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.

COVID-19 Treatments Sold Online Without Prescription Requirements in the United States: Cross-sectional Study Evaluating Availability, Safety and Marketing of Medications.

BACKGROUND: The COVID-19 pandemic has increased online purchases and heightened interest in existing treatments. Dexamethasone, hydroxychloroquine, and lopinavir-ritonavir have been touted as potential COVID-19 treatments. OBJECTIVE: This study assessed the availability of 3 potential COVID-19 treatments online and evaluated the safety and marketing characteristics of websites selling these products during the pandemic. METHODS: A cross-sectional study was conducted in the months of June 2020 to August 2020, by searching the first 100 results on Google, Bing, and Yahoo! mimicking a US consumer. Unique websites were included if they sold targeted medicines, were in English, offered US shipping, and were free to access. Identified online pharmacies were categorized as rogue, unclassified, or legitimate based on LegitScript classifications. Patient safety characteristics, marketing techniques, price, legitimacy, IP addresses, and COVID-19 mentions were recorded. RESULTS: We found 117 websites: 30 selling dexamethasone (19/30, 63% rogue), 39 selling hydroxychloroquine (22/39, 56% rogue), and 48 selling lopinavir-ritonavir (33/48, 69% rogue). This included 89 unique online pharmacies: 70% were rogue (n=62), 22% were unapproved (n=20), and 8% were considered legitimate (n=7). Prescriptions were not required among 100% (19/19), 61% (20/33), and 50% (11/22) of rogue websites selling dexamethasone, lopinavir-ritonavir, and hydroxychloroquine, respectively. Overall, only 32% (24/74) of rogue websites required prescriptions to buy these medications compared with 94% (31/33) of unapproved and 100% (10/10) of legitimate websites (P<.001). Rogue sites rarely offered pharmacist counseling (1/33, 3% for lopinavir-ritonavir to 2/22, 9% for hydroxychloroquine). Drug warnings were unavailable in 86% (6/7) of unapproved dexamethasone sites. It was difficult to distinguish between rogue, unapproved, and legitimate online pharmacies solely based on website marketing characteristics. Illegitimate pharmacies were more likely to offer bulk discounts and claim price discounts, yet dexamethasone and hydroxychloroquine were more expensive online. An inexpensive generic version of lopinavir-ritonavir that is not authorized for use in the United States was available online offering US shipping. Some websites claimed hydroxychloroquine and lopinavir-ritonavir were effective COVID-19 treatments despite lack of scientific evidence. In comparing IP addresses to locations claimed on the websites, only 8.5% (7/82) matched their claimed locations. CONCLUSIONS: The lack of safety measures by illegitimate online pharmacies endanger patients, facilitating access to medications without appropriate oversight by health care providers to monitor clinical response, drug interactions, and adverse effects. We demonstrated how easy it is to go online to buy medications that are touted to treat COVID-19 even when current clinical evidence does not support their use for self-treatment. We documented that illegitimate online pharmacies sidestep prescription requirements, skirt pharmacist counseling, and make false claims regarding efficacy for COVID-19 treatment. Health care professionals must urgently educate the public of the dangers of purchasing drugs from illegitimate websites and highlight the importance of seeking treatment through authentic avenues of care.

Trends and Characteristics of the US Adult Population's Behavioral Patterns in Web-Based Prescription Filling: National Survey Study.

BACKGROUND: Filling a prescription on the web has become an alternative to in-person pharmacies for individuals to access their medications. However, the adoption of web-based filling has been gradual, and the use patterns remain to be unclear. OBJECTIVE: This study aims to estimate the trend and prevalence of web-based prescription-filling behavior and identify associated factors among adults in the United States. METHODS: We used data from the US National Health Interview Survey (NHIS) from 2009 to 2018. Adult respondents (aged ≥18 years and over) self-reported their behavior of web-based prescription filling, which was defined as having filled a prescription using the internet in the past 12 months during the survey year. We reported trends using weighted percentages adjusted by the NHIS complex sampling design. We used descriptive statistics and multivariable logistic regression models to examine trends and identify factors associated with web-based prescription-filling behavior. RESULTS: The estimated number of adults reporting web-based prescription-filling behavior significantly increased from 13,319,877 (13,319,877/225,217,942, 5.91%) in 2009 to 28,308,262 (28,308,262/246,611,125, 11.48%) in 2018 (P<.001). Those who were more likely to report filling a prescription on the web were aged between 35 and 74 years, female, White, and frequent users of the computer or internet; these adults also reported higher education, higher income, insurance coverage, and poorer health status. CONCLUSIONS: Web-based prescription-filling behavior among US adults has increased significantly from 2009 to 2018. Health care providers should be aware of the upward trend in the use of web-based pharmacies and ensure the clinical safety of web-based prescriptions.

Managing Illicit Online Pharmacies: Web Analytics and Predictive Models Study.

BACKGROUND: Online pharmacies have grown significantly in recent years, from US $29.35 billion in 2014 to an expected US $128 billion in 2023 worldwide. Although legitimate online pharmacies (LOPs) provide a channel of convenience and potentially lower costs for patients, illicit online pharmacies (IOPs) open the doors to unfettered access to prescription drugs, controlled substances (eg, opioids), and potentially counterfeits, posing a dramatic risk to the drug supply chain and the health of the patient. Unfortunately, we know little about IOPs, and even identifying and monitoring IOPs is challenging because of the large number of online pharmacies (at least 30,000-35,000) and the dynamic nature of the online channel (online pharmacies open and shut down easily). OBJECTIVE: This study aims to increase our understanding of IOPs through web data traffic analysis and propose a novel framework using referral links to predict and identify IOPs, the first step in fighting IOPs. METHODS: We first collected web traffic and engagement data to study and compare how consumers access and engage with LOPs and IOPs. We then proposed a simple but novel framework for predicting the status of online pharmacies (legitimate or illicit) through the referral links between websites. Under this framework, we developed 2 prediction models, the reference rating prediction method (RRPM) and the reference-based K-nearest neighbor. RESULTS: We found that direct (typing URL), search, and referral are the 3 major traffic sources, representing more than 95% traffic to both LOPs and IOPs. It is alarming to see that direct represents the second-highest traffic source (34.32%) to IOPs. When tested on a data set with 763 online pharmacies, both RRPM and R2NN performed well, achieving an accuracy above 95% in their predictions of the status for the online pharmacies. R2NN outperformed RRPM in full performance metrics (accuracy, kappa, specificity, and sensitivity). On implementing the 2 models on Google search results for popular drugs (Xanax [alprazolam], OxyContin, and opioids), they produced an error rate of only 7.96% (R2NN) and 6.20% (RRPM). CONCLUSIONS: Our prediction models use what we know (referral links) to tackle the many unknown aspects of IOPs. They have many potential applications for patients, search engines, social media, payment companies, policy makers or government agencies, and drug manufacturers to help fight IOPs. With scarce work in this area, we hope to help address the current opioid crisis from this perspective and inspire future research in the critical area of drug safety.

Consumers' satisfaction factors mining and sentiment analysis of B2C online pharmacy reviews.

BACKGROUND: In recent years, online pharmacies have been accepted by increasingly more consumers, and the prospects for online pharmacies are optimistic. This article explores the consumers' satisfaction factors addressed in Business to Customer (B2C) online pharmacy reviews and analyzes the sentiments expressed in the reviews. The goal of this work is to help B2C online pharmacy enterprises identify consumers' concerns, continuously improve the health services level. METHODS: This article was based on the Latent Dirichlet Allocation (LDA) topic model. From a third-party platform-based B2C online pharmacy and a proprietary B2C online pharmacy (JD Pharmacy and J1.COM, respectively), 136,630 pieces of over-the-counter (OTC) drug review data posted from January 1, 2015 to December 31, 2018 were selected as samples and used to explore the satisfaction factors of B2C online pharmacy consumers regarding the entire drug purchasing process. Then, the sentiments expressed in the drug reviews were analyzed with SnowNLP. RESULT: Categorization of the 12 factors identified by LDA showed that 5 factors were related to logistics; these 5 factors, which also included the most drug reviews, made up 38.5% of the reviews. The number of factors related to drug prices was second, with 3 factors, and reviews of drug prices made up 25.5% of the reviews. Customer service and drug effects each had two related factors, and a smaller percentage of these reviews (13.95%) were related to drug effects. Consumers still maintain positive opinions of JD Pharmacy and J1.COM. However, some opinions on logistics and drug prices are expressed. CONCLUSION: The most important task for online pharmacies is to improve logistics. It is better to develop self-built logistics. Both types of B2C online pharmacies can improve consumer viscosity by implementing marketing strategies. With regard to customer service, focusing on improving employees' service attitudes is necessary.

"My BMI is too high for Plan B." A changing population of women seeking ulipristal acetate emergency contraception online.

Emergency contraceptive (EC) pills may be less effective for women with higher body mass index (BMI), but little is known about public response to the fact that EC may lose efficacy as weight increases. In November 2013, European authorities changed the label for a levonorgestrel EC product to warn of a reduction in effectiveness for women with higher BMI, garnering significant media coverage in the United States. Ulipristal acetate (UPA) EC may be more effective than levonorgestrel for women with BMI levels designated as obese. Among 8,019 women who received UPA from the online pharmacy KwikMed from 2011 to 2015 and self-reported their height, weight and reasons for seeking UPA online, we analyzed changes in the proportion of women in different BMI categories before and after the label change. For the 25 month-period after the label change, the proportion of women in the obese category rose by 26.7 percentage points relative to the 35 months before (B = 0.2665, p < .01). Mean BMI (25.5 versus 29.4, p < .001) and average weight (148.6 pounds versus 175.5 pounds, p < .001) of users were higher after the label change. Some women appear to have acted on the information that EC efficacy may be associated with body weight.

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.

Prospects and challenges of online pharmacy in post-Covid world: A qualitative study of pharmacists' experiences in Ghana.

Background: Online pharmacies continue to grow worldwide, especially in the wake of the COVID-19 pandemic. Ghana is experiencing this growth in an unprecedented way since its government initiated an online pharmacy pilot in December 2021, which was followed by the launch of the National Electronic Pharmacy Platform in July 2022. This pioneering initiative calls for extensive research with pharmacists to gain their perspectives. However, there is a dearth of such studies in the sub-Saharan African countries. Objective: This study sought to understand how pharmacists in Ghana perceive online pharmacies in terms of the larger socio-cultural and policy implications, as well as the challenges they face in its implementation. Methods: Using a qualitative research design, local licensed pharmacists were recruited through purposive sampling and by specifically combining the maximum variation and snowball sample techniques. Semi-structured interviews were conducted virtually with 21 pharmacists over the months of February and March 2022. The data were analyzed by using interpretive thematic analysis. Results: Pharmacists perceived that online pharmacies would transform the pharmaceutical industry in Ghana by making it convenient for people to access medication easily and at a reasonable price, while also offering them privacy. However, concerns were expressed around existing poor infrastructure and inequities, low health literacy, and inadequate regulatory practices that could pose major challenges in the operation of this platform. Engagement of stakeholders was deemed essential for success. Conclusion: Online pharmacy in Ghana and much of the developing world has the potential to transform and advance the pharmaceutical industry to better serve people. However, it could also lead to increased and irrational use of medications, if not properly regulated. Government, policy makers, and leaders in the field of digital health and pharmacy must also address poor infrastructure and inequities in digital access.

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.

The dynamics of food for special medical purposes (FSMPs) utilization in cancer care: from doctor recommendations to online pharmacy procurement.

This cross-sectional study conducted in Romania examines the increasing role of online pharmacies in providing Food for Special Medical Purposes (FSMP) to cancer patients. Key findings indicate patient satisfaction with ease of access, significant challenges related to costs, and the critical role of healthcare professionals in guiding FSMP selection. INTRODUCTION: As cancer treatments advance, the demand for supportive nutritional care becomes increasingly critical, with FSMPs playing a vital role in patient recovery and quality of life. METHODS: Employing a cross-sectional study design, we surveyed cancer patients from Romania to assess their experiences purchasing FSMPs through traditional and online pharmacies. We analyzed the factors influencing their choices, the perceived benefits and challenges of online access, and the role of healthcare professional guidance in their decision-making process. RESULTS: The study reveals that while patients appreciate the ease of access and the broad spectrum of available FSMPs online, they grapple with the financial burden and the need for reliable information to make informed decisions. Through a cross-sectional analysis, we found that the expertise and recommendations of healthcare professionals remain integral to the FSMP selection process, suggesting that digital solutions should enhance, not replace, traditional healthcare interactions. Moreover, our findings highlight a crucial gap in the taste and variety of FSMPs, suggesting that patient adherence could be improved through product innovation. The study found a significant association between the type of medical unit where patients followed their treatment (state-owned clinic) and whether they received recommendations from a specialist oncologist for using FSMPs. Nutritionists' recommendations were also significantly associated with a higher likelihood of purchasing FSMPs online. DISCUSSIONS: The study reveals that despite the benefits of digital access, a crucial need exists for regulatory measures and professional oversight to ensure the safe and informed use of FSMPs. The trust placed in healthcare professionals' recommendations continues to be instrumental in navigating the digital marketplace. CONCLUSION: This work paves the way for future strategies to integrate online solutions with established healthcare practices to optimize cancer care in the digital age.

Pharmacy Student Perceptions and Knowledge of Online Pharmacy Use.

Objective. Currently, there is no set of accreditation standards for integrating the dangers of illegal online pharmacies into Doctor of Pharmacy (PharmD) curricula. As a result, many pharmacists are unable to recognize the differences between a legal and illegal online pharmacy or educate patients on the dangers of online pharmacies. The objectives of this study were to assess gaps in student pharmacists' knowledge and to assess the impact of adding education regarding online pharmacies into PharmD programs.Methods. A pre- and postsurvey design was developed. Data were collected through an electronic questionnaire distributed to second-year pharmacy (P2) students to evaluate student knowledge gaps at baseline and after education on illegal online pharmacies.Results. A total of 102 students responded to the presurvey, with 93 (91%) consenting to participate. Out of 100 respondents to the postsurvey, 84 (84%) students consented. Approximately 87% (81/93) of respondents indicated some awareness of prescription medications being purchased online. Most students (89%, 77/86) stated that they do not believe the university has provided adequate curriculum on illegal online pharmacies and counterfeit medications. After receiving education on the relevant topics, 64% (55/85) stated they now felt their education was adequate.Conclusion. Although pharmacy students were aware of the existence of illegal online pharmacies, they were not aware of the significance of this patient safety issue or how to accurately identify suspicious websites. It is imperative that PharmD programs incorporate formal education on the risks that illegal online pharmacies pose to patient and medication safety.

News Media Coverage of the Problem of Purchasing Fake Prescription Medicines on the Internet: Thematic Analysis.

BACKGROUND: More people are turning to internet pharmacies to purchase their prescription medicines. This kind of purchase is associated with serious risks, including the risk of buying fake medicines, which are widely available on the internet. This underresearched issue has been highlighted by many newspaper articles in the past few years. Newspapers can play an important role in shaping public perceptions of the risks associated with purchasing prescription medicines on the internet. Thus, it is important to understand how the news media present this issue. OBJECTIVE: This study aimed to explore newspaper coverage of the problem of purchasing fake prescription medicines on the internet. METHODS: Newspaper articles were retrieved from the ProQuest electronic database using search terms related to the topic of buying fake prescription medicines on the internet. The search was limited to articles published between April 2019 and March 2022 to retrieve relevant articles in this fast-developing field. Articles were included if they were published in English and focused on prescription medicines. Thematic analysis was employed to analyze the articles, and the Theory of Planned Behavior framework was used as a conceptual lens to develop the coding of themes. RESULTS: A total of 106 articles were included and analyzed using thematic analysis. We identified 4 superordinate themes that represent newspaper coverage of the topic of buying prescription medicines on the internet. These themes are (1) the risks of purchasing medicines on the internet (eg, health risks and product quality concerns, financial risks, lack of accountability, risk of purchasing stolen medicines), (2) benefits that entice consumers to make the purchase (eg, convenience and quick purchase, lower cost, privacy of the purchase), (3) social influencing factors of the purchase (influencers, health care providers), and (4) facilitators of the purchase (eg, medicines shortages, pandemic disease such as COVID-19, social media, search engines, accessibility, low risk perception). CONCLUSIONS: This theory-based study explored the news media coverage of the problem of fake prescription medicines being purchased on the internet by highlighting the complexity of personal beliefs and the range of external circumstances that could influence people to make these purchases. Further research is needed in this area to identify the factors that lead people to buy prescription medicines on the internet. Identifying these factors could enable the development of interventions to dissuade people from purchasing medicines from unsafe sources on the internet, thus protecting consumers from unsafe or illegal medicines.

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.

Assessing Trustworthiness of Internet Pharmacies with an Internet Browser Extension.

Background: Many people are turning to online pharmacies for medication purchases leading to a growing number of legal and illegal online pharmacies (IOPs). With a growing number of IOPs, consumers are more likely to receive substandard or falsified medications when purchasing medications online. Objectives: This study aims to identify the number of verified, not recommended, and not verified pharmacy websites consumers see using different keywords and medications on an Internet browser based off the National Association Boards of Pharmacy's (NABP) list of verified and not recommended websites. It also aims to compare which keywords result in more not recommended pharmacy websites compared with verified pharmacy websites for consumers over time. Design and Methods: We created an Internet browser extension compatible with different Internet browsers to quickly identify which search results are verified, not recommended, and not verified based on NABP lists. We then utilized an application programming interface to automatically search different key terms and classify the search results as verified, not recommended, and not verified over a 4-week data collection period for analysis. Results: A total of 131 key terms were used for the search. There was an average signal determining the number of verified and not recommended search results compared with not verified results of 4.3% over the 4-week data collection period. There was about a 3:1 ratio of not recommended to verified search results noted. Top signal and not recommended search result producing keywords contained words such as "shipped" and "cheap." Conclusion: The Internet browser extension will aid in making it easier to identify which search results are safe and which are not safe when searching to purchase medications online. This study has set the premise on expanding how to use an Internet pharmacy extension to combat IOPs, improve patient safety, and increase safe access to medications.

Clinical relevance of potential self-medication drug interactions in antineoplastic and immune-modulating therapy among online pharmacy customers.

Background: Modern oral antineoplastic and immune-modulating drugs offer an array of therapeutic advantages, and yet pose challenges in daily use for patients, physicians and pharmacists. In contrast to intravenous administration, these drugs are not subject to direct medical control. Recently, we have seen a huge rise in sales of non-prescription over-the-counter (OTC) medicines via the internet without any advice from a healthcare professional. Objectives: The aim of this study was to investigate whether the risk of known potential drug-drug interactions between modern oral antineoplastic and immune-modulating drugs and OTC drugs differs between sales in traditional community pharmacies versus online pharmacies. Design: Real-life sales data from community and online pharmacies were used as basis for the analysis. Methods: We determined the most frequently purchased antineoplastic and immune-modulating drug-substances in 14 local community pharmacies within the Munich area, Germany and identified the OTC substance groups that could potentially cause interactions with oncological therapies. Using sales data from 11 local community pharmacies and three online pharmacies, we investigated whether OTC purchases differed between the two sales channels. Results: We identified 10 relevant OTC substance classes and detected significant variations in patients' preferred sales channels between the drug classes. Certain OTC drugs, which seem to be bought more often over the internet, pose risks during antineoplastic and immune-modulating therapy. Conclusion: Patients should therefore be proactively made aware of the corresponding risks in order not to jeopardize the activity of the antineoplastic and immune-modulating drugs and thus the success of their therapy.

Comparing Community and Online Pharmacies: Investigating Potential Interactions Between Cancer and Immune-Modulating Drugs with Over-the-Counter Medications, and the Importance of Patient Awareness and Healthcare Professional Guidance in Minimizing Adverse Effects and Maintaining Treatment Efficacy Modern anticancer and immune-modulating drugs have the advantage of often being taken orally, but they present other challenges in daily use. Unlike intravenously administered drugs, these are usually not administered by a physician but taken by the patient at home. In these cases, patients may be more likely to buy and take self-medicating drugs over-the-counter (OTC) without consulting a healthcare professional. This study aimed to investigate whether there is a different risk of drug interactions between cancer or immune-modulating drugs and OTC drugs when bought in a community pharmacy versus an online pharmacy. Therefore, we looked at the most common cancer and immune-modulating drugs purchased in 14 local community pharmacies in Munich and identified which OTC drugs could cause problems when used simultaneously. Additionally, we analyzed the sales data from 11 local and 3 online pharmacies to determine if people were more likely to buy different OTC drugs from the two types of pharmacies. As a result, this study showed 10 relevant OTC drug types that potentially cause problems and influence effectiveness when used with cancer or immune-modulating drugs. Furthermore, we observed that some of these OTC drugs were purchased more often online than in community pharmacies and thus are more distant from the control of a physician or pharmacist. It is therefore essential for patients to be aware of the risks associated with easily accessible OTC drugs in combination with their cancer or immune-modulating medication, as serious side effects or decreased efficacy may develop. Patients should remember to consult their doctor or pharmacist if there is any uncertainty about potential drug interactions. At the same time, healthcare professionals should proactively draw their patients' attention to these potential risks, especially when purchasing online.

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

BACKGROUND: Online pharmacies are used less than other e-commerce sites in Germany. Shopping behavior does not correspond to consumption behavior, as online purchases are predominantly made for over-the-counter (OTC) medications. OBJECTIVE: The objective of this study was to understand the purchasing experiences of online pharmacy customers in terms of critical factors for online pharmacy adoption. METHODS: This study examined the perceived risk, perceived trust, and emotions related to purchasing medications online and, consequently, the purchase intention toward online pharmacies. In a within-subjects design (N=37 participants), 2 German online pharmacies with different perceptions of risk and trust were investigated for their main business, namely OTC and prescription drugs. The results of a preliminary study led to 1 online pharmacy with high and 1 with significantly low self-reported risk by the prestudy sample. Emotions were measured with a multimethod approach during and after the purchase situation as follows: (1) neural evaluation processes using functional near-infrared spectroscopy, (2) the automated direct motor response during the use of the online pharmacy via facial expression analysis (FaceReader), and (3) subjective evaluations through self-reports. Following the shopping experiences at both pharmacies for both product types, risk, trust, and purchase intention toward the pharmacies were assessed using self-assessments. RESULTS: The 2 online pharmacies were rated differently in terms of risk, trust, emotions, and purchase intention. The high-risk pharmacy was also perceived as having lower trust and vice versa. Significantly stronger negative emotional expressions on customers' faces and different neural activations in the ventromedial prefrontal cortex and dorsomedial prefrontal cortex were measured when purchasing prescription drugs from the high-risk pharmacy than from the low-risk pharmacy, combined with OTC medications. In line with this, customers' self-ratings indicated higher negative emotions for the high-risk pharmacy and lower negative emotions for the low-risk pharmacy. Moreover, the ratings showed lower purchase intention for the high-risk pharmacy. CONCLUSIONS: Using multimethod measurements, we showed that the preceding neural activation and subsequent verbal evaluation of online pharmacies are reflected in the customers' immediate emotional facial expressions. High-risk online pharmacies and prescription drugs lead to stronger negative emotional facial expressions and trigger neural evaluation processes that imply perceived loss. Low-risk online pharmacies and OTC medications lead to weaker negative emotional facial expressions and trigger neural evaluation processes that signify certainty and perceived reward. The results may provide an explanation for why OTC medications are purchased online more frequently than prescription medications.

Problems of purchasing pharmacy products through online orders.

Online pharmacy services and online ordering of pharmaceutical products are in demand, especially in the context of the COVID-19 pandemic. The problems of the purchase of pharmacy products through online orders in the Far Eastern Federal District were analyzed. Sociological survey of the population (n = 3789) was carried out. Spearman's Rank correlation coefficient was used. Drugs, dietary supplements, hygiene, and care items are most often purchased in online pharmacies. There is a correlation with the female sex, which may be related to care about family/loved people. The purchase of prescription drugs through e-pharmacies is also more often in demand among women and older patients. Among prescription drugs, the order of drugs used in the treatment of coronavirus infection and its complications (antibiotics, nonsteroidal anti-inflammatory, gastroenterological, and hormonal) is widespread. The problems of e-pharmacies identified due to the study are the lack of proper control over prescription drugs, low role of the pharmaceutical worker in compliance of the patient, and frequent refusals of Internet orders. It is necessary clarify the regulatory status of e-pharmacies and the role of pharmaceutical specialists in it, to reduce the possibility of error in the preparation and/or assembly of orders, to reduce the risk of the presence of defective goods. These ways can increase customer loyalty to this service.

Use of failure mode and effect analysis to reduce patient safety risks in purchasing prescription drugs from online pharmacies in China.

Background: Online pharmacies have gradually penetrated the market, but pose risks to patients' health. Failure Mode and Effect Analysis (FMEA) is an effective and reliable method for reducing pharmacy and medication risks. The purpose of this study was to conduct a prospective risk analysis of the process of purchasing prescription drugs from online pharmacies in China to guarantee drug quality and patient safety. Methods: The FMEA was performed at Sichuan University, China. A multidisciplinary team was assembled comprising a leader, four regulators, four pharmacists, two experts, etc. The process was composed of eight subprocesses: searching for prescription drugs, submitting medication requirements, completing patient information forms, dispensing, delivering, etc. Brainstorming was used to identify and prioritize failure modes, propose corrective actions, and reduce risks. Risk priority numbers were the main criterion and were obtained by multiplying three scores: severity, occurrence and detectability, which were scored by the team The team proposed corrective actions for each selected failure mode. Results: A total of forty-one potential failure modes were identified, and the causes, effects, and corrective actions of the 30 top failure modes were analyzed. The highest risk value was assigned to "photocopies of paper prescriptions uploaded were reused by patients." Three failure modes for the S value of 5 were: "drugs are eroded and polluted by moisture or insects in the process of transportation," "the qualification information of the pharmacies were absent or fake," and "pharmacists fail to check prescriptions in accordance with Prescription Administrative Regulation." Of the top failure modes, 36.67% were from Step 5, delivering the drug. After taking corrective measures to control risks, the risks reduced by 69.26%. Conclusion: The results of this study proves that the FMEA is a valuable tool for identifying and prioritizing the risks inherent in online pharmacies. This study shows that there are many potential risks in the process of purchasing prescription drugs from online pharmacies, especially in the drug delivery stage. Enhanced training and the introduction of smart devices may minimize risks. Online pharmacies and Chinese regulators should consider these findings for risk mitigation and the improvement of regulations pertaining to online pharmacies.

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.

Evaluation of pharmacists' awareness of illegal online pharmacies and perceived impact on safe access to medicines.

Background: An estimated 95% of all online pharmacies operate unlawfully. Illegal online pharmacies distribute substandard and falsified medical products that may result in patient harm and suboptimal treatment, leading to an overall mistrust of medications, healthcare providers, and health systems. As medication experts, pharmacists are trusted to guide patients in selection of safe and effective medication therapy. Objective: The objective of this study was to determine gaps in knowledge and recognition of the negative clinical and safety impacts associated with illegal Internet pharmacies by licensed pharmacists. Methods: A 37-question electronic survey was developed and distributed to pharmacists across the United States by email via a database from the American Pharmacists Association. Descriptive statistics was utilized to analyze data. Results: A total of 347 pharmacists from across the United States responded to at least one question in the survey. In all, 58% of pharmacists reported a lack of confidence in their ability to counsel patients on the identification of illegal pharmacy websites. Fewer than 60% of pharmacists were able to accurately identify the legitimacy of a webpage based on visual characteristics. In addition, 75% of pharmacists reported being unfamiliar with resources available to help consumers identify safe and legitimate online pharmacies. Conclusion: Integration of the topic into pharmacy education curricula, training on available resources, and additional research into the prevalence and impact of illegal pharmacy websites are necessary to ensure that pharmacists and other healthcare professionals are adequately prepared to protect their communities from the threat of illegal online pharmacies.