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Turkish pharmacies for viagra

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Due to the different methods of sample selection, distribution varies greatly in the articles. In the samples that did not use prescription as a criterion for inclusion or exclusion, the prescription requirement varied widely: Those who looked deeper into this issue found that the identity of the professional who made the prescription was not usually provided [ 57 ], whereas they often declared that the questionnaire reviewer was a physician [ 57 , 61 , 62 , 66 , 84 ] or, more rarely, a pharmacist [ 27 , 84 ].

Gallagher and Chapman [ 71 ] reported that, of the 26 websites using a questionnaire, 1 involved multiple-choice check-box answers and drop-down menu answers, and the others used questionnaires that allowed users to type in an answer.

Eysenbach [ 66 ]—who attempted to buy the products—found that the identity of the physician who made out the prescription was revealed in 2 out of 10 orders. The US Government Accountability Office GAO [ 72 , 73 ] found the collaboration of licensed physicians, although when they verified these licenses [ 72 ] almost all of them were nonexistent or not valid for all the US states where they were declared to be.

No study found the use of a validated or standardized questionnaire. Since the questionnaires were often incomplete, the authors concluded that they appeared to aim more at giving the consumer a false sense of health assurance than at actually assessing health status. The questionnaire frequently investigated personal characteristics, allergies, medical conditions, current therapies, and medical history [ 57 , 61 , 62 , 66 , 72 , 73 , 85 ].

Declaration of geographical location is an important feature with regard to transparency. Orizio et al [ 84 ] found that online pharmacies asking for a prescription were significantly more likely to declare their geographical location than were online pharmacies that did not, which were more often just virtual interfaces. Online pharmacies were most frequently based in the United States in virtually all the studies that investigated samples that were not restricted geographically [ 10 , 57 , 60 , 61 , 62 , 66 , 73 , 84 ].

Other studies focused on online pharmacies based in specific countries, such as the United States [ 87 , 88 , 95 ], the United States and Europe [ 27 ], the United States and Canada [ 89 ], Canada [ 94 ], or Brazil [ 92 ].

Some researchers looked for where the websites were registered, and they found the United States to be the most frequent location of domain registration [ 10 , 67 , 68 , 84 , 93 ].

Armstrong et al [ 57 ] found that US-based websites were more likely to ask for medical information and provide information about risk of treatment or its efficacy, and the GAO [ 73 ] found a better quality in websites based in the United States.

The attempt by Bate and Hess [ 59 ] to purchase drugs showed several cases of shipments from a different location from what was indicated on the website. Both Arruanda [ 58 ] and Bessel et al [ 60 ] found that two-thirds of the online pharmacy samples sold internationally, whereas all the websites sampled by Schifano et al [ 91 ] did.

Raine et al [ 90 ] selected only online pharmacies delivering to the United Kingdom. Makinen et al [ 27 ] related the fact of shipping abroad to the prescription requirements: None of the small sample of 4 US-based online pharmacies analyzed by Wagner et al [ 95 ] delivered internationally. 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 , Bloom and Iannacone [ 61 ] studied a sample of online pharmacies in which the majority sold 1 or 2 drugs only, one for erectile dysfunction and the other for alopecia; in the same year Armstrong et al [ 57 ] found an entire sample of 77 websites selling sildenafil.

In Arruanda [ 58 ] found that their sample was equally divided into 3 groups: The various studies reported several specific drug offers: Bloom and Iannacone [ 62 ] reported that separate medications were offered in their sample, which gives an idea of how widely differentiated the drug offer is. Quon et al [ 89 ] compared the offers of 12 Canadian-based Internet pharmacies with 3 US-based drug chain pharmacies for 44 different drugs. The GAO [ 73 ] found that some drugs were more widely available and easier to purchase Celebrex, Lipitor, Viagra, and Zoloft than others, which were available from fewer sources or were more difficult to obtain Accutane and Clozaril.

Schedule I is reserved for the most dangerous drugs that have no recognized medical use, while Schedule V is the classification used for the least dangerous drugs.

Some studies focused on specific classes of drugs. They looked for Parkinson disease medications [ 95 ], 3 types of controlled substances opioids, and central nervous system depressants and stimulants [ 63 ], opiates [ 64 , 67 - 70 ] , analgesics [ 90 ], dextropropoxyphene a painkiller [ 91 ], antibiotics [ 82 ], and specifically ciprofloxacin [ 93 ], contraceptives [ 83 ], the erectile dysfunction medication sildenafil [ 57 , 66 , 71 ], and psoriasis medications [ 81 ].

Littlejohn et al [ 80 ] and Makinen et al [ 27 ] linked the drugs offered to the type of online pharmacy: Both generic and brand drugs were available on the market [ 14 , 58 , 79 , 89 , 95 ]. Several researchers who attempted to evaluate the presence of information on side effects found that a fairly consistent portion of online pharmacies, ranging from a quarter to a third, declared none of them [ 84 , 86 , 90 , 92 , 93 ].

Wagner et al [ 95 ] found in all the online pharmacies in their small sample 4 US-based online pharmacies more comprehensive information than received from the community store.

Peterson [ 87 ] did not find a statistically significant difference between the types of pharmacies and the provision of drug information, although it should be noted that his sample was small for performing a group comparison 33 online pharmacies.

A comparison of online pharmacy and retail pharmacy prices had different results. Wagner et al [ 95 ], who compared prices of US retail versus US online pharmacies, found that the latter were cheaper for both generic and brand-name medications. Levaggi et al [ 79 ] found that drugs bought without a prescription cost more than with one.

Interestingly, they found that Viagra offered on noncredentialed websites was on average far more expensive than from credentialed ones, and for all the drugs purchased Lipitor, Celebrex, Nexium, and Zoloft , except Viagra, prices were higher at physical-location pharmacies. Quon et al [ 89 ] compared US retail prices with those of Canadian online pharmacies, and they found savings when purchasing from Canadian online pharmacies for the majority of brand drugs 3 exceptions in the drug sample were medications for erectile dysfunction , whereas generics were more expensive.

The same result is confirmed by an aggregate macroeconomic analysis based on IMS Incorporated data on prices, patents, and cross-border Internet pharmacies between online Canada and retail US pharmacies [ 15 ]. Memmel et al [ 83 ] found lower prices for contraceptives purchased online. Additional costs have to be considered: Online prescription could be another added cost [ 57 ]. It is interesting to note that, although a prescription is not necessary in marketing messages, Levaggi et al [ 79 ] found in their price analysis that the prescription has a value on the market; indeed, when you buy a drug without a prescription, the drug costs more.

Only a few articles focused on the marketing strategies of online pharmacies. Levaggi et al [ 79 ] and Orizio et al [ 84 ] disclosed the persuasive statements more frequently used by websites to promote their products, and identified arguments regarding privacy, service and drug quality, price offers, reassurances that buying drugs online is legal, and the suggestion that you can obtain a drug while avoiding a visit to the doctor.

Armstrong et al [ 57 ] reported that one-third of their sample pointed out the advantages of ordering online, including confidentiality, ease of ordering, and lower cost. Forman and Block [ 70 ] analyzed the implied legitimacy and credibility claims, which they divided into 3 types: Gurau [ 75 ] pointed out that providing contact information may be a way to reduce the perceived risk of online transactions; moreover, statements about price, convenience, choice, and discreetness of service are more frequently used by online pharmacies not asking for a prescription than by those asking for one.

A special study was performed by Kuzma [ 78 ] about the Web vulnerability of a random sample of 60 online pharmacies. Kunz and Osborne [ 77 ] assessed the readability of 16 online pharmacies using Storytoolz; they found that the majority of the information provided on direct-to-consumer pharmaceutical websites is written at a level far higher than that which the average consumer can understand. Arruanda [ 58 ] found that the sample online pharmacies had been online for a length of time ranging from just over 1 year to 7 years.

We found 13 studies [ 59 , 64 - 66 , 73 , 74 , 82 , 83 , 94 , - ] in which the researchers bought prescription drugs online and evaluated the actual dispatch and its characteristics, and the quality of the products received Table 2.

It should be noted that the various groups of researchers ordered and purchased different types of drugs from different samples of online pharmacies. Some were interested in specific categories of drugs [ 64 , 66 , 82 , 83 , 94 , , , ], whereas others ordered several active ingredients [ 59 , 65 , 73 , 74 , ]. Articles on the quality of drugs purchased online, listed in alphabetical order according to the first author. The online questionnaire was completed by a fictitious patient with clear contraindications for sildenafil.

The actual purchase of drugs without having an original medical prescription was verified by all authors except for Dean et al [ ], Veronin and Youan [ ], Veronin et al [ 94 ], and Westenberger et al [ ], who did not specify whether a prescription was used.

Two studies evaluated the effectiveness of online questionnaires for assessing health status. The results highlighted the low performance of this tool, which allowed the purchase of contraindicated products by fictitious consumers in some or all orders [ 66 , 83 ].

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 [ 66 , 73 , 74 , ] or having to join clubs, only to find no drugs available after having paid the necessary fee [ 64 ].

One study reported subsequent advertising by email and phone for more than 4 months after ordering [ 64 ]. Regarding drug quality characteristics, researchers evaluated different features: As to packaging characteristics, packaging showed problems in more than half of the drug samples in the GAO [ 73 ] study.

Memmel et al [ 83 ] found that all packaging appeared legitimate and products were within the expiration date, but patient education material instructions did not always match the product. Westenberger et al [ ] found that only 1 of 20 samples had final packaging, including package insert, similar to that of the US products. The final packaging of the remainder consisted of bubble wrap inside a paper envelope, a Styrofoam sheet inside a paper envelope, loose blister packs, capsules or tablets in clear plastic bags without labels, and capsules or tablets in opaque plastic containers or boxes with labels.

Bate and Hess [ 59 ] reported that many drugs, including some that did not fail in spectrometry testing, had an unclear or problematic origin or problematic packaging. The GAO [ 73 ] found that the chemical composition of 4 samples out of 68 was not comparable with the product ordered: An analysis of counterfeit dapoxetine a short-acting selective serotonin-reuptake inhibitor , used against premature ejaculation, found that the tablets contained undisclosed sildenafil [ ]. Westenberger et al [ ] found that 2 out of 20 samples failed in terms of dissolution and chromatographic purity; Veronin and Youan in [ ] found differences in simvastatin tablet formulation, obtained from 5 countries via the Internet, using near-infrared spectroscopy chemical imaging methods to assess blend uniformity.

In contrast, Veronin et al in [ 94 ] found a quality standard comparable with that of the American manufacturer and the Canadian generic drug product tested.

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: Table 3 shows the 15 articles [ 12 , 64 , 75 , - ] dealing with consumer characteristics and based on surveys. Most studies were US based, except for 4, which were conducted in Europe [ 75 , , ] and South America [ ]. The findings were published between [ ] and [ - , - ]. Seven studies investigated the general population [ 12 , 75 , , , , , ], while the remainder were about specific groups, described in Table 3 [ 64 , , , , , , , ].

Articles about consumers buying from online pharmacies, listed in alphabetical order according to the first author. The UK-based survey considered both having bought and the intention to buy, so a third of the sample gave a positive response [ 75 ]. As in the general population studies, Mazer et al [ ] found that 5. The 2 papers by Inciardi et al [ , ] were based on several sources of information investigating different populations, including Internet-savvy high school and college students, chronic drug users, and members of the general population.

The authors concluded that, although the Internet is indeed a source for prescription drugs, the overwhelming volume of purchases is probably at the wholesale level, since few end users report accessing the Internet for drugs.

The results of the work by Inciardi et al [ ] seem to confirm the findings of the previous paper: Bechara et al [ ] in Argentina investigated the recreational use of PDE5Is by healthy young men and found that 2. Some reports suggest widespread use of online pharmacies in people over 35 years of age [ 75 , ] and in women [ ].

Mazer et al [ ] found no difference in age between those who bought drugs online and those who did not, and no difference in student status, but patients on multiple medications and those with prescription plans used online pharmacies more frequently. The most frequent reasons quoted by interviewees for buying or intending to buy online were convenience and saving money [ 12 , 75 ], followed by information anonymity and choice [ 75 ].

Regarding location of online pharmacies, the majority of buyers chose or would have chosen sites based in their own countries or in economically developed countries [ 12 , 75 ]. They sent consumers a self-administered electronic questionnaire. Their analysis showed that male, higher-educated, and higher-income consumers had a greater propensity to procure medication online, whereas insurance status did not have any influence. We found 12 published papers on clinical cases related to prescription drugs obtained via the Internet, which are shown in Multimedia Appendix 3.

One regarded the Internet purchase and injection of gamma-butyrolactone by an year-old woman that led to admission to a pediatric intensive care unit [ ]. Romero et al [ ] reported florid withdrawal delirium following the discontinuation of Fioricet a combination of butalbital, which is a barbiturate, with caffeine and acetaminophen indicated for muscle contraction headaches that a year-old woman purchased online and self-administered in escalating doses for the treatment of chronic headaches in a context of a history of depression.

Neuberg et al [ ] reported a case of life-threatening thyroid hormone abuse in a year-old woman encouraged and enabled by unconventional health advice and nonprescribed medication obtained via the Internet. Carisoprodol a muscle relaxant withdrawal after Internet purchase was reported by Eleid et al [ ]. Another report described a year-old woman who underwent surgery for brain cancer; after hospital discharge she researched adjunctive treatments of cancer on the Internet and self-initiated a day course of cesium chloride, ending up with an acquired long QT syndrome [ ].

A year-old man with squamous cell carcinoma of the maxillary sinus, who declined to undergo surgery, radiation, and chemotherapy, decided to treat his cancer using hydralazine sulfate, obtained online; he died from fatal hepatorenal failure, probably caused by the hydralazine sulfate [ ]. A series of case studies was reported by Lineberry and Bostwick [ ] regarding a suicide attempt by a year-old man using amitriptyline purchased online unbeknownst to his psychiatrist, who had prescribed him paroxetine, and 3 stories of opiate and painkiller addiction in a year-old man, a year-old man, and a year-old woman facilitated by online purchase.

Levesque [ ] reported tardive dyskinesia in a year-old man associated with the online purchase of the older antipsychotic drugs he probably received when he requested a tranquilizer.

All the cases reported so far occurred in the US, although other evidence shows that the phenomenon exists in Europe as well. A case of prolonged hypogonadotropic hypogonadism caused by anabolic steroids purchased on the Internet by a year-old Italian man was reported by Pirola et al [ ]. In the United Kingdom, orlistat-induced subacute liver failure was reported in a year-old woman [ ]. Also in the United Kingdom, acute coronary syndrome was diagnosed in a year-old man who had taken Viagra for erectile dysfunction [ ].

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 This is quite a considerable time in a rapidly changing world such as the Internet.

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. 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. As depicted in Figure 3 , all the contents that we systematized in our research can be linked to consumer safety, in terms of drug misuse, denial and delay of care, transparency issues, drug accessibility, drug quality, and consumer data protection.

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: 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 [ ]. Also connected to drug misuse is the theme of self-medication: If drug information is not available, this could minimize risk awareness.

Risk awareness can also be minimized by marketing strategies, as the findings have often shown that online pharmacies tend to market their products as if they were any other commodity. Indeed, inflation of drug demand has been suggested as an effect by the papers that have analyzed aspects related to marketing strategies adopted by online pharmacies.

The demand for drugs is enhanced not just by advertising economic advantages the true nature of which appears confused and controversial when comparing works that tackled the issue , showing that there are many triggers causing a person to buy online, not just a cheaper purchase, especially in countries other than the United States where drug prices are often negotiated; the other factors probably involved are confidentiality and willingness to avoid the doctor [ 27 , 79 ].

Whatever the reasons, the phenomenon is likely to increase, in a context in which people are becoming increasingly accustomed to online commerce, which is increasing day by day in terms of sales volumes and the number of people engaging in it. Being more accustomed does not mean always being more aware of risks: The risk of getting unnecessary drugs is also linked to pressure from marketing strategies.

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 [ 65 ].

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. 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.

Liang and Mackey [ ] proposed a statute that includes drug access costs, prohibition of Internet sales, a legal reform to give several federal agencies the authority to destroy contraband drugs, a pharmacy verification and licensure system, search engine accountability, and prevention of illicit transactions.

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 [ ], medicine 2. 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 [ 23 ].

In order 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, filling the existing legislative vacuum, although, as stated above, this would be very difficult, costly, and only partially effective. This approach should aim to increase health literacy, which is the foundation of critical thinking, a skill required for making appropriate health choices, recognizing risks, and making the most of the multitude of opportunities offered by the world of medicine 2.

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. Articles about case reports involving medicines bought on an online pharmacy, listed in alphabetical order according to the first author. National Center for Biotechnology Information , U. J Med Internet Res. Published online Sep Reviewed by Lana Ivanitskaya and Sara Rubinelli. Author information Article notes Copyright and License information Disclaimer.

Originally published in the Journal of Medical Internet Research http: This is an open-access article distributed under the terms of the Creative Commons Attribution License http: The complete bibliographic information, a link to the original publication on http: This article has been cited by other articles in PMC. Abstract Background Online pharmacies are companies that sell pharmaceutical preparations, including prescription-only drugs, on the Internet.

Objective 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. Methods We searched 4 electronic databases up to January and the gray literature on the Internet using the Google search engine and its tool Google Scholar.

Results We selected relevant articles: Conclusions 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. Internet, pharmaceutical preparations, public health, review, online pharmacies.

Introduction Neo, which pill would you choose? Previous Reviews To our knowledge, 2 reviews about online pharmacies in general and 3 others on specific aspects related to online pharmacies are available.

Objectives This review sought to investigate the available evidence on the phenomenon of online pharmacies. Methods Search Strategy The literature search covered the period up to January Open in a separate window.

Inclusion Criteria and Coding of Contents We included all articles relevant to the subject of the research—namely, online pharmacies, their characteristics, their products, and their consumers. Quality of Drugs Purchased Online We recorded studies in which the researchers bought prescription drugs online and evaluated the actual purchase and its characteristics.

Consumers Buying From Online Pharmacies We described articles dealing with the number of people purchasing drugs online, which was estimated by means of questionnaires or interviews. Types and Characteristics of Online Pharmacies We selected 47 articles about online pharmacies. Prescription Requirement One of the most controversial and widely studied features is prescription requirement.

Geographical Location Declaration of geographical location is an important feature with regard to transparency. Drugs Offered by Online Pharmacies What do online pharmacies have to offer? Marketing Strategies Only a few articles focused on the marketing strategies of online pharmacies. Website Time of Existence Arruanda [ 58 ] found that the sample online pharmacies had been online for a length of time ranging from just over 1 year to 7 years.

Process Characteristics and Drug Quality We found 13 studies [ 59 , 64 - 66 , 73 , 74 , 82 , 83 , 94 , - ] in which the researchers bought prescription drugs online and evaluated the actual dispatch and its characteristics, and the quality of the products received Table 2.

Table 2 Articles on the quality of drugs purchased online, listed in alphabetical order according to the first author. Drug Purchase Characteristics The actual purchase of drugs without having an original medical prescription was verified by all authors except for Dean et al [ ], Veronin and Youan [ ], Veronin et al [ 94 ], and Westenberger et al [ ], who did not specify whether a prescription was used.

Drug Quality Characteristics Regarding drug quality characteristics, researchers evaluated different features: Consumers Purchasing From Online Pharmacies The most difficult task in connection with online pharmacies is attempting to establish the number of people buying and the volume of money traded.

Population Surveys Table 3 shows the 15 articles [ 12 , 64 , 75 , - ] dealing with consumer characteristics and based on surveys. Table 3 Articles about consumers buying from online pharmacies, listed in alphabetical order according to the first author. Clinical Case Reports We found 12 published papers on clinical cases related to prescription drugs obtained via the Internet, which are shown in Multimedia Appendix 3.

Discussion 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.

Consumer safety as a common denominator for studying online pharmacies. Conclusions 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.

Acknowledgments The authors wish to thank the anonymous reviewers for their valuable comments and insightful suggestions to improve the quality of the paper. Multimedia Appendix 1 List of articles about online pharmacies without original data. Click here to view. Multimedia Appendix 3 Articles about case reports involving medicines bought on an online pharmacy, listed in alphabetical order according to the first author.

Footnotes Conflicts of Interest: Orizio G, Gelatti U. Public e-health and new scenarios in terms of risks and opportunities: Issues in Internet pharmacy practice. Global Observatory for eHealth series, volume 1. Fact sheet no http: Regulation of online pharmacy: An examination of selected drug availability at online pharmacies.

Int J Electron Healthc. Operation cyber chase and other agency efforts to control internet drug trafficking. An Op-Ed concerning steroids and the law: Kansas sues internet medicine suppliers. Bruckel K, Capozzoli EA. J Hosp Mark Public Relations. Controversies and legal issues of prescribing and dispensing medications using the Internet. Montoya ID, Jano E. Int J Health Serv. Nuffield Council on Bioethics. Medical Profiling and Online Medicine: Nuffield Council on Bioethics; Glover-Thomas N, Fanning J.

Is the online drugs market putting patients at risk? Buying prescription drugs on the internet: Cleve Clin J Med. Do online pharmacies fit European internal markets? Nielsen S, Barratt MJ. Counterfeit phosphodiesterase type 5 inhibitors pose significant safety risks. Int J Clin Pract. Sildenafil and the Internet. S 05 [ PubMed ] [ Google Scholar ]. Baert B, De Spiegeleer B. Quality analytics of Internet pharmaceuticals. US National Library of Medicine.

National Institutes of Health PubMed. Thomson Reuters Web of Knowledge. European Medicines Agency European Union. Five deaths resulting from abuse of dextromethorphan sold over the internet. Chinese slimming capsules containing sibutramine sold over the Internet: Amphetamine lacing of an Internet-marketed neutraceutical. Drugs on the web; the Psychonaut EU project. Prog Neuropsychopharmacol Biol Psychiatry.

The availability and portrayal of stimulants over the Internet. Availability of oral isotretinoin and terbinafine on the Internet.

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