John B. Hertig, PharmD, CPPS, FASHP
Associate Professor and Vice-Chair of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences

Matthew J. Rubin, MSL
Director, Government and Regulatory Affairs, Faegre Drinker 

At any given time, there are an estimated 35,000 online pharmacies worldwide selling prescription medications to patients (FDABeSafeRx, 2020). While online pharmacies are prevalent, knowledge pertaining to the legitimacy, legality and safety of these establishments are lacking (Ivanitskaya et al, 2010). Of all online pharmacies operating at any given time, 95% are doing so illegally, either in violation of state or federal law or relevant pharmacy practice standards (National Association of Boards of Pharmacy: 2019 Roque Rx Activity Report). Separate from the criminality of illegally operating online pharmacies, there are public health and patient safety concerns regarding quality of the medications supplied. Risks stemming from illegal online drug sales, as outlined by the World Health Organization (WHO), include no guarantees that the product supplied is what was ordered, where the product is manufactured or stored, as well as if the seller is authorized to dispense these products (WHO, 2017). Additionally, it has been shown that healthcare providers may not be adequately trained to help patients navigate these online sites when determining their legality or safety (Hertig and Sebahar, 2017). Therefore, patients may be using illegal online pharmacies without knowledge of any resources or identifiers to keep themselves safe or those under their care.

Unsurprisingly, trends in utilization of online and digital healthcare services have been amplified by the circumstances surrounding the COVID-19 pandemic. With more than 100,000 new websites launching in the month following the announcement of a public health emergency including terms such as “covid” and “corona,” criminals have leveraged fear and uncertainty to augment profits. As a result, many remain at risk of using online sources that could result in significant harm. The National Association of Boards of Pharmacy (NABP) recent review of this troubling development confirmed that over 90% of the COVID-19 related domain names identified were registered anonymously, bringing into question the legitimacy of these sites and highlighting difficulty in further investigations (NABP, Rogue Rx Activity Report May 2020). Given that the natural rise in digital healthcare consumerism has likely accelerated as a result of the global pandemic, additional research was needed to assess consumer perceptions and attitudes towards the use of online pharmacies.

SURVEY BRIEF & FINDINGS

In July 2020, researchers commissioned Abacus Data to conduct a national survey seeking to evaluate United States consumer perceptions of online pharmacies. Building on the similar BuySafeRx 2017 survey of 500 Indiana residents, the survey instrument was designed to measure awareness and perceptions of online pharmacies, while exploring any influence the COVID-19 pandemic has had on consumer behavior. Baseline research from 2017 indicated 27% of consumers are very familiar with online pharmacies, with a majority (55%) reporting they have or would consider buying medications online. One-third of respondents indicated previous use of online pharmacies for themselves or someone under their care. While less than 5% of consumers are aware of tools available to help them find safe online pharmacies, more than 90% of consumers did not discuss online pharmacies with their healthcare provider (The Alliance for Safe Online Pharmacies, 2017).

The survey consisted of 30 questions that were validated. Sampling was used to ensure 400 Indiana-based respondents to allow for direct comparison to the 2017 study cohort.  An additional 1100 random sample of demographically diverse and representative U.S. consumers was captured to allow for greater generalization of survey results. All results were anonymous and the research was determined to be exempt from full institutional review board (IRB) review.

The results confirmed a majority of Americans take prescription medication daily and a growing number of them are buying them online for convenience and cost. Thirty-five percent of respondents cited the pandemic as a driver for increased use of the internet for healthcare-related services. The data supports a significant increase in utilization of the internet for online pharmacy-related services within the past year (see Figure 1).

Despite most consumers having little first-hand experience or knowledge with the dangers posed by illegal online pharmacies, their perceived awareness and comfort with purchasing medicines via the internet is high and growing. This significant realization is only further compounded as a third of Americans turn to doctors, pharmacists and nurses for information about purchasing drugs online. However, only half of these healthcare professionals are highlighting the potential risks to their patients (see Figure 2).

A majority of consumers remain unaware of any risks associated with internet drug sales and an unsettling percentage believe that online pharmacies are worth the associated risk (see Figure 3).

Key Findings

• 37% of Americans see little to no risk in using prescription medication purchased from an online pharmacy.
• Since the 2017 baseline survey, researchers identified a 3% increase in American consumers’ use of the internet to purchase prescription drugs
• 7 in 10 Americans erroneously believe that if an online pharmacy website appears high up in a search engine search, it is likely to be legitimate.
• American’s comfort level for buying medicine via the internet for the perceived convenience and cost benefits online pharmacies offer has increased dramatically since 2017 (see Figure 4).

Based upon the evidence surrounding increased consumer utilization of digital health and telemedicine services, including a precipitous rise during the COVID-19 pandemic, it is critical that stakeholders take significant action to protect and promote public health and safety through comprehensive education and policy initiatives. The survey results indicate an anticipated reliance on the internet post-pandemic for continued access to prescription drugs and healthcare services. Of those who have initiated online pharmacy use during the pandemic, nearly three-quarters (72%) plan to continue. Similar perspectives were demonstrated by individuals that relied strictly upon brick-and-mortar healthcare services pre-pandemic. Thirty-nine percent plan to initiate virtual healthcare services within the next six months and approximately one-in-eight (13%) plan to shift healthcare services entirely virtual. Concern remains, however, as 30% of respondents note their willingness to order prescription drugs online without prior consultation with a physician. No longer is it practical to counsel consumers to avoid the internet to access healthcare.  We must shift from the messaging of “do not go online” instead to offer advice on “how to go online safely.”

The coronavirus pandemic has undoubtedly altered the way in which U.S. consumers seek out and obtain healthcare services, including access to healthcare providers and prescription-only medications. These data demonstrate a continued reliance upon the internet for healthcare information and related services. As such, healthcare providers, academia, industry and other stakeholders must continue to act in ways that promote public health and safety and aim to mitigate the risk of criminality online, with particular focus on education, outreach and engagement.

SUPPLEMENTAL MATERIALS

The final Alliance for Safe Online Pharmacies (ASOP Global) press release and data readout is available here: BuySafeRx