By SUSAN ADELMAN, MD
Doctors, do you know whether your patients actually are taking the medicines you have prescribed? Brick and mortar retail pharmacies are vanishing these days, or at least dwindling, and on-line pharmacies are proliferating. We need to understand what this means. Rite-Aid has gone bankrupt, closing 500 stores. CVS closed 244 stores between 2018 and 2020, and in 2021 it announced it would close 900. Walgreens announced in 2019 that it would close 200 stores, and in 2023 it announced it would close 150 more. Walmart is closing 11 stores in 2024, and it is divesting itself of 51 health clinics. The reason given is that these stores were unprofitable. But why? High on the list of reasons is retail theft, followed by lower fees for prescription (as a result of pharmaceutical managers) and reduced profits from household goods because of competition from Amazon and big box stores. Oh, and those on-line pharmacies.
According to Capsa, in 2010, 10% of all U.S. prescriptions were filled by mail order. Ten years later, it was close to 16%. This is unfortunate, because many of these online pharmacies lack important safeguards for the patient, and they are notoriously difficult to spot. In one study, fewer than 60% of the pharmacists asked could tell with confidence that a website is illegal, according to the National Library of Medicine in 2021. The NIM also reported that “An estimated 95% of all online pharmacies operate unlawfully”, a percentage that became much worse after COVID. Studies have shown that substances mixed in with your prescribed medicine may include brick dust, sheetrock, flour, rat poison, ethylene glycol (antifreeze), or illegal opioids. Possibly worse, the pill or capsule may contain none of the medication that you were prescribed.
According to U.S. Pharmacist, 10% of global prescriptions—I have even read 33%— may be counterfeit, especially if they are high-demand, expensive medications, such as chemotherapies, antibiotics, vaccines, weight loss aids, hormones, steroids, antivirals and antianxiety drugs. Particularly vulnerable are Viagra, Vicodin and Claritin. In 2009, Pfizer found 14 of its most counterfeited medicines marketed in 36 different countries. The countries that are most notorious for selling fake medicines are in Asia along the Western Pacific, including China, Vietnam, and the Philippines, but the countries also include Russia, India, Pakistan, and Turkey. Over 13% of reported cases come from Europe. Only 1% are from the U.S., but the number is increasing.
As any doctor will recognize, the medicines listed may be essential to a patient’s survival, and the dose may be critical. Normally, if a doctor prescribes a medication and the patient does not seem to respond, the last thing that either doctor or patient thinks of is whether the prescribed drug is even in the pill, or that it is barely in the pill. This can lead the doctor to change the prescription, raise the dose, or try other maneuvers that could cause further harm, especially if the patient tries to fill the prescription somewhere else. In the worst case, lack of the medicine could lead to death.
The recent epidemic of massive retail theft has led to so many pharmacy closures that some neighborhoods have turned into pharmaceutical deserts. Has this caused patients to turn to the internet, or, conversely, has a widespread search for bargain medicines led so many patients to the internet that it impacts on the economic viability of retail pharmacies? I do not know, but I do know that the use of unauthorized sites can lead to death when apparently identical counterfeit pills are substituted for legitimate ones. A contemporary example is the sale of pills that appear to be standard brands but that actually contain fentanyl. A Consumer Brief from the New Jersey division of the Department of Consumer Affairs cautions that patients should not buy from sites that sell drugs that are not approved by the FDA, that do not ask for a valid prescription or a doctor’s order, do not provide a registered pharmacist who can answer questions, and/or certainly that market prescription drugs from foreign websites. (Even if the website has a Canadian flag on it, that means nothing.) The patient is warned to check the packaging, to be sure it is the same as the last pills from a retail pharmacy, check the expiration date, and be sure they have an address and phone number for the site. If the site is unlicensed or sells drugs to patients who have not seen a doctor, patients are urged to contact the Board of Pharmacy.
Or tell your patients to stay away from ordering pills from the internet. They should just go to their neighborhood pharmacy whenever possible. Buy local. And it will keep the pharmacy open so they can buy their floor polish there too.