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Online pharmacies are companies that sell pharmaceutical preparations, including prescription-only drugs, on the Internet. Very little is known about this phenomenon because many online pharmacies operate from remote countries, where legal bases and business practices are largely inaccessible to international research.
The aim of the study was to perform an up-to-date and comprehensive review of the scientific literature focusing on the broader picture of online pharmacies by scanning several scientific and institutional databases, with no publication time limits.
We searched 4 electronic databases up to January 2011 and the gray literature on the Internet using the Google search engine and its tool Google Scholar. We also investigated the official websites of institutional agencies (World Health Organization, and US and European centers for disease control and drug regulation authorities). We focused specifically on online pharmacies offering prescription-only drugs. We decided to analyze and report only articles with original data, in order to review all the available data regarding online pharmacies and their usage.
We selected 193 relevant articles: 76 articles with original data, and 117 articles without original data (editorials, regulation articles, or the like) including 5 reviews. The articles with original data cover samples of online pharmacies in 47 cases, online drug purchases in 13, consumer characteristics in 15, and case reports on adverse effects of online drugs in 12. The studies show that random samples with no specific limits to prescription requirements found that at least some websites sold drugs without a prescription and that an online questionnaire was a frequent tool to replace prescription. Data about geographical characteristics show that this information can be concealed in many websites. The analysis of drug offer showed that online a consumer can get virtually everything. Regarding quality of drugs, researchers very often found inappropriate packaging and labeling, whereas the chemical composition usually was not as expected in a minority of the studies’ samples. Regarding consumers, the majority of studies found that not more than 6% of the samples had bought drugs online.
Online pharmacies are an important phenomenon that is continuing to spread, despite partial regulation, due to intrinsic difficulties linked to the impalpable and evanescent nature of the Web and its global dimension. To enhance the benefits and minimize the risks of online pharmacies, a 2-level approach could be adopted. The first level should focus on policy, with laws regulating the phenomenon at an international level. The second level needs to focus on the individual. This approach should aim to increase health literacy, required for making appropriate health choices, recognizing risks and making the most of the multitude of opportunities offered by the world of medicine 2.0.
Neo, which pill would you choose? You take the blue pill—the story ends, you wake up in your bed and believe whatever you want to believe. You take the red pill—you stay in Wonderland and I show you how deep the rabbit-hole goes[1].
Although their choice is much less metaphysical than the question posed to Neo in the science fiction movie
The online sale of drugs started in the late 1990s and has expanded so much that the US Food and Drug Administration (FDA) has implemented an entire section on its website dedicated to “Buying medicines over the Internet” [
It is very difficult to estimate the number of online pharmacies and people buying online, the volume of drugs traded, and the revenue and profits generated by such a hidden business. Moreover, the geographical distribution of the phenomenon seems to be very heterogeneous. With regard to the number of online pharmacies, MarkMonitor in a 2009 press release claimed to have found nearly 3000 websites selling prescription medicines, while a 2010 review by the US National Association of Boards of Pharmacy (NABP) investigated the characteristics of 5859 Internet outlets selling prescription medications [
This new market has undoubted advantages for patients: access to drugs for the disabled or housebound, access 24 hours a day, a virtually unlimited number of products available, relative privacy, which may encourage patients to ask questions about embarrassing issues, and more affordable prices [
To our knowledge, 2 reviews about online pharmacies in general and 3 others on specific aspects related to online pharmacies are available. With regard to general reviews, Fung et al [
Other reviews tackled specific issues but were unable to give an overall picture of the phenomenon. A recent review examined counterfeit phosphodiesterase type 5 inhibitors (PDE5Is) for the treatment of erectile dysfunction, similar to the 2000 review of sildenafil and the Internet [
This review sought to investigate the available evidence on the phenomenon of online pharmacies. We report data on the 3 main areas on which the literature focuses: the characteristics of the websites, the quality of pharmaceutical products purchased online, and the number of consumers and their characteristics.
The literature search covered the period up to January 2011. The search was performed on 3 sources: electronic databases, search engines, and institutional websites. First, we searched, without any limitations as to publication date, the following electronic databases: PubMed [
The database search identified 18,857 records, and other sources (search engines and institutional websites) gave 5893 additional records. Screening of these 24,750 records led to 730 articles, excluding duplicates and nonpertinent results. It is important to point out that such a drop in numbers depends mainly on the use of multiple key words, which are often very similar, which were used in order not to miss any pertinent studies. This resulted in a notable “noise effect,” thereby decreasing the specificity and increasing the sensitivity of our search strategy. An in-depth analysis of the 730 selected articles produced 193 eligible ones that were pertinent to the study and fit the inclusion criteria. Of these, 117 where excluded from the analysis and are listed in
Paper selection algorithm.
We included all articles relevant to the subject of the research—namely, online pharmacies, their characteristics, their products, and their consumers. We selected only articles dealing with the sale of prescription-only drugs and with websites that presented themselves as pharmacies: the purpose was to stay within the sphere of substances that are supposed to involve a doctor–patient relationship. Articles regarding only over-the-counter medicines, complementary medicines, herbal remedies, supplements, and drugs of abuse were excluded. If the researchers analyzed websites selling prescription and over-the-counter drugs, we considered websites selling prescription drugs if it was possible to identify them. We decided to deal only with prescription drugs, although over-the-counter substances can also have negative effects on people’s health, despite the no-harm claims made by their producers, as several clinical cases demonstrate [
As an additional inclusion criterion, we selected articles in English that had the abstract or the full text available. We included only scientific articles, which means that we excluded popular articles published in daily newspapers, and in weekly and monthly magazines.
We classified the articles according to whether they reported original data. We selected only the articles reporting original data, which means that we excluded articles lacking original data, which means those with only a speculative discussion about the problem or only citing data from other studies; these are, for example, editorials, letters, comments, articles about regulation issues, and reviews. However, to make this debate easily available to the reader, we have listed all articles without original data in
The original data are described according to 3 main subjects: types and characteristics of online pharmacies, drugs purchased online, and online pharmacy consumer data, which included case reports on complications occurring in consumers of drugs purchased online. Some articles with original data covered more than 1 of these subjects and were consequently allocated to more than 1 group. Each of these categories is described below.
If they were available, we recorded the number of online pharmacies analyzed in each study, year of data collection, willingness to dispense pharmaceuticals with or without a prescription, availability of a physician’s assistance or online medical consultation, disclosure of contact details, geographical location, delivery conditions, types of medicines available, availability of drug information, prices of online drugs and overall costs, sales-promotion strategies, how long websites were accessible, privacy and disclaimer statements, date of last website update, and presence of quality certifications (for instance, Verified Internet Pharmacy Practice Sites [VIPPS] by the NABP; the Health on the Net Foundation [HON] code; and the Joint Commission on Accreditation of Healthcare Organizations [JCAHCO]).
We recorded studies in which the researchers bought prescription drugs online and evaluated the actual purchase and its characteristics. We summarized data regarding the type of drug ordered, the response rate, the quality of the process, and the drugs purchased. Regarding process characteristics, we recorded prescription requirements, management of the online questionnaire, money transactions, and subsequent advertising; with regard to drug quality, we recorded data about packaging and instructions, and chemical composition.
We described articles dealing with the number of people purchasing drugs online, which was estimated by means of questionnaires or interviews. Researchers attempted to list the most frequently requested drugs, the main reasons for buying pharmaceutical products online, the importance of the location of online pharmacies they bought from, and the perceived risks related to this practice. In addition, we classified in this section articles that reported clinical cases of adverse effects to active substances and drugs purchased via the Internet as an indicator of this phenomenon.
We selected 193 relevant articles: 76 articles with original data (39%), and 117 articles without original data (editorials, regulation articles, or the like) including 5 reviews. Articles with original data concerned samples of online pharmacies in 47 cases, online drug purchase in 13, consumer characteristics in 15, and case reports of adverse effects of online drugs in 12.
We selected 47 articles about online pharmacies. All of them are shown in
Contents of articles about online pharmacies, listed in alphabetical order according to first author; the presence of each item is indicated when studied and the percentage is reported when comparable; “X” indicates that the item was analyzed but could not be tabled
First author, |
Prescription |
Online questionnaire |
Contact details |
Geographical location |
Delivery | Drugs |
Drug |
Prices | Marketing |
Quality | How long |
Privacy |
Armstrong, 1999 [ |
0 | 50 | 100 | Xa | 55 | X | X | X | X | |||
Arruanda, 2004 [ |
30 | 99 | X | X | 35 | X | X | X | ||||
Bate, 2010 [ |
X | Xa | X | |||||||||
Bessel, 2002 [ |
81 | 12 | 66 | 79 | X | X | X | X | X | |||
Bloom, 1999 [ |
Xb | Xb | 11 | X | X | |||||||
Bloom, 2006 [ |
Xb | Xb | 92 | X | X | X | ||||||
CASAc, 2008 [ |
15 | 41 | X | Xa | X | |||||||
Cicero, 2008 [ |
Xa | X | ||||||||||
European Alliance, 2008 [ |
10 | 16 | 42 | 16 | X | X | X | |||||
Eysenbach, 1999 [ |
9 | 50 | X | Xa | X | X | X | |||||
Forman, 2003 [ |
0a | X | Xa | |||||||||
Forman, 2006 [ |
0a | X | Xa | |||||||||
Forman, 2006 [ |
0a | 50 | Xa | |||||||||
Forman, 2006 [ |
0a | 52 | Xa | X | X | |||||||
Gallagher, 2010 [ |
7 | 59 | 100 | 59 | ||||||||
GAOd, 2000 [ |
58 | 28 | 81 | 61 | X | |||||||
GAOd, 2004 [ |
34 | 40 | X | X | ||||||||
Gernburd, 2007 [ |
0 | 100 | X | X | X | |||||||
Gurau, 2005 [ |
34 | 59 | 100 | X | X | |||||||
Holmes, 2005 [ |
Xe | |||||||||||
Koong, 2005 [ |
X | |||||||||||
Kunz, 2010 [ |
X | |||||||||||
Kuzma, 2011 [ |
X | |||||||||||
Levaggi, 2009 [ |
19 | 67 | 44 | X | X | X | X | |||||
Littlejohn, 2005 [ |
10 | X | X | X | ||||||||
Mahé, 2009 [ |
X | Xa | X | X | ||||||||
Mainous, 2009 [ |
0a | 64 | X | Xa | ||||||||
Makinen, 2005 [ |
X | X | Xa | X | X | X | ||||||
Memmel, 2006 [ |
0 | 75 | X | Xa | X | |||||||
NABPf, 2010 [ |
4 | 58 | 47 | X | X | |||||||
Orizio, 2009 [ |
19 | 56 | 43 | X | X | X | X | |||||
Orizio, 2009 [ |
0a | 100a | 28 | |||||||||
Orizio, 2010 [ |
22 | 45 | X | X | X | X | X | |||||
Peterson, 2001 [ |
88 | 67 | Xa | X | X | X | X | |||||
Peterson, 2003 [ |
Xa | X | X | X | X | |||||||
Quon, 2005 [ |
Xa | X | X | |||||||||
Raine, 2009 [ |
17 | 41 | 43 | Xa | Xa | X | ||||||
Schifano, 2006 [ |
0 | 10 | Xa | |||||||||
Soares Gondim, 2007 [ |
81 | Xa | X | X | ||||||||
Tsai, 2002 [ |
0a | 81 | 37 | 98 | Xa | X | X | X | ||||
Veronin, 2007 [ |
Xa | |||||||||||
Wagner, 2001 [ |
100 | 100 | Xa | X | Xa | 100 | X |
a See other specific inclusion criteria, fourth and fifth column in
b Does not specify whether the prescription is an original one from the customer’s physician or an online one.
c National Center on Addiction and Substance Abuse.
d US Government Accountability Office.
e The study aimed to evaluate the responses provided by the “ask the pharmacy” service.
f National Association of Boards of Pharmacy.
The remaining 42 articles [
The works were published between 1999 [
Online pharmacy samples varied hugely in size, from 4 [
Articles on online pharmacy characteristics (included in
One of the most controversial and widely studied features is prescription requirement. For the first time, online pharmacies are providing easy access to traditionally controlled (according to each country’s regulations) substances, such as pharmaceutical products, which in regulated systems need an original medical prescription before they can be bought. The peculiar distribution chain for prescription drugs is due to the unique nature of pharmaceutical products; the philosophy behind prescription is that consumers are not skilled enough to make their own choice, but need to be given a prescription by a health professional trained to make a risk–benefit evaluation [
Due to the different methods of sample selection, distribution varies greatly in the articles. Some online pharmacy samples were specifically selected to have only websites not asking for a prescription from the customer’s physician [
Some of the online pharmacies not asking for a prescription replaced it with an online health status evaluation, performed by means of an “online questionnaire.” Researchers reported a percentage of online pharmacies offering and/or requiring an online prescription in a range of 10% to 81% [
Contact details were revealed in the majority (ranging from 100% [
Declaration of geographical location is an important feature with regard to transparency. Apart from the studies that focused only on websites based in a specific area, the sampled websites declared a geographical location ranging from 11% to 100% [
The National Center on Addiction and Substance Abuse (CASA) [
Both Arruanda [
What do online pharmacies have to offer? From an analysis of the literature it appears that online pharmacies have become more and more complex as time passes; whereas 10 years ago they tended to sell principally lifestyle drugs such as sildenafil, it looks today as if they offer virtually anything. Back in 1999, Bloom and Iannacone [
Some studies focused on specific classes of drugs. They looked for Parkinson disease medications [
Littlejohn et al [
In 1999 Armstrong et al [
Holmes et al [
Arruanda [
A comparison of online pharmacy and retail pharmacy prices had different results. Drugs offered online were more expensive in Bloom and Iannacone’s studies [
Additional costs have to be considered: the need to join clubs or member groups and pay a nonrefundable fee, with the risk of not finding the wanted drug after joining [
Only a few articles focused on the marketing strategies of online pharmacies. Levaggi et al [
The presence of at least 1 quality certification was found to range from 12% to 13% [
Regarding health content quality, Arruanda [
As regards the security of the money transaction, Arruanda [
A special study was performed by Kuzma [
Kunz and Osborne [
Arruanda [
In several of the papers analyzed we found that some websites required the consumer to relieve the companies from all liability, from 100% of websites [
Only 1 study investigated the date of the online pharmacies’ last update, which was displayed by 4% of them (data not shown in
We found 13 studies [
Articles on the quality of drugs purchased online, listed in alphabetical order according to the first author
First author, year of |
Year(s) of data |
Type of drugs ordered | Response rate (products |
Drug purchase |
Drug quality |
Bate, 2010 [ |
2009 | Lipitor, Viagra, Celebrex, Nexium, Zoloft | Response rate not computable; 152 ordered drugs were received | Prescription requirement, money transaction | Packaging, chemical analysis |
Cicero, 2008 [ |
2006 | Opioid analgesics | 0% (0/47) of “opioid scheduled” orders, 100 (1/1) purchase of tramadol | Prescription requirement, money transaction, subsequent advertisement | |
Dean, 2010 [ |
Not declared | Dapoxetine | 100% (1/1) | Chemical analysis | |
European Alliance, 2008 [ |
Not declared | 18 different active ingredientsa | 94% (34/36) | Prescription requirement | Packaging, instructions, chemical analysis |
Eysenbach, 1999 [ |
1999 | Viagra | 30% (3/10)b | Prescription requirement, management of online questionnaire, money transaction | |
GAOc, 2004 [ |
2004 | 13 different active ingredientsd | 75% (68/90) | Prescription requirement, money transaction | Packaging, instructions, chemical analysis |
Gernburd, 2007 [ |
2006 | 13 different active ingredientse | 39% 5/13b | Prescription requirement, money transaction | |
Mainous, 2009 [ |
2008 | Antibiotics | 100% (1/1) | Prescription requirement | Instructions |
Memmel, 2006 [ |
2004–2005 | Hormonal contraceptives | 100% (10/10)f | Prescription requirement, management of the online questionnaire | Packaging, instructions |
Miller, 2001 [ |
1999–2000 | Prescription and nonprescription contraceptives | 96% (9/10 in 1999 and 15/15 in 2000) | Prescription requirement, money transaction | |
Veronin, 2004 [ |
Not declared | Simvastatin | Response rate not computable; 5 ordered samples were received | Chemical analysis | |
Veronin, 2007 [ |
2006 | Simvastatin | 100% (4/4)g | Chemical analysis | |
Westenberger, 2005 [ |
Not declared | Fluoxetine, levothyroxine sodium, metformin hydrochloride, phenytoin sodium, warfarin sodium | Response rate not computable; 20 ordered samples were received | Packaging, instructions, chemical analysis |
a The drugs purchased were Cialis, Levitra, Viagra, Propecia, Lipitor, Plavix, Seretide, Coversyl, Micardis, Spiriva, Zyprexa, Efexor, Risperdal, Aricept, Reminyl, Zoton, Reductil, and Mirapex.
b Orders made only on websites asking for an “online questionnaire” to be filled in to obtain an online prescription. The online questionnaire was completed by a fictitious patient with clear contraindications for sildenafil.
c US Government Accountability Office.
d The drugs purchased were Accutane, Celebrex, Clorazil, Combivir, Crixivan, Epogen, Humulin N, Lipitor, and OxyContin.
e The drugs purchased were Ambien, Celebrex, Cialis, Meridia, Nexium, Propecia, Soma, tramadol, Valium, Viagra, Xanax, Zithromax, and Zoloft.
f Orders made with different risk profiles.
g Orders from Canadian websites only.
The actual purchase of drugs without having an original medical prescription was verified by all authors except for Dean et al [
Several authors found a lack of reliability in the business practices of some online pharmacies, linked to completed money transactions without actual receipt of the drugs [
Regarding drug quality characteristics, researchers evaluated different features: the packaging of the drugs purchased, the instructions included, and the chemical composition.
As to packaging characteristics, packaging showed problems in more than half of the drug samples in the GAO [
The GAO [
The most difficult task in connection with online pharmacies is attempting to establish the number of people buying and the volume of money traded. Except for cases when this practice is a legal requirement, there are no official data on the issue and it was not possible to obtain details from the Internet as in the sections above.
The scientific evidence about consumers comprises 2 types of data: population surveys and case studies on the adverse effects of drugs purchased via the Internet.
Articles about consumers buying from online pharmacies, listed in alphabetical order according to the first author
First author, year of |
Year(s) of data |
Country where the |
Population investigated | Study design | Percentage of people |
Atkinson, 2009 [ |
2005 | US | Sample of general population | HINTS 2005 surveya | 13% (715/5586) (bought medicines or vitamins) |
Baker, 2003 [ |
2001–2002 | US | Sample of general population | Internet survey | 5% (over 3668 respondents) |
Bechara, 2010 [ |
2009 | Argentina | Healthy young men | Questionnaires on use of phosphodiesterase type 5 inhibitors | 2.9% (2/321) |
Cicero, 2008 [ |
2006 | US | Prescription drug abusers | Questionnaires | 6% (41/685) |
Cohen, 2010 [ |
2009 | US | Sample of general population aged 18–64 years | NHI Survey 2009b | 6% of 7192 |
Fox, 2004 [ |
2004 | US | Sample of general population | Telephone interviews | 4% (93/2200) |
Gordon, 2006 [ |
2003–2004 | US | Drug-dependent inpatients | Semistructured interviews | 6% (6/100) |
Gurau, 2005 [ |
2004 | UK | Sample of general population | Semistructured questionnaires | 34% (102/300) (people buying or intending to buy online) |
Harte, 2010 [ |
2006–2007 | US | Male college and university students | Online questionnaires on use of phosphodiesterase type 5 inhibitors | 12% (8/77) of users |
Inciardi, 2009 [ |
Varies with source | US | Drug abusers, students, street sex workers, and “club culture” population | RADARS Systemc, NSDUHd, Delaware School Study, Miami street studies, and qualitative studies | 1%–6% |
Inciardi, 2010 [ |
Varies with source | US | Drug abusers, students and young adults | RADARS Systemc, NSDUHd, MTFe | 0.5%–3% |
Mazer, 2010 [ |
2007 | US | Sample of emergency department patients | Questionnaires | 5.4% (89/1654) |
Rajamma, 2009 [ |
Not declared | US | Sample of general population born 1946–64 | Online questionnaires to a sample from the consumer panel by Common Knowledge Research Services | Not applicablef |
Schnetzler, 2010 [ |
2008 | UK, Germany, Italy | Sexually active men | Online questionnaires on use of phosphodiesterase type 5 inhibitors | 32%g |
Wiedmann, 2010 [ |
2008 | Germany | Sample of general population | Face-to-face interviews | Not applicablef |
a Health Information National Trends Survey by the National Cancer Institute.
b National Health Interview Survey.
c Researched Abuse Diversion and Addiction-Related Surveillance System.
d National Survey of Drug Use and Health.
e Monitoring The Future.
f Evaluation of online drug shopping attitude related to cognitive characteristics.
g 32% of Viagra users obtained the drug from sources outside the health system, including the Internet.
In studies about the general population, the percentage of people buying drugs online was between 4% and 6% in the United States in the studies by Fox [
As in the general population studies, Mazer et al [
Both surveys on prescription drug abusers [
A US survey on the recreational use of erectile dysfunction medications in undergraduate men showed that 12% of users had bought them on the Internet [
Some reports suggest widespread use of online pharmacies in people over 35 years of age [
Rajamma and Pelton [
We found 12 published papers on clinical cases related to prescription drugs obtained via the Internet, which are shown in
We synthesized the scientific literature on online pharmacies by performing an up-to-date and comprehensive review scanning several scientific and institutional databases, with no publication time limits, focusing on the broader picture of online pharmacies. We thought it was necessary to implement a new review because we found no recent summarizing material in the scientific literature, since the second of the only 2 available reviews with a general approach cited just 14 papers regarding online pharmacy supply and was up-to-date to 2007. This is quite a considerable time in a rapidly changing world such as the Internet. In addition, 63% (48/76) of all the studies we found with original data were published in or after 2005, which seems to indicate that the phenomenon of purchasing medications online is increasing.
The main challenge in conducting this review was that the works we further analyzed and report were fairly difficult to compare owing to the widely differing methods used to select and assess samples, and often the works were written in answer to multiple research questions. In order not to miss the multiple aspects of these works we elaborated different research questions—in our opinion the only way to analyze these data. This could be seen as a limit of the study in terms of coherence, but we prefer to view it as an added value of this review, since we wanted to impress on the reader the complexity of the papers’ methods and data, mirroring the complexity of the phenomenon of online pharmacies.
Despite this complexity, we made an effort to identify a common denominator in all the research questions scholars have used in tackling the issue, and we related them back to the broad issue of consumer safety in its multiple variations. Ultimately, the tangible side of this consumer safety framework is clinical reports of health damage caused by drugs purchased online, the last link in the chain, when the feared dangers have already occurred. Consumer studies have tried to estimate the number of exposed people and to identify at-risk groups. The majority of these studies focused on the general population or specific groups, and found that 6% or less of the sample had bought drugs online. As depicted in
One of the major risks posed by online pharmacies is drug misuse. Prescription requirement and use of online questionnaires can be linked to avoiding the physician and hence to the possible misuse of drugs. All the random samples with no specific limits regarding prescription requirements found that at least some websites sold drugs without a prescription, and that online questionnaires could be used as a substitute for prescriptions. This issue leads to the risk of one of the most feared consequences: the possible disruption of the doctor–patient relationship, which has been widely discussed. In the context of the doctor–patient relationship, drugs purchased online can have acute effects, and even chronic and irreversible ones, and nowadays doctors should always investigate the use of nonprescribed substances in their anamnesis [
Privacy issues are about the confidentiality of consumers’ data and personal data protection. The evidence suggests that online pharmacies (or ones presumed to be such) could be a tool for data fishing or fraud when they do not deliver the products (sometimes charging the consumer anyway) or send something different from what was ordered. It is not just a matter of privacy; it becomes a matter of security. This could even mean that stealing money from vulnerable consumers could lead to them not being able to afford the drug or having to wait to obtain it elsewhere, thus posing problems of denial of care and delay of care.
In terms of drug quality, when the researchers bought drugs online, they very frequently found inappropriate packaging and labeling, whereas the chemical composition was not as expected in a minority of the samples of studies, except for one [
Drug accessibility is a core issue regarding online pharmacies. Worldwide delivery eliminates national barriers for consumers; but the place of dispatch can be indicative of the place of production, and therefore it could be linked to drug quality. The analysis of the drugs on offer showed that an online consumer can get virtually anything, which is a matter of risk as well as accessibility, since some drugs are more intrinsically dangerous than others. Lastly, prices can modify drug accessibility and could be linked to drug quality.
Another important area associated with consumer safety is transparency in giving consumers details of the company they are buying from; this aspect can be assessed by analyzing the contact details, geographical location, time websites were accessible, quality certifications, and last website update. Geographical characteristics showed that this information is concealed on many websites, and that US-based websites tend to behave better than others. Studies that investigated the presence of quality certification found it in a minority of the websites.
Consumer safety as a common denominator for studying online pharmacies.
From a policy point of view, online pharmacies are only partially regulated due to intrinsic difficulties linked to the impalpable and evanescent nature of the Web and its global dimension, with no national barriers. The legal implications are really challenging, since the virtual “brave new world” created by the Internet poses issues never faced before. The fragmentary picture of online drug trading regulations is a recognized issue, and a noteworthy attempt to regulate the phenomenon is the “Implementation of the Ryan Haight Online Pharmacy Consumer Protection Act” by the US Department of Justice in 2009 [
Given the technical difficulty of reducing the risks from an enforcement point of view, the role of the consumer becomes essential. The role of the patient as an active partner in health care, and not just a passive object of diagnostic testing and medical treatment, is widely accepted. As this view is accepted, providing information to patients becomes a very crucial issue. Attempts to create some sort of labeling to distinguish trustworthy from rogue websites are valuable, but they cannot be very effective as long as people are not aware of these tools and of the risks involved in buying medication online. As described by Eysenbach [
In conclusion, online pharmacies are a case where major conflicts occur between the concept of individuals being able to decide their purchases in their own interests on the one hand, and on the other the demand that the state must prevent people from harming themselves and must use public resources fairly and efficiently, as well as the value of social solidarity [
The authors wish to thank the anonymous reviewers for their valuable comments and insightful suggestions to improve the quality of the paper.
GO participated in the conception and the design of the study, checked the collected data, analyzed and interpreted the data, and drafted the article; AM collected and assembled the data; PJS participated in the conception and the design of the study and made a critical revision of the article; UG participated in the conception and the design of the study and collection and interpretation of data, and continuously revised the article during drafting. All authors approved the final article.
None declared
List of articles about online pharmacies without original data.
List of articles about online pharmacies, sorted in alphabetical order according to first author; the characteristics of each study’s sample is shown in terms of year of data collection, selection method, inclusion criteria, and number of online pharmac
Articles about case reports involving medicines bought on an online pharmacy, listed in alphabetical order according to the first author.
National Center on Addiction and Substance Abuse
Food and Drug Administration
Government Accountability Office
Health Information National Trends Survey
Health on the Net Foundation
Joint Commission on Accreditation of Healthcare Organizations
Monitoring The Future
National Association of Boards of Pharmacy
National Survey of Drug Use and Health
phosphodiesterase type 5 inhibitors
Researched Abuse Diversion and Addiction-Related Surveillance System
Verified Internet Pharmacy Practice Sites
World Health Organization