Background Although there are numerous legal and regulated online pharmacies available on the internet, an abundance of illegitimate online pharmacies are offering medications without prescriptions and deliver products with unknown origins worldwide. Despite the fact that the problem has gained the attention of regulatory and health organisations, the awareness of patients and many healthcare professionals is relatively low.
Objectives The purpose of this work is to assess the current situation of ordering medicines online, to survey the attitude of patients regarding online drug purchase, promoting the completion of the medication history worksheet and to recommend useful tools for hospital pharmacists to facilitate online medication safety.
Methods The attitude of 422 patients regarding purchasing drugs online was evaluated in a hospital environment.
Results 8.4% of Hungarian hospital patients have ordered drugs or dietary supplements online and 3.7% of the respondents are considering this option in the future. Most hospital patients (82.8%) are unaware of the quality of these products.
Conclusions Patients are not fully aware of the risks of potential hazards associated with purchasing medicines online and presumably cannot differentiate between legal and illegal online pharmacies. Illegal and counterfeit medicines pose a serious public health risk because the origin and quality of these drugs are uncertain and patients typically take these preparations without the knowledge and supervision of physicians or pharmacists. Pharmacists can play an essential role in protecting patient safety and combating counterfeit medicines.
Statistics from Altmetric.com
Online pharmacies sell pharmaceuticals including prescription medications on the internet.1 The popularity and the number of internationally operated internet-based pharmacies and the sales of prescription medications have grown tremendously during the past decade.23 Numerous websites are selling medications without prescriptions or deliver products with unknown origins and, unfortunately, the market is dominated by high-risk online drug sources.4 Patients are often not aware that medicines obtained from such untraditional sources can be counterfeit and, accordingly, that several risks can be associated with them.5 Owing to this new and only scarcely regulated trade in medicines, the chances of accidental overdose, drug interactions and toxicity are increasing.6 Health professionals and hospital pharmacists should be aware of important questions regarding online pharmacies and the illegal sale of medications.
Protecting patients buying medicine online is a new challenge for pharmacists
Quality used to be an unquestionable property of medicines for many years. However, patients can now receive low quality or unsafe drugs either by the infiltration of counterfeit medicines into the legitimate supply chain or by purchasing drugs from unapproved online pharmacies. So far, only a small number of counterfeit medicines have reached the legitimate pharmaceutical supply chain in developed countries. In the European Union and most industrialised countries with effective regulatory systems, the incidence of these low quality medicines is estimated to be low (less than 1% of market value).7 For example, in the UK nine recalls of medicines that had reached patients/pharmacists have occurred in the past 3 years.8 Internet, e-commerce and the free movement of products have also facilitated the development of online drug markets, especially illegal drug sellers. Today the online ordering and mail delivery of medicines is probably the most important potential source of substandard and counterfeit medicines, especially as the majority of online pharmacies can be traced to rogue affiliate networks obtaining prescription drugs from questionable sources.9
The first online pharmacies began operation in the late 1990s10 and, since then, the number of international online drug stores has increased. Although there are no official data on the number of people buying from internet pharmacies or the volume of money traded, there are many estimates. In the general population the percentage of people buying drugs online is near to 6%, according to a recent systematic review by Orizio et al.1 According to a recent estimate, more than two million people in the UK buy prescription-only medicines online.5 Europeans are estimated to spend 10.5 billion Euros annually on prescription-only medicines from illicit sources,11 while the global sales of counterfeit medications was expected to be US$75 billion in 2010.12 Healthcare organisations, manufacturers and governments have realised this new phenomenon but, to date, regulation and law enforcement is an unsolved problem at the international level.
Convenience versus health hazard: pros and cons of buying medicines from online pharmacies
The new market of online accessible medicines undeniably has many advantages for customers. It also must be stated that, in the case of legal and regulated online pharmacies, these advantages can be exploited without significantly endangering consumer safety.
Internet pharmacies are easy to access at any time of the day and people can efficiently compare prices and avoid hypothetically embarrassing face-to-face consultations with healthcare professionals.1 4 6 13 A large variety of products can be accessed via the internet including over-the-counter and complementary medicines, prescription-only drugs and even medicines that are not available due to drug shortages.14–16 Consumers can easily search for a required substance on Google and find an online trader within minutes. The majority of internet pharmacies operate in English, but many websites are also accessible in multiple languages. Thus, patients can purchase pharmaceuticals from remote countries, even within a relatively short period of time. Convenience is one of the most regularly communicated benefit17 as there is no need to visit a medical doctor or go to a local pharmacy. The advantages and potential disadvantages of obtaining medicines from internet pharmacies are summarised in table 1. If a health-related question occurs, online consultation is often available although the identity of these professionals is usually not provided. Furthermore, in many cases prescription drugs can be obtained without valid physician order because online questionnaires are stated to be enough for internet pharmacy operators to evaluate the health status, need and safety of the requested treatment. These benefits are easily recognised and are also intensively advertised on most websites but, unfortunately, customers might not see the real dangers behind them.
Although the risks associated with online medications can be minimised in regulated, approved and professionally operated internet pharmacy businesses, the internet supply of medicines has numerous disadvantages, concerns and even risks (box 1). This is particularly due to the fact that high-risk online drug sources dominate the internet4 and patients are often unaware that they are purchasing medicines from illegal and unauthorised drug distributors.5
A large number of illegal websites operate on the web. These ‘rouge online pharmacies’ sell medications without prescriptions and/or deliver products with unknown origins. Unapproved, falsified, falsely-labelled and counterfeit medicines are available which are deliberately and fraudulently mislabelled with respect to identity and/or source. They may include products with the correct ingredients or with the wrong ingredients, without active ingredients, with insufficient or too much active ingredient, or with fake packaging. These drugs can look so similar to the genuine product that they can deceive health professionals as well as patients.7
Procuring medicines outside the healthcare system can have many health-related and financial concerns (see table 1 and box 1). The chances of the misuse of drugs are high because of the absence of face-to-face communication and lack of medical instructions. In addition, the diagnosis and appropriate management of serious illnesses can be delayed and drug interactions or adverse effects are more likely to occur. Online pharmacies can also enhance the abuse of controlled prescription medications. Due to the different classification of medications, the same drug can be over-the-counter in one country while a prescription may be required in another. This issue has concerns regarding the regulation of advertising prescription-only drugs to consumers. Furthermore, there is no guarantee for personal data protection, privacy and credit card data security.14–6 18
In the past, lifestyle drugs such as those for erectile dysfunction or weight reduction were most commonly targeted by counterfeiters but today treatments for severe conditions such as cancer and heart disease are increasingly being counterfeited.19 The shortage of drug products can also attract non-traditional medicine distributors that offer medications with unknown origins at substantially higher prices.20 Consequently, the illegal online medical trade and counterfeit drugs present a timely problem worldwide.
Several studies have evaluated the percentage of people buying products from online pharmacies but the results are highly dependent on geographical location, type of products ordered and specific patient groups.1 17 21 According to our previous survey among 434 community pharmacy patients, 6.2% had already ordered medicines or dietary supplements online and approximately same percentage intended buying drugs from the internet in the near future. Educated people, those aged 30–49 years and women were most likely to buy medicines via the internet.22 In our current survey we aimed to characterise the utilisation, awareness and perception of hospital patients purchasing medicines from the internet.
Box 1 Potential risks associated with online medication use without medical evaluation and valid prescription
Patients may never meet doctors or pharmacists
Misuse of drugs
Non-adherence to prescribed therapy
Foreign and/or inappropriate labelling and dosage instructions
Adverse events and toxicity
Abuse of controlled prescription medications
Use of unapproved, fraudulent, poor quality drugs
Inappropriate personal and medical data protection
Delays in delivery, non-delivery or confiscation
Additional cost (shipment, VAT, customs)
The attitude of 422 patients to purchasing drugs online was evaluated in a survey implemented in a hospital setting. The study took place between October 2010 and January 2011 in hospital wards of eight Hungarian cities (Baja, Békéscsaba, Budapest, Debrecen, Komló, Mohács, Pécs, Szeged). Adult patients participating in the study self-administered the anonymous questionnaire consisting of 13 questions. Survey questions included those relating to patient demographics, education, information on the regularity of internet use and health-related information. Subjects were asked if they had ordered products from online pharmacies, whether they would do so if lower prices were offered, and their views on the quality of online products. Participants were also asked if they saw any danger with regard to ordering medicines from the internet. Medicines and dietary supplements were observed jointly because, due to several similarities, most consumers (and occasionally even members of the healthcare team) cannot differentiate between them.
The results of the survey were analysed using SPSS20 statistical software. Descriptive statistics were calculated for all variables. Categorical data are presented as frequencies and percentages, mean and SD for age.
A total of 422 surveys were completed by hospital patients. The mean age of the patients included in the survey was close to 50 years (mean ± SD 46.8 ± 13.8), men accounted for 40.3% of patients and 28.9% of all participants had completed college or university education.
Use of the internet and searching for online medical information
Most hospital patients interviewed were regular internet users with nearly half of them (43.4%) using the internet daily and only 120 (28.4%) using it less than once a week. Our survey supported the presumption that it is almost inevitable to encounter advertisements of medicinal products since 286 (67.8%) had seen online advertisements or spam massages regarding medicines. Every fourth patient interviewed (24.4%) regularly looked for health information online while 62 (14.7%) regularly visited internet websites containing information on medicines and dietary supplements. More details are shown in table 2.
Attitude of patients and consumers regarding online purchase of medicines
Information regarding the awareness and utilisation of online medicines was analysed. Thirty-four respondents (8.1%) reported ordering drugs or dietary supplements online and an additional 15 (3.6%) disclosed that they are considering this option within a short period of time. Only 27 patients (6.7%) had never heard about the possibility of ordering medicines from the internet (figure 1).
According to our observations, the awareness of Hungarian hospital patients about the risks associated with the internet purchase of medications is relatively low as most of the respondents (n = 318; 75.4%) did not know anything about the quality of pharmaceuticals ordered online. Some patients supposed that the quality of online products is just as good (n = 26, 6.2%) or even better (n = 12, 2.8%) than products obtained from conventional pharmacies, while only 6.6% (n = 28) thought that online drugs had lower quality. Probably because of these concerns, many respondents (n = 42, 10%) intended to buy medicines from the internet if lower prices were offered (figure 2). A total of 312 (73.9%) thought that counterfeit medicines pose a significant threat worldwide. Most hospital patients interviewed (n = 290, 68.7%) believed that ordering medications from the internet can be hazardous, while every fourth patient surveyed (n = 103, 24.4%) did not see any danger in procuring medicines online.
Although slightly more male participants (OR = 1.36) and patients with a college or university diploma (OR = 1.38) bought such products online, there was no statistically significant difference according to gender (p = 0.5) or education profile (p = 0.4) between those patients who have experience in ordering medicines or food supplements from the internet and those who do not. The ratio of patients aged >50 years was nearly the same among patients who had already ordered products from the internet and those who had not (50% and 47.5%, respectively; p = 0.4).
This study examined the current situation of ordering medicines online and the attitude of hospital patients to purchasing products from online pharmacies. The majority of hospital patients participating in our survey are regular internet users, with 43.4% using the internet daily and an additional 23.7% use it at least weekly. These results almost match Hungarian and EU27 Eurostat data.23 Many hospital patients search for health information on the internet, while a slightly smaller but still considerable number of respondents visit specific websites containing information on medicines and dietary supplements.
Most hospital patients are aware that drugs are available on the internet and only a few have not heard about it. A considerable number of respondents had already bought (8.1%) or are actually thinking of buying (3.6%) products from online pharmacies. Approximately the same number of interviewees reported the willingness to purchase medicines from foreign websites if lower prices were offered.
Ordering products online can be dangerous mainly because most online pharmacy websites are illegal and may deliver fake, illegal and counterfeit drugs. Regulatory authorities and international professional organisations are focusing on the development of necessary policies and are aiming to increase the awareness of individuals on counterfeit medicines and the associated public health risks. The WHO draws the attention of patients and health professionals to the dangers of counterfeit medicines,24 while a new law, the Ryan Haigh Online Pharmacy Consumer Protection Act, was introduced in the USA in 2009. Certification logos of major pharmaceutical authorities have been developed in the USA (Verified Internet Pharmacy Practice Sites logo), Germany (German Register of Mail Order Pharmacies) and Great Britain (Registered Pharmacy by the General Pharmaceutical Council). An international campaign called Operation Pangea (involving police, customs, national drug regulators and internet service providers) regularly takes action against online counterfeit drug crime and has contributed to the shutdown of hundreds of illegal websites and the seizure of illicit and counterfeit medicines valued at millions of US dollars.25–26 It is debatable whether enough public information is available about such cases and whether people actually realise the complexity of the problem (lack of adequate enforcement, criminal elements in global drug supply chains, high incidence of counterfeit products, public health risks) as the number of internationally operated illegitimate online pharmacies is currently enormous and the volume of global sales of illegal and counterfeit medicines is high.
Based on the results of our questionnaire, a large number of hospital patients were willing to buy their medicine online and probably most of them are not fully aware of the risks. Bearing in mind the numerous potential direct (impurities, wrong dosage, interactions) and indirect (lack of information, unmanaged disease/adverse effects) dangers of online medications, pharmacists should regularly give advice to patients regarding counterfeit medicines and internet-based pharmacies. Pharmacists can play an essential role in prevention, screening and evaluation.
Raising awareness in patients, doctors and nurses of the potential health hazards of illegal online pharmacies can be an effective tool in safeguarding patient safety. Patients should be advised to purchase their medicines only from qualified pharmacists and from reliable online sources.
Patient health records may not include those medicines, herbal remedies, vitamins and food supplements which were obtained from online sources. Thus, specific questions must be included in the patient medication anamnesis procedure (in the medication history worksheet) about the origins of these drugs.
If a patient insists on buying medicines from the internet, two important aspects should be evaluated: (a) searching for signs of danger and (b) looking for safeguards of patient safety on online pharmacy websites. For example, a sign of danger can be if no valid medical prescription is required or if no contact information is available on the website. Further warning signs may be if the retailer attaches suspicious disclaimers which exempt the pharmacy and its employees from any liability or if the online text contains numerous grammatical mistakes. Independent third party certifications (signs, seals, logos) are typical safeguards of patient safety, although their validity should be analysed by clicking on them to see if they link to the correct web page of the professional organisation. The geographical location and telephone number of the pharmacy should be declared on the website. Patients should have the option to consult with healthcare professionals (physician, pharmacist) and find detailed product information (dosing, side effects, storage) about the requested medication. After a patient receives the medicine from an online pharmacy, various other techniques can identify substandard or counterfeit medicines. The country of origin, the packaging of the drugs and the contents of the patient information leaflet can easily be evaluated by pharmacists. The analysis of the chemical composition, determination of microbiological contamination and assessment of the physical properties of the pharmaceutical preparation by pharmaceutical technology methods are accurate and reliable methods although they require a significant professional and financial background.
As the number of online pharmacy services is increasing with the growth of internet users worldwide, it is highly probable that we will see more and more patients purchasing uncontrolled, counterfeit or substandard medications over the internet. Significant risks are associated with the online trade of medicines as the origin of the products can be uncertain and patients may use them without the supervision of doctors or pharmacists. Substandard and counterfeit medicines also lack the proven list of ingredients and appropriate directions for use. Pharmacists and hospital pharmacists can play an essential role in safeguarding patient and drug safety by effectively informing patients and healthcare professionals about the dangers of these medications. Since the regulation of online pharmacies is currently unsatisfactory and most patients are unaware of the risks associated with these new non-traditional online medicine distributors, prevention, screening and evaluation are the most important tasks for pharmacists at present.
Patients are not fully aware of the risks of potential hazards associated with purchasing medicines online and presumably cannot differentiate between legal and illegal online pharmacies.
Illegal and counterfeit medicines pose a serious public health risk because the origin and quality of these drugs are uncertain and patients typically take them without the knowledge and supervision of physicians or pharmacists.
Pharmacists can play an essential role in protecting patient safety and combating counterfeit medicines.
Contributors All authors contributed to the planning and conduct of the research. EL and BB conducted the survey. AF and LB completed the reporting and the review of the work described.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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