicines and self-treat conditions. They are increasingly recognised, however, as having the potential for abuse and harm despite their perceived relative safety. This study reports on a qualitative study that explored the experiences and views of community pharmacy staff in relation to current practices and concerns, management and support relating to OTC medicine abuse. Semi-structured interviews were undertaken with a purposive sample of ten pharmacists and seven medicines counter assistants in the United Kingdom. Analysis of interviews indicated that a range of medicines was implicated, including opiates, sedative antihistamines, laxatives and decongestants. A surveillance role was apparent for assistants, who placed emphasis on regulations, procedure and monitoring frequency of purchases to manage abuse, with referral on to pharmacists. Frequency of purchase was central to assistants' definition of those suspected of OTC medicine abuse, which pharmacists also utilised as well as a distinction between intentional abuse and unintentional medicine misuse. A lack of information about customers, easy access to, and poor communication between community pharmacies were emergent barriers to pharmacists providing more support. Many appeared uncertain of referral options or how pharmacists could effectively stop the problem of abuse. The commercial environment was a particular concern, in relation to customer expectations, medicine advertising and easy access to different community pharmacies. A key tension emerged between providing medicine supplies that permitted consumer freedom, with the needs of healthcare professionals to understand more about those consumers qua patients. Policy implications include the need for improved knowledge for community pharmacy staff about signposting to relevant services, increased awareness of who might be affected, and a review of how pharmacists can have more information about patients to inform OTC medicine sales.

Over-the-counter medicine abuse - a review of the literature

BACKGROUND

The sale of over-the-counter (OTC) medicines from pharmacies can help individuals self-manage symptoms. However, some OTC medicines may be abused, with addiction and harms being increasingly recognised. This review describes the current knowledge and understanding of OTC medicine abuse.

APPROACH

Comprehensive search of international empirical and review literature between 1990 and 2011.

FINDINGS

OTC MEDICINE ABUSE WAS IDENTIFIED IN MANY COUNTRIES AND ALTHOUGH IMPLICATED PRODUCTS VARIED, FIVE KEY GROUPS EMERGED: codeine-based (especially compound analgesic) medicines, cough products (particularly dextromethorphan), sedative antihistamines, decongestants and laxatives. No clear patterns relating to those affected or their experiences were identified and they may represent a hard-to-reach group, which coupled with heterogeneous data, makes estimating the scale of abuse problematic. Associated harms included direct physiological or psychological harm (e.g. opiate addiction), harm from another ingredient (e.g. ibuprofen-related gastric bleeding) and associated social and economic problems. Strategies and interventions included limiting supplies, raising public and professional awareness and using existing services and Internet support groups, although associated evaluations were lacking. Terminological variations were identified.

CONCLUSIONS

OTC medicine abuse is a recognised problem internationally but is currently incompletely understood. Research is needed to quantify scale of abuse, evaluate interventions and capture individual experiences, to inform policy, regulation and interventions.

[Conflicts of interest in the research, production and dissemination of medicines]

This paper analyzes the debate about the ethical conflicts of the methods used by the pharmaceutical industry in the research, production and dissemination of medicines. Three aspects are examined: the involvement of medical professionals with representatives of the pharmaceutical industry; the conflicts of interest regarding their role as sponsors of scientific research; and the evaluation of drugs on human beings. It is seen that the message for health promotion comes from medicalization; the major pharmaceutical industries do not exclusively produce merchandise, but especially subjectivities. In this way, the type of order established by them is revealed.

Importation of prescription medicines into New Zealand: a snapshot of intercepted products

OBJECTIVE

The aim of this research was to describe the types of prescription medicines being imported into New Zealand.

SETTING

Imported medicines intercepted at the international mail centre in Auckland and referred to the New Zealand Medicines and Medical Devices Safety Authority (Medsafe) between July and December 2007 were studied.

METHOD

During the study 3,918 prescription medicine imports were intercepted and entered into a database by Medsafe. These were categorised according to the country the medicines were posted from and medicine related details such as brand, active ingredient(s), route of administration, strength and quantity imported. Researchers systematically categorised medicines by therapeutic indications, dosage form, whether these medicines were available in New Zealand and if they were subsidised by the New Zealand government.

MAIN OUTCOME MEASURE

Types of medicines imported into New Zealand and whether or not they were legally available and subsidised by the government.

RESULTS

Medicines were most commonly imported from India and China. Seventy eight percent of the total medicines imported were already available in New Zealand, and of these almost half were subsidised by the government. Antibiotics contributed to a significant proportion of the total subsidised medicines imported, the most common being amoxicillin. Four of the five most commonly imported medicines could be considered 'lifestyle' medicines (sildenafil, tadalafil, finasteride and sibutramine). 'High risk' medicines were identified--for example medicines used in the treatment of tuberculosis, malignant diseases and mental health disorders.

CONCLUSION

This study is the first of its kind in New Zealand to explore the types of prescription medicines imported into the country. The majority of imported medicines were classified as 'lifestyle' medicines. The study findings also identified possible negative public health implications associated with some of the imported prescription medicines, for example resistance associated with the importation of antibiotics.

Dirt cheap and without prescription: how susceptible are young US consumers to purchasing drugs from rogue internet pharmacies?

Background

Websites of many rogue sellers of medications are accessible through links in email spam messages or via web search engines. This study examined how well students enrolled in a U.S. higher education institution could identify clearly unsafe pharmacies.

Objective

The aim is to estimate these health consumers´ vulnerability to fraud by illegitimate Internet pharmacies.

Methods

Two Internet pharmacy websites, created specifically for this study, displayed multiple untrustworthy features modeled after five actual Internet drug sellers which the authors considered to be potentially dangerous to consumers. The websites had none of the safe pharmacy signs and nearly all of the danger signs specified in the Food and Drug Administration´s (FDA´s) guide to consumers. Participants were told that a neighborhood pharmacy charged US$165 for a one-month supply of Beozine, a bogus drug to ensure no pre-existing knowledge. After checking its price at two Internet pharmacies—$37.99 in pharmacy A and $57.60 in pharmacy B—the respondents were asked to indicate if each seller was a good place to buy the drug. Responses came from 1,914 undergraduate students who completed an online eHealth literacy assessment in 2005-2008. Participation rate was 78%.

Results

In response to "On a scale from 0-10, how good is this pharmacy as a place for buying Beozine?" many respondents gave favorable ratings. Specifically, 50% of students who reviewed pharmacy A and 37% of students who reviewed pharmacy B chose a rating above the scale midpoint. When explaining a low drug cost, these raters related it to low operation costs, ad revenue, pressure to lower costs due to comparison shopping, and/or high sales volume. Those who said that pharmacy A or B was "a very bad place" for purchasing the drug (25%), as defined by a score of 1 or less, related low drug cost to lack of regulation, low drug quality, and/or customer information sales. About 16% of students thought that people should be advised to buy cheaper drugs at pharmacies such as these but the majority (62%) suggested that people should be warned against buying drugs from such internet sellers. Over 22% of respondents would recommend pharmacy A to friends and family (10% pharmacy B). One-third of participants supplied online health information to others for decision-making purposes. After controlling for the effects of education, health major, and age, these respondents had significantly worse judgment of Internet pharmacies than those who did not act as information suppliers.

Conclusions

At least a quarter of students, including those in health programs, cannot see multiple signs of danger displayed by rogue Internet pharmacies. Many more are likely to be misled by online sellers that use professional design, veil untrustworthy features, and mimic reputable websites. Online health information consumers would benefit from education initiatives that (1) communicate why it can be dangerous to buy medications online and that (2) develop their information evaluation skills. This study highlights the importance of regulating rogue Internet pharmacies and curbing the danger they pose to consumers.

Alternative delivery methods for pharmacy services

In many developed countries, the provision of pharmacy services is no longer restricted to the traditional “walk-in” or face-to-face approach. This paper examines whether alternative delivery methods provide patients with pharmacy services that meet their medication and related information needs, and discusses professional issues and the implications for practice. Although not appropriate for everyone, studies show that many patients do accept the alternative means of service delivery examined here. For some patients, such as those with mobility problems or who live in remote areas, technology-driven alternatives may be preferred. Health care professionals must take steps to address legitimate concerns about the protection of patient safety and confidentiality. To increase patient choice, the pharmacy profession needs to look closely at the positive aspects of these alternatives, as they can be incorporated in “traditional” pharmacy practice.

Shopping for psoriasis medications on the Internet

BACKGROUND

Numerous consumer products, including medicines, can be bought over the Internet. Previous reports indicate that patients are able to purchase the current available treatments, including expensive systemic and biological agents with side-effects, available for use on an outpatient basis. In France, as in most industrialized countries, these drug treatments are available only by prescription. Objective To evaluate whether psoriatic outpatients can buy the full range of psoriasis medications, including biological therapies, without a prescription, via the Internet.

METHODS

One investigator acted as a consumer to purchase psoriasis treatments and complementary medicines over the Internet. The website search was limited to a 4-h period. All products had to be available for delivery in France, without a prescription, and be suitable for outpatient use. Key words for the Internet search were combinations of medicinal product names, 'psoriasis', 'shopping', 'pharmacy', 'parapharmacy', entered into two major search engines, Google and Yahoo.

RESULTS

The investigator identified 47 websites offering a total of 340 products. All treatments, including biological therapies (etanercept, adalumimab and efaluzimab), were available for purchase with the exception of calcitriol and alefacept, with median prices being higher than the French price.

CONCLUSION

This study shows that it is possible for consumers to purchase the majority of treatments for psoriasis via the Internet, including systemic therapies and even the most recent and expensive products such as biological agents, without a prescription.

Email medication counseling services provided by Finnish community pharmacies

BACKGROUND

The importance of email as a mode of communication between medication users and pharmacists is likely to increase. However, little is known about the email medication counseling practices of community pharmacies.

OBJECTIVE

To determine the prevalence of email medication counseling services in Finland and to assess the accuracy and comprehensiveness of responses by pharmacies providing the opportunity for email medication counseling to inquiries related to use of antidepressants.

METHODS

An inventory was made of all Finnish community pharmacies that provided the opportunity for email medication counseling. Data related to the accuracy and comprehensiveness of responses were collected, using a virtual pseudo-customer method with 3 scenarios related to common concerns of patients on antidepressants. Two inquiries were emailed to each pharmacy that provided the opportunity for email medication counseling in January and February 2005. The responses were content analyzed by 2 researchers, using a prestructured scoring system.

RESULTS

Almost one-third (30%, n = 182) of Finnish community pharmacies maintained a working Web site, and 94% of those provided the opportunity for email medication counseling. An online "ask-the-pharmacist" service was offered by 13% (n = 23) of the pharmacies with a Web site. Pharmacies responded to 54% of the email inquiries sent by the virtual pseudo-customers. The response rate and the content score ratio between mean and maximum scores varied among the scenarios. The content score ratio was highest for the scenarios concerning the adverse effects of fluoxetine (0.53, n = 55) and interactions with mirtazapine (0.52, n = 63) and lowest for the scenario related to sexual dysfunction and weight gain associated with citalopram (0.38, n = 52).

CONCLUSIONS

Community pharmacies are potential providers of email medication counseling services. However, more attention should be directed to responding to consumer inquiries and to the content of these responses.

Will spam overwhelm our defenses? Evaluating offerings for drugs and natural health products

At least one-third of spam e-mails include offers of health products, according to this new study.

Quality of medication information available on retail pharmacy Web sites

BACKGROUND

The Internet is becoming an important source for medication information. Although the quality of consumer medication information (CMI) in brick and mortar pharmacies has been reported to be suboptimal, little is known about the quality of CMI offered by pharmacy Web sites.

OBJECTIVE

To evaluate the quality, readability, and provision of Web functionality of 4 popular medications (atenolol, nitroglycerin, atorvastatin, and glyburide) available on the websites of 3 of the largest retail pharmacies: Walgreens, CVS Pharmacy, and Rite Aid.

METHODS

The quality of online medication information was evaluated by 2 reviewers using a preexisting evaluation instrument created by a national panel of experts. Readability level was assessed using the Gunning Fog Test. We also assessed the presence of 4 Web-specific functional criteria: (1) capability for font enlargement, (2) availability of a glossary of terms, (3) presence of an "Ask a pharmacist" feature, and (4) access to detailed medication information or full prescribing information.

RESULTS

Overall, medication information was 77% adherent to the criteria evaluated. When broken down by drug, CMI was most adherent for atorvastatin (83%), followed by glyburide (77%), atenolol (76%), and nitroglycerin (75%). The average readability level was found to be 10th grade. No pharmacy Web site provided the ability for font enlargement, a glossary of terms, or access to detailed medication information; however, all pharmacy Web sites provided an "Ask a pharmacist" service.

CONCLUSION

Although pharmacy Web sites were found to have an overall good content quality, the high readability level of text, areas of incomplete information, and limited use of desirable Web functionality suggest room for improvement.

Clinical risk management of herb-drug interactions

The concomitant use of conventional and herbal medicines can lead to clinically relevant herb-drug interactions. Clinical risk management offers a systematic approach to minimize the untoward consequences of these interactions by paying attention to: (i) risk identification and assessment; (ii) development and execution of risk reduction strategies; and (iii) evaluation of risk reduction strategies. This paper reviews which steps should be explored or taken in these domains to improve the clinical risk management of adverse herb-drug interactions.

DISCERN-Genetics: quality criteria for information on genetic testing

Information currently available to the public is inadequate to support those deciding to consent to a genetic test. As genetic knowledge continues to evolve, more people will be forced to consider the complex issues raised by genetic testing. We developed and tested criteria to guide the production and appraisal of information resources produced for the public on genetic testing. Lay people with and without experience of a genetic condition, and providers and producers of health information appraised and listed the criteria they used to rate the quality of a sample of information on cystic fibrosis, Down's syndrome, familial breast cancer, familial colon cancer, haemochromatosis, Huntington's disease, sickle cell disease, and thalassaemia. These genetic conditions represent different populations, disease pathways, and treatment decisions. The information medium could be written, electronic, CD, audio or video. The quality criteria were tested iteratively (using the weighted kappa statistic) for the level of agreement between users applying successive drafts of the criteria to different samples of information. The final set of criteria consisted of 19 questions plus an overall quality rating. Chance corrected agreement (weighted kappa) among the appraisers for the overall quality rating was 0.61 (0.60-0.62). The criteria cover the scope of the information resources, information on the condition, the test procedure and results, decision making, and the reliability of the information. The DISCERN-Genetics criteria will guide the production and appraisal of information produced for the public, and will facilitate the involvement of the public in decisions around genetic screening and testing.

The birth of the e-clinic. Continuity or transformation in the UK governance of pharmaceutical consumption?

Traditional arrangements for the prescription and dispensing of pharmaceuticals have been challenged by the rise of Internet services enabling consumers to acquire these products online, without a face-to-face contact with a professional. This paper considers three moments in the emergence of the 'e-clinic' as an alternative route to prescription drugs in the United Kingdom: the electronic transfer of prescriptions; the development of the e-pharmacy and the 'virtual' pharmacist, and the establishment of online virtue medicine consultations. We examine the phenomenon in relation to issues of governance, considering the legal and voluntary frameworks that govern prescribing. Documentary and interview data suggest that the Internet has the potential to transform the relations between prescribers, dispensers and consumers, but that stakeholders seek continuity by applying existing governance frameworks and codes of conduct. This continuity can be explained by Rosenau's (Along the Domestic-Foreign Frontier. Cambridge University Press, Cambridge, 1997) model of a contested and fragmenting process of technology governance.

Medication Access through the Internet: Legal and Safety Considerations for Pharmacists

Today, it is common for patients to order prescription drugs via their home computer through an Internet pharmacy. Because of this, pharmacists may be faced with having to evaluate a patient's drug regimen that may include foreign-made imported drugs obtained through the Internet. This article addresses major issues involving drug importation via this mechanism. Topics discussed include types of Internet pharmacies, patient access to prescription drugs, self-medication, legal issues, and potential health risks. The current level of activity of Internet drug sales has reached record volume and does not appear to be subsiding; pharmacists should be aware of these emerging influences on their practice.