Online Pharmacies Selling Prescription Drugs: Systematic Review

Global perspective of the risks of falsified and counterfeit medicines: A critical review of the literature

BACKGROUND

The increasing prevalence of falsified and counterfeit medicines globally poses risks to international travellers. This narrative literature review examines the global challenge of falsified and counterfeit medicines, with a specific focus on risks for travellers. The aim is to provide a comprehensive understanding of this multidimensional issue, exploring potential solutions for effective intervention.

METHODS

A comprehensive search of databases, including PubMed, MEDLINE, and Scopus, as well as relevant reports from international organisations, was undertaken. There was a focus on extracting information pertaining to the prevalence, types, and geographical patterns of falsified and counterfeit medicines encountered by international travellers. Synthesising this information helped to identify overarching trends and patterns. This narrative review utilised a thematic analysis approach to synthesise the findings.

RESULTS

The findings revealed a diverse range of counterfeit drug categories, spanning from antibiotics to lifestyle medications, posing unique risks to travellers navigating the global pharmaceutical landscape. The review emphasises the geographical distribution of these drugs, with varying consequences for both high- and low-income nations. The inadequate formulations and inconsistent drug release arising from these practices pose severe threats to public health, especially for individuals travelling abroad. The review also highlights the significance of international collaboration in addressing this global challenge, as pharmaceutical supply chains seamlessly cross borders, necessitating a collaborative approach for effective regulation and enforcement.

CONCLUSIONS

This review underscores the need for targeted research, collaborative interventions, and technological innovations to address the complexities associated with falsified and counterfeit medicines, ensuring the safety and well-being of international travellers.

Overview of online pharmacy regulations in Saudi Arabia and the Gulf cooperation council countries and their impact on online pharmacy service providers in Saudi Arabia: a qualitative analysis

Background

Laws and regulations are needed to regulate the growing online pharmacy (OP) services. The main objective of this work was to provide an overview of the laws and regulations for OP services in the Gulf Cooperation Council (GCC) countries. In addition, the perception of how these laws and regulations in Saudi Arabia (SA) affect the online ordering of medications and health-related products from national and international OPs was explored.

Methods

A secondary data collection through emails and a qualitative descriptive analysis was used to gain insight into the OP regulations in the GCC countries. Then, a qualitative study was carried out with semi-structured interviews to investigate the impact of these regulations on the practice and the market from the OP service providers' perspective. The interviews were carried out with a sample of major OP service providers in SA, to represent the GCC countries. During the interviews, multiple open-ended questions were used to explore opinions about the OP regulations and how these regulations affected the practice. The interviews were then transcribed and thematically analysed.

Results

Responses were mainly received from regulators in SA, Bahrain, Oman and United Arab Emirates (UAE). SA and UAE allow for offering of OP services as add-on service for existing community pharmacy, while UAE also allows for standalone OP providers. SA, Bahrain, and Oman allow online ordering of both over-the-counter (OTC) and prescription-only medications (POM) from international OP; a prescription is required for POM and quantities allowed should be no more than 3 months' supply in case of SA and Oman while this was not specified in case of Bahrain. Invoice of purchase was also required for any POM to be released from customs in SA and Bahrain but not in Oman and UAE. Controlled medications were prohibited to be ordered online in SA, UAE, and Bahrain while it was allowed in Oman if the prescription was issued within 6-month, and the quantity dispensed was for 1 month only. Apart from online ordering of medications in these countries, no specific regulations existed to regulate ordering of other health-related products from local or international OPs. Whether Kwait and Qatar have regulations for OP could not be established due to lack of response. Two of the four interviewed representatives of OP service providers in SA were not aware of the existence of specific regulations for OP services. The representatives who were aware of these regulations were satisfied with them and found them beneficial for their business and for the patients at the same time. However, representatives raised concerns regarding the enforcement of regulations on international OP providers.

Conclusion

The existing regulations for online ordering of medications are somewhat comparable between the GCC countries, with no specific regulations for ordering of other health-related products from local or international OPs. In SA, there is limited awareness of the existing regulations for OP services by providers. Nevertheless, the need for detailed regulations on certain aspects of OP services was highlighted, such as regulations for international OPs and importing medications for personal use.

Fair Balance of Prescription Drug Information on Legitimate and Illegitimate Online Pharmacy Websites

Patients require important information when prescribed medications. For example, the U.S. Food and Drug Administration (FDA) requires that promotional information includes a fair balance of risks and benefits. This study evaluates how well legitimate online pharmacies (LOPs) and illegitimate online pharmacies (IOPs) comply with the spirit of the FDA's fair balance guidelines by examining the extent and equivalence of risk and benefit information on their websites. This study analyzed the content of 307 online pharmacy websites. Most (90.3%) communicated drug benefits, while 84.7% provided risks. Both risk and benefit information was moderately extensive. Presentation of risks and benefits differed between online pharmacy types. Compared to LOPs, IOPs were more likely to present risk information but also exaggerate benefits. Four in ten online pharmacies presented a fair balance of risks and benefits. However, LOPs (47.4%) were more likely to present a fair balance than IOPs (36.5%). Interestingly, IOPs were more likely to disclose instructions for use and overdose information than LOPs. These findings underscore the need for regulatory guidelines to encourage online pharmacies to present a fair balance of benefit and risk information. Also, pharmacists should develop online approaches to better fulfill their professional responsibility as drug information providers while maintaining their integrity and objectivity.

What influences consumers' online medication purchase intentions and behavior? A scoping review

Objective: Consumers increasingly buy pharmaceuticals online. No scoping review has been carried out to summarize and synthesize the studies that have identified drivers of consumers' purchase intention and behavior from online pharmacies. Thus, we conducted a scoping review to explore the extent to which prior research has studied consumer purchase intentions and behavior related to online pharmacies, the drivers previously identified to explain consumers' online pharmacy purchase intentions and behavior, and how these antecedents differ between OTC and prescription medications. Then, we identified gaps in the published literature to form a comprehensive theory-based agenda for future research. Methods: We searched PubMed, Web of Science, and Scopus to retrieve relevant studies published in English in peer-reviewed journals. The search strategy identified forty-eight eligible studies. Results: We identified twelve types of factors influencing purchase intentions and behaviors from online pharmacies: demographics, convenience, availability, price, evaluations of the purchase environment, information sources, internet usage, prior experience, perceived risk, health insurance, privacy, and product. Our analysis also revealed differences between OTC and prescription medications in drivers of purchase intentions and behaviors. Conclusion: While demographic factors tended to be the most often measured influences on intentions and behavior, their role was generally inconsistent, with many contradictory results. However, other factors (e.g., convenience, availability, lower prices, and favorable evaluations toward the purchase environment) more consistently enhanced online medication purchase intentions and behavior. An extensive agenda for future research is advanced.

Online information and availability of three doping substances (anabolic agents) in sports: role of pharmacies

Background: The Internet has become an important source for easy access to doping substances, where people and athletes may acquire, outside pharmacies and without a (medical) prescription. These online websites do not always offer quality-assured products, and are outside the regular distribution channels of medicines. The aim of this study was to estimate the availability and accessible information on the Internet about the sale of three doping substances (oxandrolone, DHEA, androstenedione). Methods: Cross-sectional exploratory study, being an observation at a point in time of the online availability of these three doping substances (WADA S1 category: anabolic agents), purchased from Spain, Puerto Rico, Canada, United States, Ukraine and Russia. The characteristics of the websites, the countries the webs sold to, the pharmaceutical forms offered and the recommendations for its use were analyzed by using a computer tool designed ad hoc. Results: There were significant differences between countries in the number of webpages that sold the products (Chi-square test, p < 0.05). Oxandrolone was available for purchase mainly when buying from Spain (27.12%) and Ukraine (26.58%), in websites dedicated to sports (77.26%). For DHEA, most of the pages offered it if the search was done from Canada (23.34%) and Russia (21.44%). Products containing androstenedione or DHEA are claimed to enhance sports performance or for sports use without providing details. Compared to the total number of websites checked, the proportion of pharmacies offering these products was low, ranging from 4.86% for DHEA to 15.79% for androstenedione. Conclusion: The three substances selected are easily available without control through the Internet. Only a small number of websites offering them were online pharmacies, and requested a prescription. Most of the doping substances are purchased from the country where they are requested. Product information described benefits for sports performance, but did not do the same with their side effects. It would be advisable for these products to be sold through pharmacies, to guarantee their quality and provide evidence-based information on their safe use, benefits and risks, and only with a prescription. Athletes should be encouraged to consult health professionals about those supplements suitable for their type of training and sports objectives.

Practices, perceptions and trust of the public regarding online drug purchasing: a web-based survey from Jordan

OBJECTIVES

Online purchasing, including drugs, increased dramatically in the last decade especially through the COVID-19 pandemic. The aim of this study was to investigate the frequency and attitudes of consumers concerning online drug purchasing and assess their perceptions regarding the benefits and disadvantages.

DESIGN

A web-based survey conducted through a self-administered questionnaire that was approved by the Institutional Review Board (IRB) committee, ethical approval number: IRB/Al-Ahliyya Amman University/3/13/2021-2022. Cronbach's alpha for the attributes of benefits and disadvantages was 0.608 and 0.744, respectively. Primary outcome measures were extent of trust of the public in online drug purchasing using Likert scale. Multivariate linear regression was used to assess predictors of the trust score.

SETTINGS

Hashemite Kingdom of Jordan.

PARTICIPANTS

Inclusion criteria; residents of the Hashemite Kingdom of Jordan 18 years or older. The questionnaire was distributed through snowball effect via different social media.

RESULTS

A total of 428 participants filled the questionnaire, their average age was 29.7±11.2. Almost all participants, 419 (98.6%) use the internet daily but only 79 (18.6%) participants shop online regularly. Fifty participants (11.8%) purchased drugs online and they had higher benefits score of online purchasing compared with those who did not buy drugs online, 12.5±3.7 and 10.9±3.1, respectively, p=0.002. Participant who purchased drugs online had an increase in trust score of 0.847 compared with those who did not purchase drugs online, p<0.001. In the multivariate model, participants with education level of high school or higher than high school, compared with those with education lower than high school had an increase in trust score of 1.336 (p=0.026) and 1.137 (p=0.039), respectively.

CONCLUSION

The public recognises the risks in buying drugs online. Awareness campaigns and regulations that control and monitor online drug purchasing should be implemented.

Reasons that lead people to buy prescription medicines on the internet: a systematic review

Aim: This systematic review explores the factors that could influence consumer's decision of purchasing prescription medicines using the Internet. Methods: Relevant databases were searched to retrieve studies published from 2012 to 2021. The studies selected for inclusion were those focused on the consumer's perspective and the purchase of prescription medicines. A narrative synthesis was employed. The Capability Opportunity Motivation-Behaviour (COM-B) and the Theoretical Domains Framework (TDF) were employed as conceptual lenses that guided the analysis. Results: Seventeen studies were included. These studies have adopted various methodologies: qualitative method (n = 4), quantitative method (n = 12), and mixed methods (n = 1). The studies were based in Europe (n = 8), North America (n = 3), Middle East (n = 4), and 2 studies were conducted in several countries (multinational). The analysis of these studies revealed 7 themes that represent the reasons that lead people to buy prescription medicines via the Internet. These themes were the consumers' beliefs about the outcomes of the purchase (perceived benefits and risks of the purchase), consumer's emotions that could influence the purchasing decision, the factors that increase or decrease consumer's level of behavioural control over the purchase (facilitators and barriers of the purchase), consumers knowledge about the purchase, the trusting beliefs that lead consumers to trust the online sellers of medicines, the social influencing factors, and the external environmental factors that could encourage the purchase. Discussion: This study provides a comprehensive review of the breadth of reasons that drive people to buy prescription medicines via the Internet. Identifying those reasons could provide the basis for regulators to design evidence-based awareness campaigns to minimise the purchase of prescription medicines via the Internet. Furthermore, future research directions have been provided in this review to build upon the existing knowledge and address the research gaps in this area.

Public awareness of online pharmacies, consumers' motivating factors, experience and satisfaction with online pharmacy services, and current barriers and motivators for non-consumers: The case of Saudi Arabia

Purpose

Online pharmacies (OPs) represent a growing field that plays a major role in providing pharmaceutical services in Saudi Arabia (SA). Thus, investigating public awareness of this option and assessing consumers' experiences and satisfaction, as well as opportunities and barriers for OPs, were the main aims of this study.

Participants and methods

In this cross-sectional study, adult participants (≥18 years) in SA completed a three-part, custom-designed online questionnaire. The first section collected information on participants' demographic characteristics, their awareness of the existence of OPs, and history of OP purchases. The second section explores customer satisfaction levels and motivating factors. Finally, the third section investigated non-consumers' reasons for not purchasing from OPs and sought information about services that could motivate them to make future purchase decisions.

Results

In total, 487 participants completed the questionnaire; they were mostly female (65.7%) and younger than 40 years (57.1%). Among all the respondents, 89.3% were aware of the existence of OPs, and 60.2% purchased from OPs in the past. Most were satisfied with the product quality (92.7%), completeness of order delivery (91.2%), and condition of the product and packaging (89.3%). Furthermore, 99.2% of respondents indicated that they would continue to purchase from OPs. Customers' main motivational factors included saving time (85.5%), offers and discounts (83.6%), and variety of products (82.1%). Among non-consumers, the main reasons for not purchasing from OPs included a personal preference to visit a community pharmacy (87.2%), the ability to talk to pharmacists directly (83.6%), and the vicinity of a pharmacy (80.0%).

Conclusions

These findings confirm the increasing level of awareness regarding the existence of OPs in SA. Overall, OP customers expressed satisfaction with the services provided. Nevertheless, various areas of improvement have emerged, such as improved delivery time and providing medical consultation services. Increasing public awareness of OP services provided is essential considering their significant role in reforming the healthcare system in SA.

Diabetes Mellitus and Its Therapy in Brunei Darussalam - A Critical Revisit

Introduction

Diabetes is becoming an increasingly common condition across the world including Brunei Darussalam. Bruneian population, although is relatively small, represents a miniature urban community of neighbouring Southeast Asian countries as they share similar dietary and ethnicity patterns. Thus, it would be valuable to examine the findings of studies conducted among Bruneians. This study aimed to identify and review research related to the practice of patients with DM in Brunei Darussalam in order to identify associated factors influencing diabetic medication knowledge and adherence.

Methods

This narrative review analyzed literature related to DM and its therapy in Brunei Darussalam. Other issues consisting of knowledge and adherence related to DM were also explored. Databases (Scopus, PubMed, and Google Scholar) were used to search literature published up to May 2022. Search terms "diabetes mellitus", "Brunei" combined using Boolean operator were used.

Results and Discussion

Conducting appropriate studies in Brunei Darussalam can benefit the government and policymakers to implement effective measures and programmes to combat the diabetes epidemic. Despite the government's efforts, additional relevant stakeholders must be included in order to work together and engage in these initiatives in order to increase diabetes awareness, give people the power to make healthy decisions, and ultimately reduce the prevalence of diabetes in Brunei Darussalam. Patients' medication knowledge proficiency plays a main component of ensuring appropriate and safe use of medication prescribed to them.

Conclusion

Relatively poor medication knowledge and inappropriate diabetes-related practices were observed in studies conducted in Brunei Darussalam. However, no study has been done which directly measures both medication awareness and compliance among Brunei Darussalam T2DM patients. Future studies can focus on the relation between these two factors in different geographical locations of the world that are characterized by different diabetes-related practices and culture.

Multifactor Quality and Safety Analysis of Antimicrobial Drugs Sold by Online Pharmacies That Do Not Require a Prescription: Multiphase Observational, Content Analysis, and Product Evaluation Study

BACKGROUND

Antimicrobial resistance is a significant global public health threat. However, the impact of sourcing potentially substandard and falsified antibiotics via the internet remains understudied, particularly in the context of access to and quality of common antibiotics. In response, this study conducted a multifactor quality and safety analysis of antibiotics sold and purchased via online pharmacies that did not require a prescription.

OBJECTIVE

The aim of this paper is to identify and characterize "no prescription" online pharmacies selling 5 common antibiotics and to assess the quality characteristics of samples through controlled test buys.

METHODS

We first used structured search queries associated with the international nonproprietary names of amoxicillin, azithromycin, amoxicillin and clavulanic acid, cephalexin, and ciprofloxacin to detect and characterize online pharmacies offering the sale of antibiotics without a prescription. Next, we conducted controlled test buys of antibiotics and conducted a visual inspection of packaging and contents for risk evaluation. Antibiotics were then analyzed using untargeted mass spectrometry (MS). MS data were used to determine if the claimed active pharmaceutical ingredient was present, and molecular networking was used to analyze MS data to detect drug analogs as well as possible adulterants and contaminants.

RESULTS

A total of 109 unique websites were identified that actively advertised direct-to-consumer sale of antibiotics without a prescription. From these websites, we successfully placed 27 orders, received 11 packages, and collected 1373 antibiotic product samples. Visual inspection resulted in all product packaging consisting of pill packs or blister packs and some concerning indicators of potential poor quality, falsification, and improper dispensing. Though all samples had the presence of stated active pharmaceutical ingredient, molecular networking revealed a number of drug analogs of unknown identity, as well as known impurities and contaminants.

CONCLUSIONS

Our study used a multifactor approach, including web surveillance, test purchasing, and analytical chemistry, to assess risk factors associated with purchasing antibiotics online. Results provide evidence of possible safety risks, including substandard packaging and shipment, falsification of product information and markings, detection of undeclared chemicals, high variability of quality across samples, and payment for orders being defrauded. Beyond immediate patient safety risks, these falsified and substandard products could exacerbate the ongoing public health threat of antimicrobial resistance by circulating substandard product to patients.

Transferability Based on Drug Structure Similarity in Automatic Classification of Noncompliant Drug Use on Social Media: Natural Language Processing Approach (Preprint)

BACKGROUND

Medication noncompliance is a critical issue because of the increased number of drugs sold on the web. Web-based drug distribution is difficult to control, causing problems such as drug noncompliance and abuse. The existing medication compliance surveys lack completeness because it is impossible to cover patients who do not go to the hospital or provide accurate information to their doctors, so a social media-based approach is being explored to collect information about drug use. Social media data, which includes information on drug usage by users, can be used to detect drug abuse and medication compliance in patients.

OBJECTIVE

This study aimed to assess how the structural similarity of drugs affects the efficiency of machine learning models for text classification of drug noncompliance.

METHODS

This study analyzed 22,022 tweets about 20 different drugs. The tweets were labeled as either noncompliant use or mention, noncompliant sales, general use, or general mention. The study compares 2 methods for training machine learning models for text classification: single-sub-corpus transfer learning, in which a model is trained on tweets about a single drug and then tested on tweets about other drugs, and multi-sub-corpus incremental learning, in which models are trained on tweets about drugs in order of their structural similarity. The performance of a machine learning model trained on a single subcorpus (a data set of tweets about a specific category of drugs) was compared to the performance of a model trained on multiple subcorpora (data sets of tweets about multiple categories of drugs).

RESULTS

The results showed that the performance of the model trained on a single subcorpus varied depending on the specific drug used for training. The Tanimoto similarity (a measure of the structural similarity between compounds) was weakly correlated with the classification results. The model trained by transfer learning a corpus of drugs with close structural similarity performed better than the model trained by randomly adding a subcorpus when the number of subcorpora was small.

CONCLUSIONS

The results suggest that structural similarity improves the classification performance of messages about unknown drugs if the drugs in the training corpus are few. On the other hand, this indicates that there is little need to consider the influence of the Tanimoto structural similarity if a sufficient variety of drugs are ensured.

Use of the Internet for Health Purposes-A National Web-Based Cross-Sectional Survey among Adults in Poland

The Internet is one of the most popular information sources. This study aimed to assess the public attitudes towards the use of the Internet for health purposes as well as to identify factors associated with the use of the Internet for health purposes among adults in Poland. A web-based cross-sectional survey was carried out between 9 and 12 September 2022 on a nationwide random-quota sample of 1092 adults in Poland. The study questionnaire included 10 questions on Internet use for health purposes. The most common reason for the use of the Internet for health purposes was searching for information on drugs and their effects (69.9%). Almost two-thirds of participants used the Internet for searching for health information (64.9%), for doctors/medical services (63.4%), or for medical facilities (65.3%). Over half of the participants used the Internet for checking online reviews of doctors (55.2%) and 43.5% of the participants ordered drugs or dietary supplements online. Out of 9 different socioeconomic factors analyzed in this study, having higher education, being female, as well as living in cities from 100,000 to 499,999 residents were the most important factors (p < 0.05) associated with the use of the Internet for health purposes. This study confirmed a high level of adoption of medical Internet in Poland.

Online Pharmacy Accessibility of Imatinib, An Oral Chemotherapy Medication

BACKGROUND

Since prices of imatinib (Gleevec) remain high, patients on oral chemotherapy are looking for alternative methods to access this life-saving medication. We assessed the accessibility of imatinib through online pharmacies and analyzed each website for medication safety, price, and marketing tactics.

METHODS

We searched the term "buy imatinib online" using 4 commonly used internet search engines (Google, Bing, Yahoo!, and DuckDuckGo) and screened web pages displayed in the first 10 pages. Websites were included if they were published in English, sold imatinib, were free to access, and offered shipping in the United States. Websites were classified using LegitScript's categorization as "certified," "unclassified," "unapproved," or "rogue." We analyzed information on websites' patient safety characteristics, marketing techniques, pricing, domain registration information, and IP addresses.

RESULTS

Of the 44 online pharmacies identified, only 3 (7%) were certified, and the remainder were classified as rogue (52%; n=23), unapproved (30%; n=13), or unclassified (11%; n=5). Thirteen online pharmacies (30%; 9 rogue, 4 unclassified) sold imatinib without a prescription. Nearly one-quarter (n=10) of online pharmacies selling imatinib did not include drug-related warnings on their websites, and nearly half (n=21) did not limit the purchasable quantity. More than three-quarters (n=34) of online pharmacies selling imatinib did not offer pharmacist consultations, even though nearly all websites extended offers to speak with sales associates (91%; n=40). Most online pharmacies selling imatinib claimed price discounts (95%; n=42), but fewer provided bulk discounts (23%; n=10) or coupons (34%; n=15). One-third of rogue pharmacies selling imatinib (n=7) claimed to be registered or accredited on their websites.

CONCLUSIONS

The lack of safety measures taken by illegitimate online pharmacies endangers patient safety because they allow patients to purchase imatinib without appropriate evaluation for response, drug interactions, and adverse effects. Healthcare providers need to be aware of this practice and should assure patient access to imatinib through safe and legitimate pharmacies.