25%, 20%, 10%, 5%, 2%, 1%?

A few years back, the FDA published the results of a survey from 2012 that showed 23% of Internet users purchase medication online. That number has been used by a variety of groups funded by pharmaceutical companies and U.S. pharmacy corporations, and apparently the Government Accountability Office, to imply that a quarter of the U.S. population is buying medication from dangerous rogue online pharmacy sites. The number is probably lower than 2%, which is still too high but it’s important that the public and our elected leaders face and tackle the online pharmacy problems that really exist, not fake ones that distort public perception and serve entrenched business interests…and lead to fewer Americans getting medicines they need.

This week, in our continuing quest to get the truth out and for our elected leaders in Congress to take bold action to protect online access to safe and affordable medication, we’re publishing the next section of our report called Online Pharmacies, Personal Drug Importation, and Public Health…

How Many Americans Are Buying Medication Online From Dangerous Websites?

 

The GAO report is confusing, lacking clarity and analysis about the numbers of online pharmacy users, reflecting a lack of independent research or scrutiny of available data. GAO states:

According to a recent survey conducted by the Food and Drug Administration (FDA), an agency within the Department of Health and Human Services, nearly one in four adult U.S. Internet consumers surveyed reported purchasing prescription drugs online. At the same time, nearly 30 percent said that they lacked confidence about how to safely purchase medicine online. This is a matter of grave concern as rogue Internet pharmacies may sell products that, among other things, have expired; been labeled, stored, or shipped improperly; and may even be counterfeits—unauthorized versions—of other drugs.

GAO’s description of the data presents a more threatening picture than what the FDA’s survey actually shows. First, as the agency affirms, the FDA’s estimate of Americans using online pharmacies is likely too high because its survey, “did not recruit randomly from the population at large, neither was it weighted to simulate representation from major demographics. As such, the findings from the survey cannot be generalized outside the population of highly engaged Internet users” (emphasis added).¹ So there are potentially far fewer Americans buying medication online than the survey suggests.

Second, the GAO report omits a crucial finding of FDA’s data: while 23% of American adults may have bought medication online, 83% of them buy medication from U.S. online pharmacies “associated with their health insurance.” These figures show that at a maximum 4% of Americans are purchasing from online pharmacies not associated with their health insurance. FDA draws the following conclusion: “Approximately 17% reported that they purchased from online pharmacies that were not associated with a local pharmacy or health insurance plan. This behavior may be risky because there are thousands of fake pharmacy websites on the Internet.” FDA does not specify why these consumers may be at risk simply because they don’t use online pharmacies associated with their health insurance or buy from a local pharmacy when purchasing online. For instance, does the FDA consider it “risky” when an American without health insurance buys from a credentialed U.S. online pharmacy? Such Americans could be buying from Costco.com, for instance, which has low generic drug prices. For those reasons, the number of Americans buying from websites that FDA views as risky may be far less than 4%.

Some international online pharmacies may not be “risky” according to FDA’s survey. FDA’s data shows that more Americans import prescription drugs through online pharmacies (21%) than Americans who may be putting themselves at risk (17%).

FDA asserts that we can’t generalize the findings to the whole adult population beyond “highly engaged Internet users.” They do not define “highly engaged Internet users,” but it’s not difficult to extrapolate an approximation of the real numbers of Americans who buy products online. One survey by the Pew Research Center’s Internet and American Life Project estimated in 2010 that 52% of Americans have bought a product over the Internet. Applying that percentage to FDA’s data to the larger adult population the chart below shows how many Americans are likely buying medications online a) overall, b) legally, c) with risks and d) internationally.

Americans Who Buy Medication Online Do So…
	A. Overall	B. Legally in the U.S	C. From sites that “may be risky”	D. from sites outside the U.S.
Percentage FDA Survey Findings	NA 23% of respondents	83% (of the 23% who buy medication online)	17% (of the 23% who buy medication online)	21% (of the 23% who buy medication online)
Raw Adult Population Data	55,248,300	45,856,080	9,392,211	11,602,143
Adjusted to general population	28,729,116	23,845,166	4,883,950 (2% of adult population)	6,033,114 (2.5% of adult population)

The adjusted data shows 6,033,114 Americans buying medication online from outside the U.S. and 4,883,950 from websites that may be of risk to consumers. That leaves, according to the FDA, 1,149,164 Americans who buy foreign medication online from websites not identified by FDA as risky. Further clarification from the agency is needed to determine this overlap, which indicates that FDA may view certain international online pharmacies as safe, at a maximum, or at least “not risky” at a minimum.

After the noted statistical adjustments of FDA’s data, its results are very similar to other much larger independent surveys. In a survey of 33,014 Americans, the CDC reports that about five million Americans buy medication from outside the U.S. due to cost. This figure corresponds well with another survey conducted by Deloitte Center for Health Solutions, which found that 4% of adults who take prescription medication, about 5.3 million, purchased medication from outside the U.S. Separately, a Consumer Reports survey estimates that 4.6 million Americans bought medication online from outside the country to save money. These three reports all support an estimate of just under five million Americans buying medication online from international sources to help them afford prescription medication.

None of the surveys mentioned above show how many Americans are buying medication internationally from online pharmacies without a valid prescription. FDA’s data that shows 1,149,164 Americans buy foreign medication online from websites that may not pose risks. That number probably represents a portion of those international prescription sales in which a prescription is known to be required. This number supports the claim by Canadian International Pharmacy Association (CIPA) that its membership serves over one million Americans each year, about ten million U.S patients since 2002. Many, but not all, members of CIPA are also members of the PharmacyChecker.com Verification Program.

A small survey conducted by the Partnership at Drugfree.org –funded by ASOP – concluded that one out of every six American adults – 36 million – have bought medication online without a prescription. The survey questions are not available to the public. It is known that the survey was conducted from November 7 to 10, 2010 by asking 1,015 adults something about online pharmacies. The figure of 36 million Americans must apply to medications purchased online without a prescription at some point in a person’s life – not on an annual basis. The time horizon could be 15 years, about the time online pharmacies have existed. On an annual basis this is about 2.4 million Americans per year, which may be a reasonable estimate. While the adjusted FDA survey data shows 4,883,950 Americans ordered from online pharmacies within the last twelve months that may pose a risk to consumers, it is not clear how many of them did not require a valid prescription. Members of congress should request clarification from the Partnership at Drugfree.org and FDA on their data.

It is likely that the number of Americans buying medication online without a prescription increased through the 2000s, reaching three to four million people, but now has now started to decline. The explanation for this trajectory is that access to rogue online pharmacies proliferated in the mid-2000s but is now being curtailed due to public education and outreach by NABP, LegitScript, PharmacyCheceker.com, and CIPA, as well as media coverage and health organizations that warn Americans about dangerous pharmacy websites. Research also shows that Google’s implementation of vigorous technical blocks of ads by rogue online pharmacies has diminished their visibility.

The BEJEAP report provided the most extensive survey data about online pharmacy shoppers, explaining who is buying medication online, why they buy it online, and what steps they take to protect themselves. The survey was done in conjunction with RxRights.org, a non-profit coalition of seniors’ and consumer rights groups, private stakeholders, and approximately 82,000 consumers. Using its newsletter list in 2011 (when it was smaller), RxRights.org asked 20,000 people to participate in the survey. Two thousand nine hundred and seven (2,907) prescription drug purchasers responded to questions about online pharmacies. The final sample was reduced to 2,522 to control for sex, age, and income variables. Of the 2,522 American respondents, less than one percent used only U.S. online pharmacies, 73.8% used only foreign online pharmacies, and 29.94% use both. Of those who use foreign online pharmacies, 92.53% reported lower prices as the reason for doing so. The survey also asked how consumers find online pharmacies. The BEJEAP report states: “Conditional on shopping online, 53.93% use Internet search, 41.11% check with a credentialing agency such as PharmacyChecker.com, 22.62% use personal referrals, and only 12.95% look for the cheapest deal. Consistently, most online shoppers restrict themselves to one primary website, sometimes with supplements from other websites.”

The data and analysis above is helpful in understanding the demographics of people who buy medication online, but the findings cannot be generalized to the American population at large. An overwhelming percentage of these people are seeking out international online pharmacies because of high drug prices in America, not to obtain a prescription drug without a prescription. The survey also demonstrates that properly educated consumers who access online pharmacy verification programs successfully protect their health and finances when buying medication online internationally.