@Article{info:doi/10.2196/59884,
author="Sattar, Anum
and Rehman, Hina
and Naveed, Safila
and Khadim, Sumaira
and Khan, Nargis
and Kazi, Furqan Ahmad
and Syed, Wajid
and Al-Rawi, A. Mahmood Basil
and Jamshed, Shazia",
title="Trustworthiness of Web-Based Pharmacy Apps in Pakistan Based on the Mobile App Rating Scale: Content Analysis and Quality Evaluation",
journal="JMIR Mhealth Uhealth",
year="2025",
month="Apr",
day="17",
volume="13",
pages="e59884",
keywords="online pharmacy",
keywords="online pharmacy apps",
keywords="apps",
keywords="mobile app",
keywords="smartphone app",
keywords="trustworthiness",
keywords="pharmacy",
keywords="digital platforms",
keywords="questionnaire",
keywords="engagement",
keywords="functionality",
keywords="Mobile App Rating Scale",
keywords="MARS",
keywords="user",
keywords="efficacy",
keywords="Pakistan",
abstract="Background: Web-based pharmacy apps facilitate the electronic exchange of health-related supplies. They are digital platforms that run on websites and smartphones. Pakistan is experiencing significant progress in smartphone integration and digital services, leading to the expansion of the online pharmacy business. However, concerns remain over the legitimacy and precision of these apps. Objective: The aim of this study was to undertake a thorough assessment of digital pharmacy apps accessible in Pakistan. Specifically, our focus was on apps accessible via the Google Play Store and the iOS App Store. To fulfill this objective, an evaluation of these apps was performed using the Mobile App Rating Scale (MARS). Methods: A research investigation was conducted to analyze the online pharmacy apps in Pakistan. Initially, 50 apps were identified, but 10 were excluded for not meeting pre-established criteria, 10 were excluded for being in languages other than English, and 7 could not be downloaded. All paid and non-English apps were also excluded. A total of 23 apps were selected for the study, acquired via the Google Play Store and iOS App Store. The evaluation was conducted by 2 researchers who maintained independence from one another by using the MARS. Results: Initially, 50 apps were identified, of which 27 were excluded for not meeting the predetermined criteria. A total of 23 apps were selected for the study, acquired via the Google Play Store and iOS App Store. Strong positive correlations between higher user engagement and better app functionality and information quality were observed. The average rating of the 23 apps ranged between 2.64 and 4.00 on a scale up to 5. The aesthetics dimension had the highest mean score of 3.6, while the information dimension had the lowest mean score of 3.2. For credibility and reliability, different tests (intraclass correlation, Cohen $\kappa$, Krippendorff $\alpha$, and Cronbach $\alpha$) on each dimension of the MARS were performed by using SPSS Statistics 27. The intraclass correlation of all MARS dimensions ranged from 0.702?0.913 (95\% CI 0.521?0.943), the Cohen $\kappa$ of all MARS dimensions ranged from 0.388?0.907 (95\% CI 0.151?0.994), the Krippendorff $\alpha$ of all MARS dimensions ranged from 0.705?0.979 (95\% CI 0.657?0.923), and Cronbach $\alpha$ had a lower score of 0.821 in the information dimension and a higher score of .911 in the subjective quality dimension of the MARS. Conclusion: This study evaluated online pharmacy apps in Pakistan by using the MARS. It is the first study on online pharmacy apps in Pakistan. The findings of the evaluation have provided insights into the reliability and efficacy of these apps. ",
doi="10.2196/59884",
url="https://mhealth.jmir.org/2025/1/e59884"
}


@Article{info:doi/10.2196/57782,
author="Lambert, Aur{\'e}lien
and Hombourger, Benoit
and Salleron, Julia
and Chergui, Fadila
and Vallance, Catherine
and Nicolas, Nad{\`e}ge
and Moussouni, Marie
and Cherif, Lounisse
and Chenot, Emile
and Gavoille, C{\'e}line
and Massard, Vincent",
title="Impact of Electronic Transition and Prefilled Templates on Drug Prescription Compliance: Retrospective Study",
journal="J Med Internet Res",
year="2025",
month="Apr",
day="9",
volume="27",
pages="e57782",
keywords="drug prescription",
keywords="electronic prescription",
keywords="handwriting",
keywords="medical oncology",
keywords="ambulatory care",
abstract="Background: The transition from traditional handwritten prescriptions to electronic prescribing systems represents a significant advancement, with the potential to enhance treatment efficacy, patient safety, and professional communication. Objective: This study aimed to examine the impact of this transition within a medical oncology service, assessing the compliance of electronic prescriptions with established good practice standards and exploring the associated risks. Methods: In this retrospective analysis, we compared handwritten prescriptions from the pre-electronic era (January to May 2018) with electronic prescriptions (January to May 2021) following the implementation of the electronic prescribing system PandaLab Pro (PandaLab SAS). The inclusion criteria focused on outpatient oncology treatments, with a clear set of exclusion parameters to ensure a focused study scope. We defined good compliance as the written mention of the evaluated terms. The compliance rates were then compared using a chi-square test. Results: Our findings, based on a sample size of 260 prescriptions (randomized among 30,526 archived prescriptions), indicate a substantial improvement in electronic prescriptions' compliance with prescribers and patient details, treatment accuracy, and overall adherence to regulatory standards. Notably, electronic formats achieved a remarkable 80.8\% accuracy rate in compliance with safety criteria compared with 8.5\% for handwritten prescriptions (P<.001). The use of prefilled prescriptions significantly increased compliance from a safety perspective (56\% vs 96.2\%; P<.001) compared with electronic prescriptions from scratch. Conclusions: The analysis further underscores the advantages of prefilled electronic prescription templates, which significantly improved compliance rates compared with manually filled electronic and handwritten prescriptions. Furthermore, the study revealed a marked shift in prescribing behaviors, with electronic prescriptions tending to be more concise yet more numerous, suggesting an impact on medication management and patient adherence, which warrants further investigation. The study supports the transition to electronic prescribing systems in oncology, highlighting enhanced traceability, compliance with health authority standards, and patient safety. The implementation of prefilled templates supported by pharmacists has emerged as a pivotal factor in this improved process. While acknowledging certain limitations, such as the nonquantitative assessment of time savings and acceptability, this research advocates for the widespread adoption of electronic prescriptions and serves as a benchmark for future e-prescription initiatives in France. ",
doi="10.2196/57782",
url="https://www.jmir.org/2025/1/e57782",
url="http://www.ncbi.nlm.nih.gov/pubmed/40202779"
}


@Article{info:doi/10.2196/55391,
author="Naughton, D. Bernard",
title="Planned Behavior in the United Kingdom and Ireland Online Medicine Purchasing Context: Mixed Methods Survey Study",
journal="JMIR Form Res",
year="2025",
month="Feb",
day="21",
volume="9",
pages="e55391",
keywords="planned behavior",
keywords="consumer behavior",
keywords="perceived behavioral control",
keywords="attitudes",
keywords="online purchasing",
keywords="medicine",
abstract="Background: Online medicine purchasing is a growing health care opportunity. However, there is a scarcity of available evidence through a behavioral lens, which addresses why consumers buy medicines online. Governments try to influence online medicine purchasing behavior using health campaigns. However, there are little data regarding specific online medicine purchasing behaviors to support these campaigns. Objective: The theory of planned behavior explains that perceived behavioral control (PBC), attitudes, and norms contribute to intentions, leading to behaviors. This study challenges these assumptions, by testing them in an online medicine purchasing context. We asked: What is the role of attitudes, norms, and PBC in an online medicine purchasing context. Methods: An anonymous online snowball convenience sample survey, including open and closed questions concerning online medicine purchasing, was implemented. The data were thematically analyzed until data saturation. The emerging themes were applied to each individual response, as part of a case-by-case narrative analysis. Results: Of the 190 consumers from the United Kingdom and Ireland who consented to participate in the study, 46 participants had purchased medicines online, 9 of which were illegal sales. Of the 113 participants who demonstrated an intention to purchase, 42 (37.2\%) completed a purchase. There were many cases in which participants demonstrated an intention to buy medicines online, but this intention did not translate to a purchasing behavior (71/190, 37.4\%). Reasons for consumers progressing from intention to behavior are suggested to be impacted by PBC and attitudes. Qualitative data identified access to medicine as a factor encouraging online medicine purchasing behaviors and a facilitator of behavior transition. Despite understanding the importance of why some medicines required a prescription, which is described as an example of legal and health norms, and despite suspicion and concern categorized as negative attitudes in this paper, some participants were still buying products illegally online. Risk reduction strategies were performed by 17 participants (17/190, 9\%). These strategies facilitated a transition from intention to behavior. Conclusions: The study results indicate that a consumer's intention to buy does not automatically translate to a purchasing behavior online; instead, a transition phase exists. Second, consumers followed different pathways to purchase and used risk reduction practices while transitioning from an intention to a behavior. Finally, owing to the covert nature of online medicine purchasing, norms do not appear to be as influential as PBC and attitudes in an online medicine purchasing setting. Understanding how a consumer transitions from an intention to a behavior could be useful for researchers, health care professionals, and policymakers involved in public health campaigns. We encourage future research to focus on different consumer behavior pathways or ideal types, rather than taking a blanket approach to public health campaigns. ",
doi="10.2196/55391",
url="https://formative.jmir.org/2025/1/e55391"
}


@Article{info:doi/10.2196/60315,
author="Knowles, Kayla
and Lee, Susan
and Yapalater, Sophia
and Taylor, Maria
and Akers, Y. Aletha
and Wood, Sarah
and Dowshen, Nadia",
title="Simulation of Contraceptive Access for Adolescents and Young Adults Using a Pharmacist-Staffed e-Platform: Development, Usability, and Pilot Testing Study",
journal="JMIR Pediatr Parent",
year="2025",
month="Feb",
day="19",
volume="8",
pages="e60315",
keywords="adolescent",
keywords="contraception",
keywords="telemedicine",
keywords="user-centered design",
keywords="young adult",
keywords="reproductive",
keywords="design",
keywords="usability",
keywords="experience",
keywords="mHealth",
keywords="mobile health",
keywords="app",
keywords="youth",
keywords="teenager",
keywords="drug",
keywords="pharmacology",
keywords="pharmacotherapy",
keywords="pharmaceutics",
keywords="medication",
keywords="pharmacy",
keywords="digital health",
keywords="platform",
keywords="access",
abstract="Background: Offering contraceptive methods at pharmacies without a prescription is an innovative solution to reduce the incidence of unintended pregnancies among adolescents and young adults (AYA). Pharmacy-prescribed contraception may increase the convenience, simplicity, and affordability of contraceptives. Objective: The aim of this study was to develop, pilot test, and evaluate the acceptability and feasibility of a telemedicine electronic platform app simulating pharmacist prescribing of contraceptives to AYA as well as assess agreement between pharmacist-simulated contraceptive approvals and contraception as prescribed in routine clinic visits. Methods: This study was conducted in two phases: (1) development and usability testing of a prototype app to simulate pharmacists prescribing contraceptives to AYA and (2) pilot testing the app in a simulation for AYA requesting contraception from a pharmacist with pharmacist review and request approval or rejection. Eligibility criteria in both phases included the following: assigned female sex at birth, age 15-21 years, seeking contraceptive services at an academic adolescent medicine clinic, prior history of or intention to have penile-vaginal intercourse in the next 12 months, smartphone ownership, and English language proficiency. Phase 1 (usability) involved a video-recorded ``think aloud'' interview to share feedback and technical issues while using the app prototype on a smartphone and the completion of sociodemographic, sexual history, and perception of the prototype surveys to further develop the app. Phase 2 (pilot) participants completed phase 1 surveys, tested the updated app in a simulation, and shared their experiences in an audio-recorded interview. Descriptive analyses were conducted for quantitative survey data, and thematic analyses were used for interview transcripts. Results: Of the 22 participants, 10 completed usability testing, with a mean age of 16.9 (SD 1.97) years, and 12 completed pilot testing, with a mean age of 18.25 (SD 1.48) years. Three issues with the prototype were identified during ``think aloud'' interviews: challenges in comprehension of medical language, prototype glitches, and graphic design suggestions for engagement. Usability testing guided the frontend and backend creation of the platform. Overall, participants agreed or strongly agreed that using an app to receive contraceptives would make it easier for teens to access (n=19, 86\%) and make contraceptive use less stigmatizing (n=19, 86\%). In addition, participants agreed that receiving contraception prescriptions from a pharmacist without a clinic visit would be safe (n=18, 82\%), convenient (n=19, 86\%), acceptable (n=18, 82\%), and easy (n=18, 82\%). Pharmacists and medical providers had 100\% agreement on the prescribed contraceptive method for pilot participants. Conclusions: AYA found contraceptive prescription by a pharmacist via an app to be highly acceptable and provided critical feedback to improve the design and delivery of the app. Additionally, pharmacist contraceptive approvals and contraception as prescribed in routine clinic visits were identical. ",
doi="10.2196/60315",
url="https://pediatrics.jmir.org/2025/1/e60315"
}


@Article{info:doi/10.2196/72007,
author="Vordenberg, E. Sarah
and Nichols, Julianna
and Marshall, D. Vincent
and Weir, Rebecca Kristie
and Dorsch, P. Michael",
title="Authors' Reply: Enhancing the Clinical Relevance of Al Research for Medication Decision-Making",
journal="J Med Internet Res",
year="2025",
month="Feb",
day="18",
volume="27",
pages="e72007",
keywords="older adults",
keywords="artificial intelligence",
keywords="vignette",
keywords="pharmacology",
keywords="medication",
keywords="decision-making",
keywords="aging",
keywords="attitude",
keywords="perception",
keywords="perspective",
keywords="electronic heath record",
doi="10.2196/72007",
url="https://www.jmir.org/2025/1/e72007",
url="http://www.ncbi.nlm.nih.gov/pubmed/39964740"
}


@Article{info:doi/10.2196/70657,
author="Wang, Qi
and Chen, Mingxian",
title="Enhancing the Clinical Relevance of Al Research for Medication Decision-Making",
journal="J Med Internet Res",
year="2025",
month="Feb",
day="18",
volume="27",
pages="e70657",
keywords="older adults",
keywords="artificial intelligence",
keywords="medication",
keywords="decision-making",
keywords="data security",
keywords="patient trust",
doi="10.2196/70657",
url="https://www.jmir.org/2025/1/e70657",
url="http://www.ncbi.nlm.nih.gov/pubmed/39964744"
}


@Article{info:doi/10.2196/53957,
author="Scharf, Tamara
and Huber, A. Carola
and N{\"a}pflin, Markus
and Zhang, Zhongxing
and Khatami, Ramin",
title="Trends in Prescription of Stimulants and Narcoleptic Drugs in Switzerland: Longitudinal Health Insurance Claims Analysis for the Years 2014-2021",
journal="JMIR Public Health Surveill",
year="2025",
month="Jan",
day="7",
volume="11",
pages="e53957",
keywords="prescription trends",
keywords="claims data",
keywords="cross-sectional data",
keywords="narcolepsy",
keywords="prescribers",
keywords="prescribing practices",
keywords="medical care",
keywords="stimulants",
keywords="stimulant medication",
abstract="Background: Stimulants are potent treatments for central hypersomnolence disorders or attention-deficit/hyperactivity disorders/attention deficit disorders but concerns have been raised about their potential negative consequences and their increasing prescription rates. Objective: We aimed to describe stimulant prescription trends in Switzerland from 2014 to 2021. Second, we aimed to analyze the characteristics of individuals who received stimulant prescriptions in 2021 and investigate the link between stimulant prescriptions and hospitalization rates in 2021, using hospitalization as a potential indicator of adverse health outcomes. Methods: Longitudinal and cross-sectional data from a large Swiss health care insurance were analyzed from all insureds older than 6 years. The results were extrapolated to the Swiss general population. We identified prescriptions for methylphenidate, lisdexamfetamine, modafinil, and sodium oxybate and calculated prevalences of each drug prescription over the period from 2014 to 2021. For 2021 we provide detailed information on the prescribers and evaluate the association of stimulant prescription and the number and duration of hospitalization using logistic regression models. Results: We observed increasing prescription rates of all stimulants in all age groups from 2014 to 2021 (0.55\% to 0.81\%, 43,848 to 66,113 insureds with a prescription). In 2021, 37.1\% (28,057 prescriptions) of the medications were prescribed by psychiatrists, followed by 36.1\% (n=27,323) prescribed by general practitioners and 1\% (n=748) by neurologists. Only sodium oxybate, which is highly specific for narcolepsy treatment, was most frequently prescribed by neurologists (27.8\%, 37 prescriptions). Comorbid psychiatric disorders were common in patients receiving stimulants. Patients hospitalized in a psychiatric institution were 5.3 times (odds ratio 5.3, 95\% CI 4.63?6.08, P<.001) more likely to have a stimulant prescription than those without hospitalization. There were no significant associations between stimulant prescription and the total length of inpatient stay (odds ratio 1, 95\% CI 1?1, P=.13). Conclusions: The prescription of stimulant medication in Switzerland increased slightly but continuously over years, but at lower rates compared to the estimated prevalence of central hypersomnolence disorders and attention-deficit/hyperactivity disorders/attention deficit disorders. Most stimulants are prescribed by psychiatrists, closely followed by general practitioners. The increased odds for hospitalization to psychiatric institutions for stimulant receivers reflects the severity of disease and the higher psychiatric comorbidities in these patients. ",
doi="10.2196/53957",
url="https://publichealth.jmir.org/2025/1/e53957"
}


@Article{info:doi/10.2196/60535,
author="Jeanmougin, Pauline
and Larramendy, St{\'e}phanie
and Fournier, Jean-Pascal
and Gaultier, Aur{\'e}lie
and Rat, C{\'e}dric",
title="Effect of a Feedback Visit and a Clinical Decision Support System Based on Antibiotic Prescription Audit in Primary Care: Multiarm Cluster-Randomized Controlled Trial",
journal="J Med Internet Res",
year="2024",
month="Dec",
day="18",
volume="26",
pages="e60535",
keywords="antibacterial agents",
keywords="feedback",
keywords="clinical decision support system",
keywords="prescriptions",
keywords="primary health care",
keywords="clinical decision",
keywords="antibiotic prescription",
keywords="antimicrobial",
keywords="antibiotic stewardship",
keywords="interventions",
keywords="health insurance",
keywords="systematic antibiotic prescriptions",
abstract="Background: While numerous antimicrobial stewardship programs aim to decrease inappropriate antibiotic prescriptions, evidence of their positive impact is needed to optimize future interventions. Objective: This study aimed to evaluate 2 multifaceted antibiotic stewardship interventions for inappropriate systemic antibiotic prescription in primary care. Methods: An open-label, cluster-randomized controlled trial of 2501 general practitioners (GPs) working in western France was conducted from July 2019 to January 2021. Two interventions were studied: the standard intervention, consisting of a visit by a health insurance representative who gave prescription feedback and provided a leaflet for treating cystitis and tonsillitis; and a clinical decision support system (CDSS)--based intervention, consisting of a visit with prescription feedback and a CDSS demonstration on antibiotic prescribing. The control group received no intervention. Data on systemic antibiotic dispensing was obtained from the National Health Insurance System (Syst{\`e}me National d'Information Inter-R{\'e}gimes de l'Assurance Maladie) database. The overall antibiotic volume dispensed per GP at 12 months was compared between arms using a 2-level hierarchical analysis of covariance adjusted for annual antibiotic prescription volume at baseline. Results: Overall, 2501 GPs were randomized (n=1099, 43.9\% women). At 12 months, the mean volume of systemic antibiotics per GP decreased by 219.2 (SD 61.4; 95\% CI ?339.5 to ?98.8; P<.001) defined daily doses in the CDSS-based visit group compared with the control group. The decrease in the mean volume of systemic antibiotics dispensed per GP was not significantly different between the standard visit group and the control group (?109.7, SD 62.4; 95\% CI ?232.0 to 12.5 defined daily doses; P=.08). Conclusions: A visit by a health insurance representative combining feedback and a CDSS demonstration resulted in a 4.4\% (-219.2/4930) reduction in the total volume of systemic antibiotic prescriptions in 12 months. Trial Registration: ClinicalTrials.gov NCT04028830; https://clinicaltrials.gov/study/NCT04028830 ",
doi="10.2196/60535",
url="https://www.jmir.org/2024/1/e60535",
url="http://www.ncbi.nlm.nih.gov/pubmed/39693139"
}


@Article{info:doi/10.2196/60794,
author="Vordenberg, E. Sarah
and Nichols, Julianna
and Marshall, D. Vincent
and Weir, Rebecca Kristie
and Dorsch, P. Michael",
title="Investigating Older Adults' Perceptions of AI Tools for Medication Decisions: Vignette-Based Experimental Survey",
journal="J Med Internet Res",
year="2024",
month="Dec",
day="16",
volume="26",
pages="e60794",
keywords="older adults",
keywords="survey",
keywords="decisions",
keywords="artificial intelligence",
keywords="vignette",
keywords="drug",
keywords="pharmacology",
keywords="pharmaceutic",
keywords="medication",
keywords="decision-making",
keywords="geriatric",
keywords="aging",
keywords="surveys",
keywords="attitude",
keywords="perception",
keywords="perspective",
keywords="recommendation",
keywords="electronic heath record",
abstract="Background: Given the public release of large language models, research is needed to explore whether older adults would be receptive to personalized medication advice given by artificial intelligence (AI) tools. Objective: This study aims to identify predictors of the likelihood of older adults stopping a medication and the influence of the source of the information. Methods: We conducted a web-based experimental survey in which US participants aged ?65 years were asked to report their likelihood of stopping a medication based on the source of information using a 6-point Likert scale (scale anchors: 1=not at all likely; 6=extremely likely). In total, 3 medications were presented in a randomized order: aspirin (risk of bleeding), ranitidine (cancer-causing chemical), or simvastatin (lack of benefit with age). In total, 5 sources of information were presented: primary care provider (PCP), pharmacist, AI that connects with the electronic health record (EHR) and provides advice to the PCP (``EHR-PCP''), AI with EHR access that directly provides advice (``EHR-Direct''), and AI that asks questions to provide advice (``Questions-Direct'') directly. We calculated descriptive statistics to identify participants who were extremely likely (score 6) to stop the medication and used logistic regression to identify demographic predictors of being likely (scores 4-6) as opposed to unlikely (scores 1-3) to stop a medication. Results: Older adults (n=1245) reported being extremely likely to stop a medication based on a PCP's recommendation (n=748, 60.1\% [aspirin] to n=858, 68.9\% [ranitidine]) compared to a pharmacist (n=227, 18.2\% [simvastatin] to n=361, 29\% [ranitidine]). They were infrequently extremely likely to stop a medication when recommended by AI (EHR-PCP: n=182, 14.6\% [aspirin] to n=289, 23.2\% [ranitidine]; EHR-Direct: n=118, 9.5\% [simvastatin] to n=212, 17\% [ranitidine]; Questions-Direct: n=121, 9.7\% [aspirin] to n=204, 16.4\% [ranitidine]). In adjusted analyses, characteristics that increased the likelihood of following an AI recommendation included being Black or African American as compared to White (Questions-Direct: odds ratio [OR] 1.28, 95\% CI 1.06-1.54 to EHR-PCP: OR 1.42, 95\% CI 1.17-1.73), having higher self-reported health (EHR-PCP: OR 1.09, 95\% CI 1.01-1.18 to EHR-Direct: OR 1.13 95\%, CI 1.05-1.23), having higher confidence in using an EHR (Questions-Direct: OR 1.36, 95\% CI 1.16-1.58 to EHR-PCP: OR 1.55, 95\% CI 1.33-1.80), and having higher confidence using apps (EHR-Direct: OR 1.38, 95\% CI 1.18-1.62 to EHR-PCP: OR 1.49, 95\% CI 1.27-1.74). Older adults with higher health literacy were less likely to stop a medication when recommended by AI (EHR-PCP: OR 0.81, 95\% CI 0.75-0.88 to EHR-Direct: OR 0.85, 95\% CI 0.78-0.92). Conclusions: Older adults have reservations about following an AI recommendation to stop a medication. However, individuals who are Black or African American, have higher self-reported health, or have higher confidence in using an EHR or apps may be receptive to AI-based medication recommendations. ",
doi="10.2196/60794",
url="https://www.jmir.org/2024/1/e60794"
}


@Article{info:doi/10.2196/64300,
author="Youn, G. Christopher
and Kim, Yeon Joo
and Yang, B. Vivian
and Bae, H. Gordon",
title="Improving Affordability in Dermatology: Cost Savings in Mark Cuban Cost Plus Drug Company Versus GoodRx",
journal="JMIR Dermatol",
year="2024",
month="Dec",
day="13",
volume="7",
pages="e64300",
keywords="dermatology",
keywords="cost",
keywords="affordability",
keywords="drug company",
keywords="United States",
keywords="US",
keywords="financial burden",
keywords="prescription",
keywords="medication",
keywords="pharmaceutical",
keywords="dermatologic",
keywords="burden",
keywords="financial distress",
keywords="health outcomes",
keywords="pharmacist",
keywords="pharmacy",
keywords="convenience",
doi="10.2196/64300",
url="https://derma.jmir.org/2024/1/e64300"
}


@Article{info:doi/10.2196/65440,
author="Ashraf, Reza Amir
and Mackey, Ken Tim
and Vida, Gy{\"o}rgy R{\'o}bert
and Kulcs{\'a}r, Gy?z?
and Schmidt, J{\'a}nos
and Bal{\'a}zs, Orsolya
and Domi{\'a}n, M{\'a}rk B{\'a}lint
and Li, Jiawei
and Cs{\'a}k{\'o}, Ibolya
and Fittler, Andr{\'a}s",
title="Multifactor Quality and Safety Analysis of Semaglutide Products Sold by Online Sellers Without a Prescription: Market Surveillance, Content Analysis, and Product Purchase Evaluation Study",
journal="J Med Internet Res",
year="2024",
month="Nov",
day="7",
volume="26",
pages="e65440",
keywords="semaglutide",
keywords="Ozempic",
keywords="Wegovy",
keywords="search engines",
keywords="online pharmacies",
keywords="patient safety",
keywords="medication safety",
keywords="nondelivery schemes",
keywords="counterfeit",
keywords="substandard and falsified medical products",
abstract="Background: Over the past 4 decades, obesity has escalated into a global epidemic, with its worldwide prevalence nearly tripling. Pharmacological treatments have evolved with the recent development of glucagon-like peptide 1 agonists, such as semaglutide. However, off-label use of drugs such as Ozempic for cosmetic weight loss has surged in popularity, raising concerns about potential misuse and the emergence of substandard and falsified products in the unregulated supply chain. Objective: This study aims to conduct a multifactor investigation of product quality and patient safety risks associated with the unregulated online sale of semaglutide by examining product availability and vendor characteristics and assessing product quality through test purchases. Methods: We used a complex risk and quality assessment methodology combining online market surveillance, search engine results page analysis, website content assessment, domain traffic analytics, conducting targeted product test purchases, visual quality inspection of product packaging, microbiological sterility and endotoxin contamination evaluation, and quantitative sample analysis using liquid chromatography coupled with mass spectrometry. Results: We collected and evaluated 1080 links from search engine results pages and identified 317 (29.35\%) links belonging to online pharmacies, of which 183 (57.7\%) led to legal pharmacies and 134 (42.3\%) directed users to 59 unique illegal online pharmacy websites.?Web traffic data for the period between July and September 2023 revealed that the top 30 domains directly or indirectly affiliated with illegal online pharmacies accumulated over 4.7 million visits.?Test purchases were completed from?6 illegal online pharmacies with the highest number of links offering semaglutide products for sale without prescription at the lowest price range. Three injection vial purchases were delivered; none of the 3 Ozempic prefilled injection pens were received due to nondelivery e-commerce scams.?All purchased vials were considered probable substandard and falsified products, as visual inspection indicated noncompliance in more than half (59\%-63\%) of the evaluated criteria. The semaglutide content of samples substantially exceeded labeled amounts by 28.56\%-38.69\%, although no peptide-like impurities were identified. The lyophilized peptide samples were devoid of viable microorganisms at the time of testing; however, endotoxin was detected in all samples with levels ranging between 2.1645 EU/mg and 8.9511 EU/mg. Furthermore, the measured semaglutide purity was significantly low, ranging between 7.7\% and 14.37\% and deviating from the 99\% claimed on product labels by manufacturers. Conclusions: Glucagon-like peptide 1 agonist drugs promoted for weight loss, similar to erectile dysfunction medications more than 2 decades ago, are becoming the new blockbuster lifestyle medications for the illegal online pharmacy market. Protecting the pharmaceutical supply chain from substandard and falsified weight loss products and raising awareness regarding online medication safety must be a public health priority for regulators and technology platforms alike. ",
doi="10.2196/65440",
url="https://www.jmir.org/2024/1/e65440"
}


@Article{info:doi/10.2196/59791,
author="Barker, Wesley
and Chang, Wei
and Everson, Jordan
and Gabriel, Meghan
and Patel, Vaishali
and Richwine, Chelsea
and Strawley, Catherine",
title="The Evolution of Health Information Technology for Enhanced Patient-Centric Care in the United States: Data-Driven Descriptive Study",
journal="J Med Internet Res",
year="2024",
month="Oct",
day="28",
volume="26",
pages="e59791",
keywords="interoperability",
keywords="e-prescribing",
keywords="electronic public health reporting",
keywords="patient access to health information",
keywords="electronic health records",
keywords="health IT",
abstract="Background: Health information technology (health IT) has revolutionized health care in the United States through interoperable clinical care data exchange, e-prescribing, electronic public health reporting, and electronic patient access to health information. Objective: This study aims to examine progress in health IT adoption and its alignment with the Office of the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health IT (ASTP's) mission to enhance health care through data access and exchange. Methods: This study leverages data on end users of health IT to capture trends in engagement in interoperable clinical care data exchange (ability to find, send, receive, and integrate information from outside organizations), e-prescribing, electronic public health reporting, and capabilities to enable patient access to electronic health information. Data were primarily sourced from the American Hospital Association Annual Survey IT Supplement (2008 to 2023), Surescripts e-prescribing use data (2008 to 2023), the National Cancer Institute's Health Information National Trends Survey (2014 to 2022), and the National Center for Health Statistics' National Electronic Health Records Survey (2009 to 2023). Results: Since 2009, there has been a 10-fold increase in electronic health record (EHR) use among hospitals and a 5-fold increase among physicians. This enabled the interoperable exchange of electronic health information, e- prescribing, electronic public health data exchange, and the means for patients and their caregivers to access crucial personal health information digitally. As of 2023, 70\% of hospitals are interoperable, with many providers integrated within EHR systems. Nearly all pharmacies and 92\% of prescribers possess e-prescribing capabilities, an 85\%-point increase since 2008. In 2013, 40\% of hospitals and one-third of physicians allowed patients to view their online medical records. Patient access has improved, with 97\% of hospitals and 65\% of physicians possessing EHRs that enable patients to access their online medical records. As of 2022, three-fourths of individuals report being offered access to patient portals, and over half (57\%) report engaging with their health information through their patient portal. Electronic public health reporting has also seen an increase, with most hospitals and physicians actively engaged in key reporting types. Conclusions: Federal incentives have contributed to the widespread adoption of EHRs and broad digitization in health care, while efforts to promote interoperability have encouraged collaboration across health care entities. As a result, interoperable clinical care data exchange, e-prescribing, electronic public health reporting, and patient access to health information have grown substantially over the past quarter century and have been shown to improve health care outcomes. However, interoperability hurdles, usability issues, data security concerns, and inequitable patient access persist. Addressing these issues will require collaborative efforts among stakeholders to promote data standardization, implement governance structures, and establish robust health information exchange networks. ",
doi="10.2196/59791",
url="https://www.jmir.org/2024/1/e59791",
url="http://www.ncbi.nlm.nih.gov/pubmed/39466303"
}


@Article{info:doi/10.2196/51080,
author="Apte, Aditi
and Bright, Rew Heber
and Kadam, Sandeep
and Sundarsanam, David Thambu
and Chandy, J. Sujith",
title="Facilitators, Barriers, and Potential Impacts of Implementation of e-Pharmacy in India and its Potential Impact on Cost, Quality, and Access to Medicines: Scoping Review",
journal="Online J Public Health Inform",
year="2024",
month="Oct",
day="9",
volume="16",
pages="e51080",
keywords="online pharmacy",
keywords="internet pharmacy",
keywords="telepharmacy",
keywords="ePharmacy",
keywords="prescribing systems",
keywords="drug prescribing",
keywords="prescriptions",
keywords="medications",
abstract="Background: e-Pharmacy can potentially solve problems related to the quality of services and products, cost, and access to medicines in low- and middle-income countries. This review aims to understand the facilitators and barriers to the implementation of e-pharmacy in India. Objective: This scoping review aimed (1) to understand the facilitators and barriers to the use of e-pharmacy in India and (2) to estimate the potential for e-pharmacy in India for improving access to medication, improving the quality of services and medicines, and decreasing costs of medications. Methods: All published and gray literature from July 1, 2011, to June 30, 2021, relating to e-pharmacy, was searched from MEDLINE, Scopus, ProQuest, and Google using a systematic search strategy. Results: In total, 1464 titles and abstracts were screened, of which 47 full-texts were included in the review. e-Pharmacy can potentially improve access to medications for remote areas, and old and debilitated individuals. e-Pharmacies can enable lean supply chain management, lower cost, and allow easy tracking of dispensed medicines. There is potential for integration of e-pharmacy services into the national program of Bhartiya Jan Aushadhi Pariyojana. However, the country is not adequately regulated to prevent the growth of illicit e-pharmacies. Lack of global accreditation and internet coverage, digital literacy, and transnational access are other challenges. Conclusions: E-pharmacy has the potential to improve universal health coverage in India by improving access to medicines and lowering the overall cost of health care. However, future growth will need specific regulations and accreditation mechanisms. Trial Registration: Open Science Forum; https://doi.org/10.17605/OSF.IO/6R9YQ ",
doi="10.2196/51080",
url="https://ojphi.jmir.org/2024/1/e51080"
}


@Article{info:doi/10.2196/57651,
author="Josendal, Vik Anette
and Bergmo, Strand Trine",
title="Medication Self-Management for Home Care Users Receiving Multidose Drug Dispensing: Qualitative Interview Study",
journal="JMIR Aging",
year="2024",
month="Oct",
day="4",
volume="7",
pages="e57651",
keywords="home care",
keywords="medication management",
keywords="adherence",
keywords="self-management",
keywords="multidose drug dispensing",
keywords="Norway",
keywords="primary care",
keywords="older adults",
abstract="Background: Multidose drug dispensing (MDD) is an adherence aid where medicines are machine-dispensed in disposable unit bags, usually for a 14-day period. MDD replaces manually filled dosettes in many home care services in Norway. While evidence suggests that MDD can improve medication adherence and reduce errors, there are few studies on how patients manage MDD at home and how this affects their daily routines. Objective: The aim of the study is to identify factors influencing medication self-management behavior among MDD users living at home and explore how MDD affects medication self-management. Methods: We conducted semistructured interviews with 19 MDD users in Oslo between August 2019 and February 2020. The interviews were held at the participants' homes, and the interview transcripts were analyzed thematically. Results: All participants in the study received some form of assistance with medication management from home care services. This assistance ranged from MDD delivery every other week to actual assistance with medication administration multiple times daily. However, regardless of the level of assistance received, participants primarily managed their MDD medications themselves. Daily medication routines and knowledge about medicines varied among the participants, with some taking an active role in their medication management, while others relied on others to take responsibility. The degree of involvement seemed determined by motivation rather than capability. Conclusions: MDD can support medication self-management, but its effectiveness varies among patients. The level of medication management by MDD users is not solely determined by their actual capabilities. Factors such as interest in self-care and independence, available support, information, and cognitive capacity all play a role in determining the degree of autonomy. ",
doi="10.2196/57651",
url="https://aging.jmir.org/2024/1/e57651"
}


@Article{info:doi/10.2196/51635,
author="Li, Xingang
and Guo, Heng
and Li, Dandan
and Zheng, Yingming",
title="Engine of Innovation in Hospital Pharmacy: Applications and Reflections of ChatGPT",
journal="J Med Internet Res",
year="2024",
month="Oct",
day="4",
volume="26",
pages="e51635",
keywords="ChatGPT",
keywords="hospital pharmacy",
keywords="natural language processing",
keywords="drug information",
keywords="drug therapy",
keywords="drug interaction",
keywords="scientific research",
keywords="innovation",
keywords="pharmacy",
keywords="quality",
keywords="safety",
keywords="pharmaceutical care",
keywords="tool",
keywords="medical care quality",
doi="10.2196/51635",
url="https://www.jmir.org/2024/1/e51635",
url="http://www.ncbi.nlm.nih.gov/pubmed/39365643"
}


@Article{info:doi/10.2196/56755,
author="Aronson, David Ian
and Ardouin-Guerrier, Mary-Andr{\'e}e
and Baus, Esteban Juan
and Bennett, S. Alex",
title="Barriers to, and Facilitators of, Checking Drugs for Adulterants in the Era of Fentanyl and Xylazine: Qualitative Study",
journal="JMIR Form Res",
year="2024",
month="Jul",
day="3",
volume="8",
pages="e56755",
keywords="overdose",
keywords="overdoses",
keywords="fentanyl",
keywords="xylazine",
keywords="benzodiazepines",
keywords="adulterants",
keywords="drug",
keywords="drugs",
keywords="substance",
keywords="substances",
keywords="illicit drug",
keywords="illicit drugs",
keywords="drug test",
keywords="drug testing",
keywords="drug checking",
keywords="qualitative",
keywords="interview",
keywords="interviews",
keywords="digital health",
keywords="digital technology",
keywords="digital intervention",
keywords="digital interventions",
keywords="technological intervention",
keywords="technological interventions",
keywords="technology-based intervention",
keywords="technology-based interventions",
abstract="Background: Overdose deaths continue to reach new records in New York City and nationwide, largely driven by adulterants such as fentanyl and xylazine in the illicit drug supply. Unknowingly consuming adulterated substances dramatically increases risks of overdose and other health problems, especially when individuals consume multiple adulterants and are exposed to a combination of drugs they did not intend to take. Although test strips and more sophisticated devices enable people to check drugs for adulterants including fentanyl and xylazine prior to consumption and are often available free of charge, many people who use drugs decline to use them. Objective: We sought to better understand why people in the New York City area do or do not check drugs before use. We plan to use study findings to inform the development of technology-based interventions to encourage consistent drug checking. Methods: In summer 2023, team members who have experience working with people who use drugs conducted 22 semistructured qualitative interviews with a convenience sample of people who reported illicit drug use within the past 90 days. An interview guide examined participants' knowledge of and experience with adulterants including fentanyl, xylazine, and benzodiazepines; using drug testing strips; and whether they had ever received harm reduction services. All interviews were audio recorded, transcribed, and analyzed for emerging themes. Results: Most participants lacked knowledge of adulterants, and only a few reported regularly checking drugs. Reasons for not checking included lacking convenient access to test supplies, or a place to check samples out of the public's view, as well as time considerations. Some participants also reported a strong belief that they were not at risk from fentanyl, xylazine, or other adulterants because they exclusively used cocaine or crack, or that they were confident the people they bought drugs from would not sell them adulterated substances. Those who did report testing their drugs described positive interactions with harm reduction agency staff. Conclusions: New forms of outreach are needed not only to increase people's knowledge of adulterated substances and awareness of the increasing risks they pose but also to encourage people who use drugs to regularly check their substances prior to use. This includes new intervention messages that highlight the importance of drug checking in the context of a rapidly changing and volatile drug supply. This messaging can potentially help normalize drug checking as an easily enacted behavior that benefits public health. To increase effectiveness, messages can be developed with, and outreach can be conducted by, trusted community members including people who use drugs and, potentially, people who sell drugs. Pairing this messaging with access to no-cost drug-checking supplies and equipment may help address the ongoing spiral of increased overdose deaths nationwide. ",
doi="10.2196/56755",
url="https://formative.jmir.org/2024/1/e56755"
}


@Article{info:doi/10.2196/55228,
author="Wallman, Andy
and Sv{\"a}rdsudd, Kurt
and Bobits, Kent
and Wallman, Thorne",
title="Antibiotic Prescribing by Digital Health Care Providers as Compared to Traditional Primary Health Care Providers: Cohort Study Using Register Data",
journal="J Med Internet Res",
year="2024",
month="Jun",
day="26",
volume="26",
pages="e55228",
keywords="telehealth prescribing",
keywords="physical-primary health care",
keywords="internet-primary health care",
keywords="antibiotics",
keywords="prescription",
keywords="infectious disease",
keywords="antibiotic",
keywords="prescriptions",
keywords="prescribing",
keywords="telehealth",
keywords="health care",
keywords="traditional",
keywords="digital",
keywords="telemedicine",
keywords="virtual care",
keywords="Swedish",
keywords="Sweden",
keywords="primary care",
keywords="quality of care",
keywords="online setting",
keywords="ePrescription",
keywords="ePrescriptions",
keywords="ePrescribing",
keywords="eHealth",
keywords="compare",
keywords="comparison",
keywords="online consultation",
keywords="digital care",
keywords="patient record",
keywords="patient records",
keywords="mobile phone",
abstract="Background: ?``Direct-to-consumer (DTC) telemedicine'' is increasing worldwide and changing the map of primary health care (PHC). Virtual care has increased in the last decade and with the ongoing COVID-19 pandemic, patients' use of online care has increased even further. In Sweden, online consultations are a part of government-supported health care today, and there are several digital care providers on the Swedish market, which makes it possible to get in touch with a doctor within a few minutes. The fast expansion of this market has raised questions about the quality of primary care provided only in an online setting without any physical appointments. Antibiotic prescribing is a common treatment in PHC. Objective: ?This study aimed to compare antibiotic prescribing between digital PHC providers (internet-PHC) and traditional physical PHC providers (physical-PHC) and to determine whether prescriptions for specific diagnoses differed between internet-PHC and physical-PHC appointments, adjusted for the effects of attained age at the time of appointment, gender, and time relative to the COVID-19 pandemic. Methods: ?Antibiotic prescribing data based on Anatomical Therapeutic Chemical (ATC) codes were obtained for Region S{\"o}rmland residents from January 2020 until March 2021 from the Regional Administrative Office. In total, 160,238 appointments for 68,332 S{\"o}rmland residents were included (124,398 physical-PHC and 35,840 internet-PHC appointments). Prescriptions issued by internet-PHC or physical-PHC physicians were considered. Information on the appointment date, staff category serving the patient, ICD-10 (International Statistical Classification of Diseases, Tenth Revision) diagnosis codes, ATC codes of prescribed medicines, and patient-attained age and gender were used. Results: ?A total of 160,238 health care appointments were registered, of which 18,433 led to an infection diagnosis. There were large differences in gender and attained age distributions among physical-PHC and internet-PHC appointments. Physical-PHC appointments peaked among patients aged 60-80 years while internet-PHC appointments peaked at 20-30 years of age for both genders. Antibiotics with the ATC codes J01A-J01X were prescribed in 9.3\% (11,609/124,398) of physical-PHC appointments as compared with 6.1\% (2201/35,840) of internet-PHC appointments. In addition, 61.3\% (6412/10,454) of physical-PHC infection appointments resulted in antibiotic prescriptions, as compared with only 25.8\% (2057/7979) of internet-PHC appointments. Analyses of the prescribed antibiotics showed that internet-PHC followed regional recommendations for all diagnoses. Physical-PHC also followed the recommendations but used a wider spectrum of antibiotics. The odds ratio of receiving an antibiotic prescription (after adjustments for attained age at the time of appointment, patient gender, and whether the prescription was issued before or during the COVID-19 pandemic) during an internet-PHC appointment was 0.23-0.39 as compared with a physical-PHC appointment. Conclusions: ?Internet-PHC appointments resulted in a significantly lower number of antibiotics prescriptions than physical-PHC appointments, adjusted for the large differences in the characteristics of patients who consult internet-PHC and physical-PHC. Internet-PHC prescribers showed appropriate prescribing according to guidelines. ",
doi="10.2196/55228",
url="https://www.jmir.org/2024/1/e55228"
}


@Article{info:doi/10.2196/54023,
author="Hakariya, Hayase
and Yokoyama, Natsuki
and Lee, Jeonse
and Hakariya, Arisa
and Ikejiri, Tatsuki",
title="Illicit Trade of Prescription Medications Through X (Formerly Twitter) in Japan: Cross-Sectional Study",
journal="JMIR Form Res",
year="2024",
month="May",
day="28",
volume="8",
pages="e54023",
keywords="illegal trading",
keywords="pharmacovigilance",
keywords="social networking service",
keywords="SNS",
keywords="overdose",
keywords="social support",
keywords="antipsychotics",
keywords="Japan",
keywords="prescription medication",
keywords="cross-sectional study",
keywords="prescription drug",
keywords="social networking",
keywords="medication",
keywords="pharmaceutical",
keywords="pharmaceutical drugs",
keywords="Japanese",
keywords="psychiatric",
keywords="support",
abstract="Background: Nonmedical use of prescription drugs can cause overdose; this represents a serious public health crisis globally. In this digital era, social networking services serve as viable platforms for illegal acquisition of excessive amounts of medications, including prescription medications. In Japan, such illegal drug transactions have been conducted through popular flea market applications, social media, and auction websites, with most of the trades being over-the-counter (OTC) medications. Recently, an emerging unique black market, where individuals trade prescription medications---predominantly nervous system drugs---using a specific keyword (``Okusuri Mogu Mogu''), has emerged on X (formerly Twitter). Hence, these dynamic methods of illicit trading should routinely be monitored to encourage the appropriate use of medications. Objective: This study aimed to specify the characteristics of medications traded on X using the search term ``Okusuri Mogu Mogu'' and analyze individual behaviors associated with X posts, including the types of medications traded and hashtag usage. Methods: We conducted a cross-sectional study with publicly available posts on X between September 18 and October 1, 2022. Posts that included the term ``Okusuri Mogu Mogu'' during this period were scrutinized. Posts were categorized on the basis of their contents: buying, selling, self-administration, heads-up, and others. Among posts categorized as buying, selling, and self-administration, medication names were systematically enumerated and categorized using the Anatomical Therapeutic Chemical (ATC) classification. Additionally, hashtags in all the analyzed posts were counted and classified into 6 categories: medication name, mental disorder, self-harm, buying and selling, community formation, and others. Results: Out of 961 identified posts, 549 were included for analysis. Of these posts, 119 (21.7\%) referenced self-administration, and 237 (43.2\%; buying: n=67, 12.2\%; selling: n=170, 31.0\%) referenced transactions. Among these 237 posts, 1041 medication names were mentioned, exhibiting a >5-fold increase from the study in March 2021. Categorization based on the ATC classification predominantly revealed nervous system drugs, representing 82.1\% (n=855) of the mentioned medications, consistent with the previous survey. Of note, the diversity of medications has expanded to include medications that have not been approved by the Japanese government. Interestingly, OTC medications were frequently mentioned in self-administration posts (odds ratio 23.6, 95\% CI 6.93-80.15). Analysis of hashtags (n=866) revealed efforts to foster community connections among users. Conclusions: This study highlighted the escalating complexity of trading of illegal prescription medication facilitated by X posts. Regulatory measures to enhance public awareness should be considered to prevent illegal transactions, which may ultimately lead to misuse or abuse such as overdose. Along with such pharmacovigilance measures, social approaches that could direct individuals to appropriate medical or psychiatric resources would also be beneficial as our hashtag analysis shed light on the formation of a cohesive or closed community among users. ",
doi="10.2196/54023",
url="https://formative.jmir.org/2024/1/e54023",
url="http://www.ncbi.nlm.nih.gov/pubmed/38805262"
}


@Article{info:doi/10.2196/48850,
author="Ers{\"o}z, Semra
and Nissen, Anika
and Sch{\"u}tte, Reinhard",
title="Risk, Trust, and Emotion in Online Pharmacy Medication Purchases: Multimethod Approach Incorporating Customer Self-Reports, Facial Expressions, and Neural Activation",
journal="JMIR Form Res",
year="2023",
month="Dec",
day="25",
volume="7",
pages="e48850",
keywords="online pharmacy",
keywords="emotion",
keywords="facial expression",
keywords="fNIRS",
keywords="functional near-infrared spectroscopy",
keywords="risk",
keywords="trust",
keywords="pharmacy",
keywords="purchase",
keywords="purchasing",
keywords="consumer",
keywords="consumers",
keywords="customer",
keywords="customers",
keywords="drug",
keywords="drugs",
keywords="pharmaceutical",
keywords="buy",
keywords="buyer",
keywords="pharmacies",
keywords="perception",
keywords="perceived",
keywords="pharmaceutics",
keywords="pharmaceutic",
keywords="business",
keywords="commerce",
keywords="commercial",
keywords="e-commerce",
abstract="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. ",
doi="10.2196/48850",
url="https://formative.jmir.org/2023/1/e48850",
url="http://www.ncbi.nlm.nih.gov/pubmed/38145483"
}


@Article{info:doi/10.2196/45021,
author="Kariya, Azusa
and Okada, Hiroshi
and Suzuki, Shota
and Dote, Satoshi
and Nishikawa, Yoshitaka
and Araki, Kazuo
and Takahashi, Yoshimitsu
and Nakayama, Takeo",
title="Internet-Based Inquiries From Users With the Intention to Overdose With Over-the-Counter Drugs: Qualitative Analysis of Yahoo! Chiebukuro",
journal="JMIR Form Res",
year="2023",
month="Nov",
day="22",
volume="7",
pages="e45021",
keywords="abuse",
keywords="consumer-generated media",
keywords="CGM",
keywords="overdose",
keywords="over-the-counter drug",
keywords="OTC drug",
keywords="question and answer site",
keywords="Q and A site",
abstract="Background: Public concern with regard to over-the-counter (OTC) drug abuse is growing rapidly across countries. OTC drug abuse has serious effects on the mind and body, such as poisoning symptoms, and often requires specialized treatments. In contrast, there is concern about people who potentially abuse OTC drugs whose symptoms are not serious enough to consult medical institutions or drug addiction rehabilitation centers yet are at high risk of becoming drug dependent in the future. Objective: Consumer-generated media (CGM), which allows users to disseminate information, is being used by people who abuse (and those who are trying to abuse) OTC drugs to obtain information about OTC drug abuse. This study aims to analyze the content of CGM to explore the questions of people who potentially abuse OTC drugs. Methods: The subject of this research was Yahoo! Chiebukuro, the largest question and answer website in Japan. A search was performed using the names of drugs commonly used in OTC drug abuse and the keywords overdose and OD, and the number of questions posted on the content of OTC drug abuse was counted. Furthermore, a thematic analysis was conducted by extracting text data on the most abused antitussive and expectorant drug, BRON. Results: The number of questions about the content of overdose medications containing the keyword BRON has increased sharply as compared with other product names. Furthermore, 467 items of question data that met the eligibility criteria were obtained from 528 items of text data on BRON; 26 codes, 6 categories, and 3 themes were generated from the 578 questions contained in these items. Questions were asked about the effects they would gain from abusing OTC drugs and the information they needed to obtain the effects they sought, as well as about the effects of abuse on their bodies. Moreover, there were questions on how to stop abusing and what is needed when seeking help from a health care provider if they become dependent. It has become clear that people who abuse OTC drugs have difficulty in consulting face-to-face with others, and CGM is used as a means to obtain the necessary information anonymously. Conclusions: On CGM, people who abused or tried to abuse OTC drugs were asking questions about their abuse expectations and anxieties. In addition, when they became dependent, they sought advice to quit their abuse. CGM was used to exchange information about OTC drug abuse, and many questions on anxieties and hesitations were posted. This study suggests that it is necessary to produce and disseminate information on OTC drug abuse, considering the situation of those who abuse or are willing to abuse OTC drugs. Support from pharmacies and drugstores would also be essential to reduce opportunities for OTC drug abuse. ",
doi="10.2196/45021",
url="https://formative.jmir.org/2023/1/e45021",
url="http://www.ncbi.nlm.nih.gov/pubmed/37991829"
}


@Article{info:doi/10.2196/42453,
author="J{\~o}gi, Reelika
and Timonen, Johanna
and Saastamoinen, Leena
and Laius, Ott
and Volmer, Daisy",
title="Implementation of European Cross-border Electronic Prescription and Electronic Dispensing Service: Cross-sectional Survey",
journal="J Med Internet Res",
year="2023",
month="Apr",
day="4",
volume="25",
pages="e42453",
keywords="electronic prescription",
keywords="ePrescription",
keywords="cross-border ePrescription",
keywords="electronic dispensing",
keywords="eDispensing",
keywords="eHealth",
keywords="digital health",
keywords="implementation",
keywords="European Union",
abstract="Background: The European cross-border electronic prescription (CBeP) and cross-border electronic dispensing system was first implemented in January 2019 when it became possible to purchase medications from community pharmacies in Estonia using a Finnish ePrescription. In 2020, Estonian ePrescriptions became available to be dispensed in Finnish pharmacies. The CBeP is an important milestone in increasing access to medicines across the European Union, and it has been unstudied to date. Objective: This study aimed to investigate Estonian and Finnish pharmacists' experiences of factors influencing access to, and dispensing of, CBePs. Methods: A web-based survey was conducted among Estonian and Finnish pharmacists between April and May 2021. The survey was distributed to all 664 community pharmacies (n=289, 43.5\% in Estonia and n=375, 56.5\% in Finland) where CBePs had been dispensed in 2020. The data were analyzed using frequencies and a chi-square test. Answers to open-ended questions were categorized using content analysis and then analyzed by frequency. Results: In total, 66.7\% (84/126) of the responses from Estonia and 76.6\% (154/201) of the responses from Finland were included in the study. The majority of Estonian (74/84, 88\%) and Finnish (126/154, 81.8\%) respondents agreed that CBePs have improved patients' access to medications. Problems with the availability of medications when dispensing CBePs were reported by 76\% (64/84) of the Estonian respondents and 35.1\% (54/154) of the Finnish respondents. In Estonia, the most commonly reported availability problem concerned the same active ingredient (49/84, 58\%) of the medication not being available in the market, whereas in Finland, the most common issue was the unavailability of equivalent package size in the market (30/154, 19.5\%). Encountering ambiguities or errors in the CBePs was reported by 61\% (51/84) of the Estonian respondents and 42.8\% (66/154) of the Finnish respondents. Mostly, the availability issues and ambiguities or errors were encountered rarely. The most commonly encountered ambiguities or errors were incorrect pharmaceutical form (23/84, 27\%) in Estonia and incorrect total amount of medication (21/154, 13.6\%) in Finland. Technical problems with using the CBeP system were reported by 57\% (48/84) of the Estonian respondents and 40.2\% (62/154) of the Finnish respondents. Most of the Estonian and Finnish respondents (53/84, 63\%, and 133/154, 86.4\%, respectively) had access to guidelines for dispensing CBePs. More than half of the Estonian (52/84, 62\%) and Finnish (95/154, 61.7\%) respondents felt that they had received sufficient training on dispensing CBePs. Conclusions: Pharmacists in both Estonia and Finland agreed that CBePs improve access to medications. However, interfering factors, such as ambiguities or errors in CBePs and technical problems in the CBeP system, can reduce access to medications. The respondents had received sufficient training and were informed of the guidelines; however, they felt that the content of the guidelines could be improved. ",
doi="10.2196/42453",
url="https://www.jmir.org/2023/1/e42453",
url="http://www.ncbi.nlm.nih.gov/pubmed/37014689"
}


@Article{info:doi/10.2196/45147,
author="Almomani, Hamzeh
and Patel, Nilesh
and Donyai, Parastou",
title="News Media Coverage of the Problem of Purchasing Fake Prescription Medicines on the Internet: Thematic Analysis",
journal="JMIR Form Res",
year="2023",
month="Mar",
day="21",
volume="7",
pages="e45147",
keywords="prescription medicine",
keywords="internet",
keywords="online pharmacy",
keywords="fake medicine",
keywords="media",
keywords="newspaper article",
keywords="Theory of Planned Behavior",
keywords="thematic analysis",
abstract="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. ",
doi="10.2196/45147",
url="https://formative.jmir.org/2023/1/e45147",
url="http://www.ncbi.nlm.nih.gov/pubmed/36943354"
}


@Article{info:doi/10.2196/42887,
author="Almomani, Hamzeh
and Patel, Nilesh
and Donyai, Parastou",
title="Reasons That Lead People to End Up Buying Fake Medicines on the Internet: Qualitative Interview Study",
journal="JMIR Form Res",
year="2023",
month="Feb",
day="16",
volume="7",
pages="e42887",
keywords="fake medicines",
keywords="prescription-only medicines",
keywords="internet",
keywords="theory of planned behavior",
keywords="interviews",
keywords="thematic analysis",
keywords="the United Kingdom",
abstract="Background: Many people in the United Kingdom are turning to the internet to obtain prescription-only medicines (POMs). This introduces substantial concerns for patient safety, particularly owing to the risk of buying fake medicines. To help reduce the risks to patient safety, it is important to understand why people buy POMs on the web in the first place. Objective: This study aimed to identify why people in the United Kingdom purchase medicines, specifically POMs, from the internet, and their perceptions of risks posed by the availability of fake medicines on the web. Methods: Semistructured interviews were conducted with adults from the United Kingdom who had previously purchased medicines on the web. Purposive sampling was adopted using various methods to achieve diversity in participants' experiences and demographics. The recruitment was continued until data saturation was reached. Thematic analysis was employed, with the theory of planned behavior acting as a framework to develop the coding of themes. Results: A total of 20 participants were interviewed. Participants had bought various types of POMs or medicines with the potential to be misused or that required a higher level of medical oversight (eg, antibiotics and controlled medicines). Participants demonstrated awareness of the presence and the risks of fake medicines available on the internet. The factors that influence participants' decision to buy medicines on the web were grouped into themes, including the advantages (avoiding long waiting times, bypassing gatekeepers, availability of medicines, lower costs, convenient process, and privacy), disadvantages (medicine safety concerns, medicine quality concerns, higher costs, web-based payment risks, lack of accountability, and engaging in an illegal behavior) of purchasing medicines on the web, social influencing factors (interactions with health care providers, other consumers' reviews and experiences, word of mouth by friends, and influencers' endorsement), barriers (general barriers and website-specific barriers) and facilitators (facilitators offered by the illegal sellers of medicines, facilitators offered by internet platforms, COVID-19 outbreak as a facilitating condition, and participants' personality) of the purchase, and factors that lead people to trust the web-based sellers of medicines (website features, product appearance, and past experience). Conclusions: In-depth insights into what drives people in the United Kingdom to buy medicines on the web could enable the development of effective and evidence-based public awareness campaigns that warn consumers about the risks of buying fake medicines from the internet. The findings enable researchers to design interventions to minimize the purchasing of POMs on the web. A limitation of this study is that although the interviews were in-depth and data saturation was reached, the findings may not be generalizable, as this was a qualitative study. However, the theory of planned behavior, which informed the analysis, has well-established guidelines for developing a questionnaire for a future quantitative study. ",
doi="10.2196/42887",
url="https://formative.jmir.org/2023/1/e42887",
url="http://www.ncbi.nlm.nih.gov/pubmed/36795460"
}


@Article{info:doi/10.2196/41834,
author="Mackey, Ken Tim
and Jarmusch, K. Alan
and Xu, Qing
and Sun, Kunyang
and Lu, Aileen
and Aguirre, Shaden
and Lim, Jessica
and Bhakta, Simran
and Dorrestein, C. Pieter",
title="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",
journal="JMIR Public Health Surveill",
year="2022",
month="Dec",
day="23",
volume="8",
number="12",
pages="e41834",
keywords="online pharmacy",
keywords="antimicrobial resistance",
keywords="drug safety",
keywords="cyberpharmacies",
keywords="public health",
keywords="health website",
keywords="online health",
keywords="web surveillance",
keywords="patient safety",
abstract="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. ",
doi="10.2196/41834",
url="https://publichealth.jmir.org/2022/12/e41834",
url="http://www.ncbi.nlm.nih.gov/pubmed/36563038"
}


@Article{info:doi/10.2196/36652,
author="Brady, E. Julianne
and Linsky, M. Amy
and Simon, R. Steven
and Yeksigian, Kate
and Rubin, Amy
and Zillich, J. Alan
and Russ-Jara, L. Alissa",
title="The Perceived Effectiveness of Secure Messaging for Medication Reconciliation During Transitions of Care: Semistructured Interviews With Patients",
journal="JMIR Hum Factors",
year="2022",
month="Aug",
day="3",
volume="9",
number="3",
pages="e36652",
keywords="medication reconciliation",
keywords="patient portals",
keywords="telemedicine",
keywords="pharmacist-patient relationship",
keywords="medication errors",
abstract="Background: Medication discrepancies can lead to adverse drug events and patient harm. Medication reconciliation is a process intended to reduce medication discrepancies. We developed a Secure Messaging for Medication Reconciliation Tool (SMMRT), integrated into a web-based patient portal, to identify and reconcile medication discrepancies during transitions from hospital to home. Objective: We aimed to characterize patients' perceptions of the ease of use and effectiveness of SMMRT. Methods: We recruited 20 participants for semistructured interviews from a sample of patients who had participated in a randomized controlled trial of SMMRT. Interview transcripts were transcribed and then qualitatively analyzed to identify emergent themes. Results: Although most patients found SMMRT easy to view at home, many patients struggled to return SMMRT through secure messaging to clinicians due to technology-related barriers. Patients who did use SMMRT indicated that it was time-saving and liked that they could review it at their own pace and in the comfort of their own home. Patients reported SMMRT was effective at clarifying issues related to medication directions or dosages and that SMMRT helped remove medications erroneously listed as active in the patient's electronic health record. Conclusions: Patients viewed SMMRT utilization as a positive experience and endorsed future use of the tool. Veterans reported SMMRT is an effective tool to aid patients with medication reconciliation. Adoption of SMMRT into regular clinical practice could reduce medication discrepancies while increasing accessibility for patients to help manage their medications. Trial Registration: ClinicalTrials.gov NCT02482025; https://clinicaltrials.gov/ct2/show/NCT02482025 ",
doi="10.2196/36652",
url="https://humanfactors.jmir.org/2022/3/e36652",
url="http://www.ncbi.nlm.nih.gov/pubmed/35921139"
}


@Article{info:doi/10.2196/27704,
author="Ozawa, Sachiko
and Billings, Joanna
and Sun, Yujiao
and Yu, Sushan
and Penley, Benjamin",
title="COVID-19 Treatments Sold Online Without Prescription Requirements in the United States: Cross-sectional Study Evaluating Availability, Safety and Marketing of Medications",
journal="J Med Internet Res",
year="2022",
month="Feb",
day="16",
volume="24",
number="2",
pages="e27704",
keywords="COVID-19",
keywords="medication",
keywords="internet",
keywords="online pharmacy",
keywords="drug",
abstract="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. ",
doi="10.2196/27704",
url="https://www.jmir.org/2022/2/e27704",
url="http://www.ncbi.nlm.nih.gov/pubmed/34662286"
}


@Article{info:doi/10.2196/25855,
author="Penley, Benjamin
and Minshew, Lana
and Chen, Hui-Han
and Eckel, Stephen
and Ozawa, Sachiko",
title="Accessibility of Low-cost Insulin From Illegitimate Internet Pharmacies: Cross-sectional Study",
journal="J Med Internet Res",
year="2022",
month="Feb",
day="14",
volume="24",
number="2",
pages="e25855",
keywords="insulin",
keywords="diabetes",
keywords="internet",
keywords="online",
keywords="pharmacy",
keywords="medication",
keywords="cost",
abstract="Background: There is much public debate regarding the high cost of insulin. With 1-in-4 patients in the United States with type 1 diabetes reporting difficulties affording insulin, there is concern that some of these patients might look for cost savings on the internet, unaware that 96\% of internet pharmacies are illegitimate. Patients who purchase insulin from illegitimate internet pharmacies remove themselves from traditional health care systems that ensure safe, quality-assured, and effective medication use. Objective: This study aims to determine the accessibility of Humalog and NovoLog insulin from internet pharmacies and characterize how these sites approached patient safety, and priced as well as marketed their products. Methods: From September to December 2019, we queried the phrases buy insulin online, buy Humalog online, and buy NovoLog online in common search engines. The first 100 search results from Google and Bing, and the first 50 search results from Yahoo! and DuckDuckGo were screened. Websites were included if they claimed to sell Humalog or NovoLog insulin, were active, free access, in the English language, and had a unique URL. The legitimacy of websites was classified using LegitScript. Safety and marketing characteristics were compared across the legitimacy of internet pharmacies. Internet pharmacy prices were compared with the prices offered through brick-and-mortar pharmacies using GoodRx. Results: We found that 59\% (n=29) of the 49 internet pharmacies in our analysis were illegitimate, whereas only 14\% (n=7) were legitimate and 27\% (n=13) were unclassified. Across illegitimate internet pharmacies, Humalog and NovoLog insulin were 2 to 5 times cheaper as compared with both legitimate internet pharmacies and brick-and-mortar stores. Risks associated with the use of illegitimate internet pharmacies by American consumers were evident: 57\% (8/14) did not require a prescription, 43\% (6/14) did not display medication information or warnings, and only 21\% (3/14) offered access to purported pharmacists. This included 9 rogue internet pharmacies that sold Humalog and NovoLog insulin within the United States, where 11\% (1/9) required a prescription, 11\% (1/9) placed quantity limits per purchase, and none offered pharmacist services. Rogue internet pharmacies often offered bulk discounts (11/18, 61\%), assured privacy (14/18, 78\%), and promoted other products alongside insulin (13/18, 72\%). The marketing language of illegitimate internet pharmacies appealed more to quality, safety, and customer service as compared with legitimate sites. Conclusions: The ease of access to low-cost insulin through illegitimate internet pharmacies calls for urgent attention. Illegitimate internet pharmacies place patients at risk of poor-quality medications and subpar pharmacy services, resulting in adverse events and poor diabetes control. A multifaceted approach is needed to close illegitimate internet pharmacies through legal and regulatory measures, develop better search engine filters, raise public awareness of the dangers of illegitimate internet pharmacies, and address the high costs of insulin. ",
doi="10.2196/25855",
url="https://www.jmir.org/2022/2/e25855",
url="http://www.ncbi.nlm.nih.gov/pubmed/35156937"
}


@Article{info:doi/10.2196/35590,
author="Crawford, D. Natalie
and Harrington, V. Kristin R.
and Alohan, I. Daniel
and Sullivan, S. Patrick
and Holland, P. David
and Klepser, G. Donald
and Quamina, Alvan
and Siegler, J. Aaron
and Young, N. Henry",
title="Integrating and Disseminating Pre-Exposure Prophylaxis (PrEP) Screening and Dispensing for Black Men Who Have Sex With Men in Atlanta, Georgia: Protocol for Community Pharmacies",
journal="JMIR Res Protoc",
year="2022",
month="Feb",
day="9",
volume="11",
number="2",
pages="e35590",
keywords="PrEP",
keywords="MSM",
keywords="HIV",
keywords="prevention",
keywords="pharmacy",
keywords="implementation",
keywords="pre-exposure prophylaxis",
keywords="men who have sex with men",
keywords="protocol",
keywords="integration",
keywords="dissemination",
keywords="prophylaxis",
keywords="screening",
keywords="race",
keywords="demographic",
keywords="sex",
keywords="sexuality",
keywords="development",
keywords="access",
abstract="Background: Black men who have sex with men (BMSM) suffer from alarmingly high rates of HIV in the United States. Pre-exposure prophylaxis (PrEP) can reduce the risk of HIV infection by 99\% among men who have sex with men, yet profound racial disparities in the uptake of PrEP persist. Low PrEP uptake in BMSM is driven by poor access to PrEP, including inconvenient locations of PrEP-prescribing physicians, distrust of physicians, and stigma, which limit communication about PrEP and its side effects. Previous work indicates that offering HIV prevention services in pharmacies located in low-income, underserved neighborhoods is feasible and can reduce stigma because pharmacies offer a host of less stigmatized health services (eg, vaccinations). We present a protocol for a pharmacy PrEP model that seeks to address challenges and barriers to pharmacy-based PrEP specifically for BMSM. Objective: We aim to develop a sustainable pharmacy PrEP delivery model for BMSM that can be implemented to increase PrEP access in low-income, underserved neighborhoods. Methods: This study design is a pilot intervention to test a pharmacy PrEP delivery model among pharmacy staff and BMSM. We will examine the PrEP delivery model's feasibility, acceptability, and safety and gather early evidence of its impact and cost with respect to PrEP uptake. A mixed-methods approach will be performed, including three study phases: (1) a completed formative phase with qualitative interviews from key stakeholders; (2) a completed transitional pilot phase to assess customer eligibility and willingness to receive PrEP in pharmacies during COVID-19; and (3) a planned pilot intervention phase which will test the delivery model in 2 Atlanta pharmacies in low-income, underserved neighborhoods. Results: Data from the formative phase showed strong support of pharmacy-based PrEP delivery among BMSM, pharmacists, and pharmacy staff. Important factors were identified to facilitate the implementation of PrEP screening and dissemination in pharmacies. During the transitional pilot phase, we identified 81 individuals who would have been eligible for the pilot phase. Conclusions: Pharmacies have proven to be a feasible source for offering PrEP for White men who have sex with men but have failed to reach the most at-risk, vulnerable population (ie, BMSM). Increasing PrEP access and uptake will reduce HIV incidence and racial inequities in HIV. Translational studies are required to build further evidence and scale pharmacy-based PrEP services specifically for populations that are disconnected from HIV prevention resources. International Registered Report Identifier (IRRID): DERR1-10.2196/35590 ",
doi="10.2196/35590",
url="https://www.researchprotocols.org/2022/2/e35590",
url="http://www.ncbi.nlm.nih.gov/pubmed/35138252"
}


@Article{info:doi/10.2196/27431,
author="Gullslett, Knudsen Monika
and Strand Bergmo, Trine",
title="Implementation of E-prescription for Multidose Dispensed Drugs: Qualitative Study of General Practitioners' Experiences",
journal="JMIR Hum Factors",
year="2022",
month="Jan",
day="17",
volume="9",
number="1",
pages="e27431",
keywords="e-prescribing of multidose drug dispensing (eMDD)",
keywords="pharmacy",
keywords="start-up",
keywords="general practitioner (GP)",
keywords="Norway",
keywords="digital health",
keywords="digital tools",
keywords="e-prescriptions",
keywords="physicians",
keywords="qualitative study",
abstract="Background: Increased use of pharmaceuticals challenges both capacity and safety related to medication management for patients and changes in how general practitioners (GPs) and other health personnel interact with and follow up with patients. E-prescribing of multidose drug dispensing (eMDD) is 1 of the national measures being tested in Norway. Objective: The objective of this study is to explore GPs' experiences with the challenges and benefits of implementing eMDD in Norway. Methods: Qualitative in-depth and group interviews were conducted with a total of 25 GPs between 2018 and 2020. Transcribed files were saved in NVivo to conduct a step-by-step content analysis. NVivo is a software tool for organizing, managing, and analyzing qualitative data. Results: The study revealed that eMDD offers many benefits. At the same time, there are several challenges related to information, training, and initiation, as well as to the responsibility for the medication, interactions, and the risk of incorrect medication. An important activity in the start-up phase was an information meeting with pharmacies and technology suppliers, as well as exchanging information and instructions with pharmacies on how to get started. Four analytic themes emerged through the extraction of data: (1) start-up with eMDD (``Be patient''); (2) the need for training; (3) interaction, safety, and efficiency; and (4) the working day with eMDD. Conclusions: There is a variation in different GPs' needs regarding training and information, and considerable variation in competence and motivation related to the use of digital tools. There are also different degrees of understanding the everyday work of the other actors in the medication chain. In particular, the harmonization of medication lists related to the use of time, expenditures, and challenges with technological solutions in the introduction phase was emphasized as a challenge. Overall, GPs who have started using the system report great benefits; these are largely related to an increased overview of patients' total medication lists, less time spent on prescribing prescriptions, and increased collaboration with pharmacies and nurses, both in service from providers in homes and in nursing homes. ",
doi="10.2196/27431",
url="https://humanfactors.jmir.org/2022/1/e27431",
url="http://www.ncbi.nlm.nih.gov/pubmed/35037881"
}


@Article{info:doi/10.2196/31321,
author="Passardi, Alessandro
and Serra, Patrizia
and Donati, Caterina
and Fiori, Federica
and Prati, Sabrina
and Vespignani, Roberto
and Taglioni, Gabriele
and Farfaneti Ghetti, Patrizia
and Martinelli, Giovanni
and Nanni, Oriana
and Altini, Mattia
and Frassineti, Luca Giovanni
and Minguzzi, Vittoria Martina",
title="An Integrated Model to Improve Medication Reconciliation in Oncology: Prospective Interventional Study",
journal="J Med Internet Res",
year="2021",
month="Dec",
day="20",
volume="23",
number="12",
pages="e31321",
keywords="medication recognition",
keywords="medication reconciliation",
keywords="IT platform",
keywords="community pharmacies",
keywords="healthcare transitions",
keywords="pharmacy",
keywords="oncology",
keywords="drug incompatibility",
keywords="information technology",
keywords="drug interactions",
abstract="Background: Accurate medication reconciliation reduces the risk of drug incompatibilities and adverse events that can occur during transitions in care. Community pharmacies (CPs) are a crucial part of the health care system and could be involved in collecting essential information on conventional and supplementary drugs used at home. Objective: The aim of this paper was to establish an alliance between our cancer institute, Istituto Romagnolo per lo Studio dei Tumori (IRST), and CPs, the latter entrusted with the completion of a pharmacological recognition survey. We also aimed to integrate the national information technology (IT) platform of CPs with the electronic medical records of IRST. Methods: Cancer patients undergoing antiblastic treatments were invited to select a CP taking part in the study and to complete the pharmacological recognition step. The information collected by the pharmacist was sent to the electronic medical records of IRST through the new IT platform, after which the oncologist performed the reconciliation process. Results: A total of 66 CPs completed surveys for 134 patients. An average of 5.9 drugs per patient was used at home, with 12 or more used in the most advanced age groups. Moreover, 60\% (80/134) of the patients used nonconventional products or critical foods. Some potential interactions between nonconventional medications and cancer treatments were reported. Conclusions: In the PROF-1 (Progetto di Rete in Oncologia con le Farmacie di comunit{\`a} della Romagna) study, an alliance was created between our cancer center and CPs to improve medication reconciliation, and a new integrated IT platform was validated. Trial Registration: ClinicalTrials.gov NCT04796142; https://clinicaltrials.gov/ct2/show/NCT04796142 ",
doi="10.2196/31321",
url="https://www.jmir.org/2021/12/e31321",
url="http://www.ncbi.nlm.nih.gov/pubmed/34932001"
}


@Article{info:doi/10.2196/29187,
author="Black, Joshua
and Margolin, R. Zachary
and Bau, Gabrielle
and Olson, Richard
and Iwanicki, L. Janetta
and Dart, C. Richard",
title="Web-Based Discussion and Illicit Street Sales of Tapentadol and Oxycodone in Australia: Epidemiological Surveillance Study",
journal="JMIR Public Health Surveill",
year="2021",
month="Dec",
day="20",
volume="7",
number="12",
pages="e29187",
keywords="Australia",
keywords="opioids",
keywords="web-based discussion",
keywords="diversion",
abstract="Background: Opioid use disorder and its consequences are a persistent public health concern for Australians. Web activity has been used to understand the perception of drug safety and diversion of drugs in contexts outside of Australia. The anonymity of the internet offers several advantages for surveilling and inquiring about specific covert behaviors, such as diversion or discussion of sensitive subjects where traditional surveillance approaches might be limited. Objective: This study aims to characterize the content of web posts and compare reports of illicit sales of tapentadol and oxycodone from sources originating in Australia. First, post content is evaluated to determine whether internet discussion encourages or discourages proper therapeutic use of the drugs. Second, we hypothesize that tapentadol would have lower street price and fewer illicit sales than oxycodone. Methods: Web posts originating in Australia between 2017 and 2019 were collected using the Researched Abuse, Diversion, and Addiction-Related Surveillance System Web Monitoring Program. Using a manual coding process, unstructured post content from social media, blogs, and forums was categorized into topics of discussion related to the harms and behaviors that could lead to harm. Illicit sales data in a structured format were collected through a crowdsourcing website between 2016 and 2019 using the Researched Abuse, Diversion, and Addiction-Related Surveillance System StreetRx Program. In total, 2 multivariable regression models assessed the differences in illicit price and number of sales. Results: A total of 4.7\% (28/600) of tapentadol posts discussed an adverse event, whereas 10.27\% (95\% CI 9.32-11.21) of oxycodone posts discussed this topic. A total of 10\% (60/600) of tapentadol posts discussed unsafe use or side effects, whereas 20.17\% (95\% CI 18.92-21.41) of oxycodone posts discussed unsafe use or side effects. There were 31 illicit sales reports for tapentadol (geometric mean price per milligram: Aus \$0.12 [US \$0.09]) and 756 illicit sales reports for oxycodone (Aus \$1.28 [US \$0.91]). Models detected no differences in the street price or number of sales between the drugs when covariates were included, although the potency of the pill significantly predicted the street price (P<.001) and availability predicted the number of sales (P=.03). Conclusions: Australians searching the web for opinions could judge tapentadol as safer than oxycodone because of the web post content. The illicit sales market for tapentadol was smaller than that of oxycodone, and drug potency and licit availability are likely important factors influencing the illicit market. ",
doi="10.2196/29187",
url="https://publichealth.jmir.org/2021/12/e29187",
url="http://www.ncbi.nlm.nih.gov/pubmed/34932012"
}


@Article{info:doi/10.2196/30786,
author="Baumgartner, L. Susan
and Buffkin Jr, Eric D.
and Rukavina, Elise
and Jones, Jason
and Weiler, Elizabeth
and Carnes, C. Tony",
title="A Novel Digital Pill System for Medication Adherence Measurement and Reporting: Usability Validation Study",
journal="JMIR Hum Factors",
year="2021",
month="Nov",
day="8",
volume="8",
number="4",
pages="e30786",
keywords="digital pills",
keywords="digital medication",
keywords="ingestible event marker",
keywords="ingestible sensor",
keywords="human factors",
keywords="usability",
keywords="validation study",
keywords="medication adherence",
keywords="medication nonadherence",
keywords="remote patient monitoring",
keywords="mobile phone",
abstract="Background: Medication nonadherence is a costly problem that is common in clinical use and clinical trials alike, with significant adverse consequences. Digital pill systems have proved to be effective and safe solutions to the challenges of nonadherence, with documented success in improving adherence and health outcomes. Objective: The aim of this human factors validation study is to evaluate a novel digital pill system, the ID-Cap System from etectRx, for usability among patient users in a simulated real-world use environment. Methods: A total of 17 patients with diverse backgrounds who regularly take oral prescription medications were recruited. After training and a period of training decay, the participants were asked to complete 12 patient-use scenarios during which errors or difficulties were logged. The participants were also interviewed about their experiences with the ID-Cap System. Results: The participants ranged in age from 27 to 74 years (mean 51 years, SD 13.8 years), and they were heterogeneous in other demographic factors as well, such as education level, handedness, and sex. In this human factors validation study, the patient users completed 97.5\% (196/201) of the total use scenarios successfully; 75.1\% (151/201) were completed without any failures or errors. The participants found the ID-Cap System easy to use, and they were able to accurately and proficiently record ingestion events using the device. Conclusions: The participants demonstrated the ability to safely and effectively use the ID-Cap System for its intended use. The ID-Cap System has great potential as a useful tool for encouraging medication adherence and can be easily implemented by patient users. ",
doi="10.2196/30786",
url="https://humanfactors.jmir.org/2021/4/e30786",
url="http://www.ncbi.nlm.nih.gov/pubmed/34747709"
}


@Article{info:doi/10.2196/24486,
author="Li, Zhengyi
and Du, Xiangyu
and Liao, Xiaojing
and Jiang, Xiaoqian
and Champagne-Langabeer, Tiffany",
title="Demystifying the Dark Web Opioid Trade: Content Analysis on Anonymous Market Listings and Forum Posts",
journal="J Med Internet Res",
year="2021",
month="Feb",
day="17",
volume="23",
number="2",
pages="e24486",
keywords="opioids",
keywords="black market",
keywords="anonymous markets and forums",
keywords="opioid supply chain",
keywords="text mining",
keywords="machine learning",
keywords="opioid crisis",
keywords="opioid epidemic",
keywords="drug abuse",
abstract="Background: Opioid use disorder presents a public health issue afflicting millions across the globe. There is a pressing need to understand the opioid supply chain to gain new insights into the mitigation of opioid use and effectively combat the opioid crisis. The role of anonymous online marketplaces and forums that resemble eBay or Amazon, where anyone can post, browse, and purchase opioid commodities, has become increasingly important in opioid trading. Therefore, a greater understanding of anonymous markets and forums may enable public health officials and other stakeholders to comprehend the scope of the crisis. However, to the best of our knowledge, no large-scale study, which may cross multiple anonymous marketplaces and is cross-sectional, has been conducted to profile the opioid supply chain and unveil characteristics of opioid suppliers, commodities, and transactions. Objective: We aimed to profile the opioid supply chain in anonymous markets and forums via a large-scale, longitudinal measurement study on anonymous market listings and posts. Toward this, we propose a series of techniques to collect data; identify opioid jargon terms used in the anonymous marketplaces and forums; and profile the opioid commodities, suppliers, and transactions. Methods: We first conducted a whole-site crawl of anonymous online marketplaces and forums to solicit data. We then developed a suite of opioid domain--specific text mining techniques (eg, opioid jargon detection and opioid trading information retrieval) to recognize information relevant to opioid trading activities (eg, commodities, price, shipping information, and suppliers). Subsequently, we conducted a comprehensive, large-scale, longitudinal study to demystify opioid trading activities in anonymous markets and forums. Results: A total of 248,359 listings from 10 anonymous online marketplaces and 1,138,961 traces (ie, threads of posts) from 6 underground forums were collected. Among them, we identified 28,106 opioid product listings and 13,508 opioid-related promotional and review forum traces from 5147 unique opioid suppliers' IDs and 2778 unique opioid buyers' IDs. Our study characterized opioid suppliers (eg, activeness and cross-market activities), commodities (eg, popular items and their evolution), and transactions (eg, origins and shipping destination) in anonymous marketplaces and forums, which enabled a greater understanding of the underground trading activities involved in international opioid supply and demand. Conclusions: The results provide insight into opioid trading in the anonymous markets and forums and may prove an effective mitigation data point for illuminating the opioid supply chain. ",
doi="10.2196/24486",
url="http://www.jmir.org/2021/2/e24486/",
url="http://www.ncbi.nlm.nih.gov/pubmed/33595442"
}


@Article{info:doi/10.2196/20794,
author="Mackey, Ken Tim
and Li, Jiawei
and Purushothaman, Vidya
and Nali, Matthew
and Shah, Neal
and Bardier, Cortni
and Cai, Mingxiang
and Liang, Bryan",
title="Big Data, Natural Language Processing, and Deep Learning to Detect and Characterize Illicit COVID-19 Product Sales: Infoveillance Study on Twitter and Instagram",
journal="JMIR Public Health Surveill",
year="2020",
month="Aug",
day="25",
volume="6",
number="3",
pages="e20794",
keywords="COVID-19",
keywords="coronavirus",
keywords="infectious disease",
keywords="social media",
keywords="surveillance",
keywords="infoveillance",
keywords="infodemiology",
keywords="infodemic",
keywords="fraud",
keywords="cybercrime",
abstract="Background: The coronavirus disease (COVID-19) pandemic is perhaps the greatest global health challenge of the last century. Accompanying this pandemic is a parallel ``infodemic,'' including the online marketing and sale of unapproved, illegal, and counterfeit COVID-19 health products including testing kits, treatments, and other questionable ``cures.'' Enabling the proliferation of this content is the growing ubiquity of internet-based technologies, including popular social media platforms that now have billions of global users. Objective: This study aims to collect, analyze, identify, and enable reporting of suspected fake, counterfeit, and unapproved COVID-19--related health care products from Twitter and Instagram. Methods: This study is conducted in two phases beginning with the collection of COVID-19--related Twitter and Instagram posts using a combination of web scraping on Instagram and filtering the public streaming Twitter application programming interface for keywords associated with suspect marketing and sale of COVID-19 products. The second phase involved data analysis using natural language processing (NLP) and deep learning to identify potential sellers that were then manually annotated for characteristics of interest. We also visualized illegal selling posts on a customized data dashboard to enable public health intelligence. Results: We collected a total of 6,029,323 tweets and 204,597 Instagram posts filtered for terms associated with suspect marketing and sale of COVID-19 health products from March to April for Twitter and February to May for Instagram. After applying our NLP and deep learning approaches, we identified 1271 tweets and 596 Instagram posts associated with questionable sales of COVID-19--related products. Generally, product introduction came in two waves, with the first consisting of questionable immunity-boosting treatments and a second involving suspect testing kits. We also detected a low volume of pharmaceuticals that have not been approved for COVID-19 treatment. Other major themes detected included products offered in different languages, various claims of product credibility, completely unsubstantiated products, unapproved testing modalities, and different payment and seller contact methods. Conclusions: Results from this study provide initial insight into one front of the ``infodemic'' fight against COVID-19 by characterizing what types of health products, selling claims, and types of sellers were active on two popular social media platforms at earlier stages of the pandemic. This cybercrime challenge is likely to continue as the pandemic progresses and more people seek access to COVID-19 testing and treatment. This data intelligence can help public health agencies, regulatory authorities, legitimate manufacturers, and technology platforms better remove and prevent this content from harming the public. ",
doi="10.2196/20794",
url="http://publichealth.jmir.org/2020/3/e20794/",
url="http://www.ncbi.nlm.nih.gov/pubmed/32750006"
}


@Article{info:doi/10.2196/17239,
author="Zhao, Hui
and Muthupandi, Sowmyasri
and Kumara, Soundar",
title="Managing Illicit Online Pharmacies: Web Analytics and Predictive Models Study",
journal="J Med Internet Res",
year="2020",
month="Aug",
day="25",
volume="22",
number="8",
pages="e17239",
keywords="online pharmacy",
keywords="web analytics",
keywords="classification",
keywords="illicit online pharmacies",
keywords="online traffic analysis",
abstract="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. ",
doi="10.2196/17239",
url="http://www.jmir.org/2020/8/e17239/",
url="http://www.ncbi.nlm.nih.gov/pubmed/32840485"
}


@Article{info:doi/10.2196/19678,
author="Ding, Liang
and She, Qiuru
and Chen, Fengxian
and Chen, Zitong
and Jiang, Meifang
and Huang, Huasi
and Li, Yujin
and Liao, Chaofeng",
title="The Internet Hospital Plus Drug Delivery Platform for Health Management During the COVID-19 Pandemic: Observational Study",
journal="J Med Internet Res",
year="2020",
month="Aug",
day="6",
volume="22",
number="8",
pages="e19678",
keywords="internet hospital",
keywords="drug delivery",
keywords="internet hospital plus drug delivery",
keywords="IHDD",
keywords="health management",
keywords="COVID-19",
abstract="Background: Widespread access to the internet has boosted the emergence of online hospitals. A new outpatient service called ``internet hospital plus drug delivery'' (IHDD) has been developed in China, but little is known about this platform. Objective: The aim of this study is to investigate the characteristics, acceptance, and initial impact of IHDD during the outbreak of COVID-19 in a tertiary hospital in South China Methods: The total number of and detailed information on online prescriptions during the first 2 months after work resumption were obtained. Patients' gender, age, residence, associated prescription department, time of prescription, payment, and drug delivery region were included in the analysis. Results: A total of 1380 prescriptions were picked up or delivered between March 2 and April 20, 2020. The largest group of patients were 36-59 years old (n=680, 49.3\%), followed by the 18-35 years age category (n=573, 41.5\%). In total, 39.4\% (n=544) of the patients chose to get their medicine by self-pickup, while 60.6\% (n=836) preferred to receive their medicine via drug delivery service. The top five online prescription departments were infectious diseases (n=572, 41.4\%), nephrology (n=264, 19.1\%), endocrinology (n=145, 10.5\%), angiocardiopathy (n=107, 7.8\%), and neurology (n=42, 3\%). Of the 836 delivered prescriptions, 440 (52.6\%) were sent to Guangdong Province (including 363 [43.4\%] to Shenzhen), and 396 (47.4\%) were sent to other provinces in China. Conclusions: The IHDD platform is efficient and convenient for various types of patients during the COVID-19 crisis. Although offline visits are essential for patients with severe conditions, IHDD can help to relieve pressure on hospitals by reducing an influx of patients with mild symptoms. Further efforts need to be made to improve the quality and acceptance of IHDD, as well as to regulate and standardize the management of this novel service. ",
doi="10.2196/19678",
url="http://www.jmir.org/2020/8/e19678/",
url="http://www.ncbi.nlm.nih.gov/pubmed/32716892"
}


@Article{info:doi/10.2196/12076,
author="Walmsley, Ben
and Gallant, Dan
and Naccarato, Mark
and Hull, Mark
and Smith, Alex
and Tan, Hoi-San Darrell",
title="The PrEP You Want: A Web-Based Survey of Online Cross-Border Shopping for HIV Prophylaxis Medications",
journal="J Med Internet Res",
year="2019",
month="Jul",
day="22",
volume="21",
number="7",
pages="e12076",
keywords="pre-exposure prophylaxis",
keywords="tenofovir disoproxil fumarate/emtricitabine",
keywords="generic antiretroviral drugs",
keywords="online medication shopping",
keywords="men who have sex with men",
keywords="HIV",
abstract="Background: In response to the high cost of HIV pre-exposure prophylaxis (PrEP) medications in Canada, community organizations have created internet-based guides detailing how to legally order generic medications online and travel to collect them in the United States. However, little is known about the patients following these guides. Objective: Our primary objective was to measure the proportion of Ontario gay, bisexual, and other men who have sex with men (GBMSM) accessing these online guides who intended to use the border-crossing approach. Our secondary objectives were to explore their demographic characteristics, their completion of the steps in the border-crossing approach, and the barriers they perceived. Methods: Between July 20, 2017, and May 18, 2018, we administered two online surveys of GBMSM accessing an online border-crossing guide posted by a gay men's health organization in Ontario. Participants completed an open baseline survey posted on the border-crossing guide's Web page and a follow-up survey 3 months later. The data were analyzed using descriptive statistics. We used multivariable logistic regression to identify characteristics associated with the intention to use the border-crossing approach. Results: Most of the 141 participants were young (median age 23, interquartile range 22-25 years) and black (79.4\%; 112/141) GBMSM who had completed a college or an undergraduate degree (62.4\%; 88/141). In addition, 19.9\% (28/141) of them reported a total family income less than Can \$30,000 and another 53.9\% (76/141) reported income between Can \$30,000 and Can \$60,000. 54.6\% (76/141) paid for medications entirely out of pocket. Most participants indicated that they were likely to complete a border-crossing approach: 80.1\% (113/141) at baseline and 79.1\% (87/110) at follow-up. The characteristics associated with the intention to use the approach included being black (adjusted odds ratio [aOR] 5.73, 95\% CI 2.06-16.61), paying for medications out of pocket (aOR 5.18, 95\% CI 1.82-17.04), and having a provider who was thought to be willing to prescribe PrEP (aOR 4.42, 95\% CI 1.63-12.41). Comparing baseline and follow-up for the 110 participants who completed both surveys, 65.4\% (72/110) and 80.0\% (88/110) had discussed PrEP with a health care provider, 18.1\% (20/110) and 25.4\% (28/110) had obtained a PrEP prescription, and 8.2\% (9/110) and 5.5\% (6/110) had ordered medications to that mailbox, whereas only 1.0\% (1/110) and 0.0\% (0/110) had crossed the border to collect them at baseline and follow-up, respectively. Reported barriers included perceived concerns about the approach's legality (56.0\%; 79/141), the security of personal health information (39.0\%; 55/141), and the safety of online vendors (38.3\%; 54/141). Conclusions: Despite high interest in pursuing an online border-crossing approach to get PrEP medications, such an approach may not be a viable option for PrEP scale-up among interested GBMSM because of logistical challenges and perceptions of safety and legitimacy. ",
doi="10.2196/12076",
url="http://www.jmir.org/2019/7/e12076/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31333200"
}


@Article{info:doi/10.2196/11115,
author="Fittler, Andr{\'a}s
and Vida, Gy{\"o}rgy R{\'o}bert
and K{\'a}pl{\'a}r, M{\'a}ty{\'a}s
and Botz, Lajos",
title="Consumers Turning to the Internet Pharmacy Market: Cross-Sectional Study on the Frequency and Attitudes of Hungarian Patients Purchasing Medications Online",
journal="J Med Internet Res",
year="2018",
month="Aug",
day="22",
volume="20",
number="8",
pages="e11115",
keywords="survey",
keywords="internet pharmacy",
keywords="online medications",
keywords="Hungary",
keywords="attitude",
abstract="Background: During the past two decades, the internet has become an accepted way to purchase products and services. Buying medications online are no exception. Besides its benefits, several patient safety risks are linked to the purchase of medicines outside the traditional supply chain. Although thousands of internet pharmacies are accessible on the web, the actual size of the market is unknown. Currently, there is limited data available on the use of internet pharmacies, the number, and attitude of people obtaining medications and other health products from the internet. Objective: This study aims to gather information on the frequency and attitudes of patients purchasing medications online in a nationally representative sample of outpatients. Attitudes towards main supply chain channels, perceived benefits, and disadvantages of influencing online medication purchase are evaluated. Methods: A cross-sectional explorative study using a personally administered survey was conducted in a representative sample of Hungarian outpatients in 2018. Results: A total of 1055 outpatients completed the survey (response rate 77.23\%). The mean age was 45 years, and 456 (43.22\%) reported having chronic health conditions. The majority (872/1055, 82.65\%) of the respondents were aware that medications could be obtained online, but only 44 (4.17\%) used the internet for previous medication purchases. Attitudes towards the different pharmaceutical supply chain retail channels showed significant differences (P<.001), respondents accepted retail pharmacy units as the most appropriate source of medications while rejected internet pharmacies. Respondents were asked to evaluate 9 statements regarding the potential benefits and disadvantages about the online medicine purchase, and based on the computed relative attitude rate there is a weak still significant tendency toward rejection (P<.001). Correspondence of demographic factors, internet usage behavior, and prospective online drug purchase attitude was evaluated. Respondents who use the internet more and purchase goods online will be more likely to buy medications online. Furthermore, youth and education will determine the medication purchase behavior. Conclusions: Many patients will purchase medications on the internet in the future. Currently, there is an increased risk of patients buying products from illegal sites because these dominate the global online pharmacy market. Consequently, improved patient-provider communication and promotion campaigns are needed to inform the public about the safe use of internet pharmacies, as these initiatives can directly prevent patient safety threats. ",
doi="10.2196/11115",
url="http://www.jmir.org/2018/8/e11115/",
url="http://www.ncbi.nlm.nih.gov/pubmed/30135053"
}


@Article{info:doi/10.2196/jmir.7959,
author="Sullivan, W. Helen
and O'Donoghue, C. Amie
and Gard Read, Jennifer
and Amoozegar, B. Jacqueline
and Aikin, J. Kathryn
and Rupert, J. Douglas",
title="Testimonials and Informational Videos on Branded Prescription Drug Websites: Experimental Study to Assess Influence on Consumer Knowledge and Perceptions",
journal="J Med Internet Res",
year="2018",
month="Jan",
day="23",
volume="20",
number="1",
pages="e13",
keywords="Internet",
keywords="marketing",
keywords="drug prescriptions",
keywords="risk",
abstract="Background: Direct-to-consumer (DTC) promotion of prescription drugs can affect consumer behaviors and health outcomes, and Internet drug promotion is growing rapidly. Branded drug websites often capitalize on the multimedia capabilities of the Internet by using videos to emphasize drug benefits and characteristics. However, it is unknown how such videos affect consumer processing of drug information. Objective: This study aimed to examine how videos on prescription drug websites, and the inclusion of risk information in those videos, influence consumer knowledge and perceptions. Methods: We conducted an experimental study in which online panel participants with acid reflux (n=1070) or high blood pressure (n=1055) were randomly assigned to view 1 of the 10 fictitious prescription drug websites and complete a short questionnaire. On each website, we manipulated the type of video (patient testimonial, mechanism of action animation, or none) and whether the video mentioned drug risks. Results: Participants who viewed any video were less likely to recognize drug risks presented only in the website text (P?.01). Including risk information in videos increased participants' recognition of the risks presented in the videos (P?.01). However, in some cases, including risk information in videos decreased participants' recognition of the risks not presented in the videos (ie, risks presented in text only; P?.04). Participants who viewed a video without drug risk information thought that the website placed more emphasis on benefits, compared with participants who viewed the video with drug risk information (P?.01). Compared with participants who viewed a video without drug risk information, participants who viewed a video with drug risk information thought that the drug was less effective in the high blood pressure sample (P=.03) and thought that risks were more serious in the acid reflux sample (P=.01). There were no significant differences between risk and nonrisk video conditions on other perception measures (P>.05). In addition, we noted a few differences among the types of videos. Conclusions: Including risks in branded drug website videos may increase in-video risk retention at the expense of text-only risk retention. ",
doi="10.2196/jmir.7959",
url="http://www.jmir.org/2018/1/e13/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29362205"
}


@Article{info:doi/10.2196/jmir.6899,
author="Zwier, Sandra",
title="``Click for Closer Care'': A Content Analysis of Community Pharmacy Websites in Four Countries",
journal="J Med Internet Res",
year="2017",
month="Jun",
day="14",
volume="19",
number="6",
pages="e205",
keywords="community pharmacy services",
keywords="pharmaceutical services",
keywords="online pharmacies",
keywords="marketing of health services",
keywords="commerce",
keywords="pharmacy ethics",
abstract="Background: Combinations of professional and commercial communication are typically very controversial, particularly in health care communication on the Internet. Websites of licensed community pharmacies on the other hand tend to raise remarkably little controversy, although they typically contain controversial combinations of clinical and commercial services previously unprecedented in professional health care communication. Objective: The aim of this study was to fill the void of knowledge about the combination of clinical and commercial services presented on the websites of licensed community pharmacies. Methods: A content analysis of clinical and commercial services presented in a random sample of 200 licensed community pharmacy websites from Great Britain, the Netherlands, the Canadian provinces British Columbia and Manitoba, and the Australian states New South Wales and Western Australia was conducted. Results: The top five specific services mentioned on the community pharmacy websites were cosmetic products (126/200, 63.0\%), medication refill request options (124/200, 62.0\%), over-the-counter medicine (115/200, 57.5\%), complementary and alternative medicine (107/200, 53.5\%), and home medical aids (98/200, 49.0\%). On average, 72.5\% (145/200) of the community pharmacy websites across the 4 countries included a combination of clinical and commercial services. A combination of clinical and commercial services was more often present on chain pharmacy websites (120/147, 82.8\%) than single pharmacy websites (25/53, 47\%; P<.001), and most often on the Canadian community pharmacy websites, followed by the Australian, British, and Dutch pharmacy websites, respectively (P<.02). Furthermore, more than half of the pharmacies' homepages contained a combination of clinical and commercial images (107/200, 53.5\%), and almost half of the homepage menus contained a combination of clinical and commercial items (99/200, 49.5\%). The latter were, again, more common on chain pharmacy than single pharmacy websites (P<.001), with significant differences between countries (P<.001). Conclusions: A considerable share of websites of licensed community pharmacies in Great Britain, the Netherlands, Canada, and Australia combine clinical services with commercial services. Previous research into the presence of a combination of commercial and professional services suggests that such a combination may lead to increased interest in commercial services that may be unnecessary or inappropriate to patients' health. ",
doi="10.2196/jmir.6899",
url="http://www.jmir.org/2017/6/e205/",
url="http://www.ncbi.nlm.nih.gov/pubmed/28615153"
}


@Article{info:doi/10.2196/publichealth.5390,
author="Assi, Sulaf
and Thomas, Jordan
and Haffar, Mohamed
and Osselton, David",
title="Exploring Consumer and Patient Knowledge, Behavior, and Attitude Toward Medicinal and Lifestyle Products Purchased From the Internet: A Web-Based Survey",
journal="JMIR Public Health Surveill",
year="2016",
month="Jul",
day="18",
volume="2",
number="2",
pages="e34",
keywords="consumer knowledge",
keywords="attitude",
keywords="behaviour authenticity",
keywords="effectiveness",
keywords="toxicity",
keywords="counterfeit",
keywords="medicinal and lifestyle products",
keywords="Internet",
abstract="Background: In recent years, lifestyle products have emerged to help improve people's physical and mental performance. The Internet plays a major role in the spread of these products. However, the literature has reported issues regarding the authenticity of medicines purchased from the Internet and the impact of counterfeit medicines on public health. Little or no data are available on the authenticity of lifestyle products and actual toxicity associated with their use and misuse. Objective: Our aim was to investigate consumer and patient attitudes toward the purchase of lifestyle products from the Internet, their knowledge of product authenticity and toxicity, and their experiences with counterfeit lifestyle products. Methods: A Web-based study was performed between May 2014 and May 2015. Uniform collection of data was performed through an anonymous online questionnaire. Participants were invited worldwide via email, social media, or personal communication to complete the online questionnaire. A total of 320 participants completed the questionnaire. Results: The results of the questionnaire showed that 208 (65.0\%) participants purchased lifestyle products from the Internet mainly due to convenience and reduced cost. More than half (55.6\%, 178/320) of participants purchased cosmetic products, whereas only a minority purchased medicinal products. Yet, 62.8\% (201/320) of participants were aware of the presence of counterfeit lifestyle products from the Internet, and 11.9\% (38/320) experienced counterfeit products. In only 0.9\% (3/320) of those cases were counterfeit lifestyle products reported to authorities. Moreover, 7.2\% (23/320) of the participants experienced adverse effects due to counterfeit lifestyle products. Conclusions: In summary, patients experienced counterfeit lifestyle products that resulted in adverse effects on their health. Although certain adverse effects were reported in this study, counterfeit products were underreported to authorities. Further public awareness campaigns and patient education are needed. ",
doi="10.2196/publichealth.5390",
url="http://publichealth.jmir.org/2016/2/e34/",
url="http://www.ncbi.nlm.nih.gov/pubmed/27430264"
}


@Article{info:doi/10.2196/jmir.5182,
author="Adams, Crystal",
title="Fair Balance and Adequate Provision in Direct-to-Consumer Prescription Drug Online Banner Advertisements: A Content Analysis",
journal="J Med Internet Res",
year="2016",
month="Feb",
day="18",
volume="18",
number="2",
pages="e33",
keywords="direct-to-consumer advertising",
keywords="prescription drugs",
keywords="Internet",
keywords="pharmaceutical policy",
keywords="United States Food and Drug Administration",
abstract="Background: The current direct-to-consumer advertising (DTCA) guidelines were developed with print, television, and radio media in mind, and there are no specific guidelines for online banner advertisements. Objective: This study evaluates how well Internet banner ads comply with existing Food and Drug Administration (FDA) guidelines for DTCA in other media. Methods: A content analysis was performed of 68 banner advertisements. A coding sheet was developed based on (1) FDA guidance documents for consumer-directed prescription drug advertisements and (2) previous DTCA content analyses. Specifically, the presence of a brief summary detailing the drug's risks and side effects or of a ``major statement'' identifying the drug's major risks, and the number and type of provisions made available to consumers for comprehensive information about the drug were coded. In addition, the criterion of ``fair balance,'' the FDA's requirement that prescription drug ads balance information relating to the drug's risks with information relating to its benefits, was measured by numbering the benefit and risk facts identified in the ads and by examining the presentation of risk and benefit information. Results: Every ad in the sample included a brief summary of risk information and at least one form of adequate provision as required by the FDA for broadcast ads that do not give audiences a brief summary of a drug's risks. No ads included a major statement. There were approximately 7.18 risk facts for every benefit fact. Most of the risks (98.85\%, 1292/1307) were presented in the scroll portion of the ad, whereas most of the benefits (66.5\%, 121/182) were presented in the main part of the ad. Out of 1307 risk facts, 1292 were qualitative and 15 were quantitative. Out of 182 benefit facts, 181 were qualitative and 1 was quantitative. The majority of ads showed neutral images during the disclosure of benefit and risk facts. Only 9\% (6/68) of the ads displayed positive images and none displayed negative images when presenting risks facts. When benefit facts were being presented, 7\% (5/68) showed only positive images. No ads showed negative images when the benefit facts were being presented. Conclusions: In the face of ambiguous regulatory guidelines for online banner promotion, drug companies appear to make an attempt to adapt to regulatory guidelines designed for traditional media. However, banner ads use various techniques of presentation to present the advertised drug in the best possible light. The FDA should formalize requirements that drug companies provide a brief summary and include multiple forms of adequate provision in banner ads. ",
doi="10.2196/jmir.5182",
url="http://www.jmir.org/2016/2/e33/",
url="http://www.ncbi.nlm.nih.gov/pubmed/26892749"
}


@Article{info:doi/10.2196/jmir.5144,
author="Katsuki, Takeo
and Mackey, Ken Tim
and Cuomo, Raphael",
title="Establishing a Link Between Prescription Drug Abuse and Illicit Online Pharmacies: Analysis of Twitter Data",
journal="J Med Internet Res",
year="2015",
month="Dec",
day="16",
volume="17",
number="12",
pages="e280",
keywords="social media",
keywords="surveillance",
keywords="prescription drug abuse",
keywords="twitter",
keywords="eHealth",
keywords="illicit Internet pharmacies",
keywords="cyberpharmacies",
keywords="infodemiology",
keywords="infoveillance",
abstract="Background: Youth and adolescent non-medical use of prescription medications (NUPM) has become a national epidemic. However, little is known about the association between promotion of NUPM behavior and access via the popular social media microblogging site, Twitter, which is currently used by a third of all teens. Objective: In order to better assess NUPM behavior online, this study conducts surveillance and analysis of Twitter data to characterize the frequency of NUPM-related tweets and also identifies illegal access to drugs of abuse via online pharmacies. Methods: Tweets were collected over a 2-week period from April 1-14, 2015, by applying NUPM keyword filters for both generic/chemical and street names associated with drugs of abuse using the Twitter public streaming application programming interface. Tweets were then analyzed for relevance to NUPM and whether they promoted illegal online access to prescription drugs using a protocol of content coding and supervised machine learning. Results: A total of 2,417,662 tweets were collected and analyzed for this study. Tweets filtered for generic drugs names comprised 232,108 tweets, including 22,174 unique associated uniform resource locators (URLs), and 2,185,554 tweets (376,304 unique URLs) filtered for street names. Applying an iterative process of manual content coding and supervised machine learning, 81.72\% of the generic and 12.28\% of the street NUPM datasets were predicted as having content relevant to NUPM respectively. By examining hyperlinks associated with NUPM relevant content for the generic Twitter dataset, we discovered that 75.72\% of the tweets with URLs included a hyperlink to an online marketing affiliate that directly linked to an illicit online pharmacy advertising the sale of Valium without a prescription. Conclusions: This study examined the association between Twitter content, NUPM behavior promotion, and online access to drugs using a broad set of prescription drug keywords. Initial results are concerning, as our study found over 45,000 tweets that directly promoted NUPM by providing a URL that actively marketed the illegal online sale of prescription drugs of abuse. Additional research is needed to further establish the link between Twitter content and NUPM, as well as to help inform future technology-based tools, online health promotion activities, and public policy to combat NUPM online. ",
doi="10.2196/jmir.5144",
url="http://www.jmir.org/2015/12/e280/",
url="http://www.ncbi.nlm.nih.gov/pubmed/26677966"
}


@Article{info:doi/10.2196/jmir.4161,
author="Benetoli, Arcelio
and Chen, F. Timothy
and Spagnardi, Sarah
and Beer, Troy
and Aslani, Parisa",
title="Provision of a Medicines Information Service to Consumers on Facebook: An Australian Case Study",
journal="J Med Internet Res",
year="2015",
month="Nov",
day="23",
volume="17",
number="11",
pages="e265",
keywords="medicines information",
keywords="Facebook",
keywords="pharmacists",
keywords="consumers",
keywords="information services",
keywords="drug information services",
keywords="social media",
abstract="Background: Social networking sites (SNSs) have changed the way people communicate. They may also change the way people seek health advice. Objective: This study describes the provision of a medicines information service on Facebook to individual consumers. It aimed to discuss the pros and cons, and inform health and pharmacy stakeholders and researchers about the opportunities and challenges of providing such a service. Methods: We adopted an exploratory approach using a case study method. Results: NPS MedicineWise, an independent, not-for-profit Australian organization, runs a public question-and-answer service on Facebook, dubbed Pharmacist Hour. Consumers following the organization's Facebook page are invited to post medication-related questions often with a suggested health topic. A wide range of questions and comments are posted related to medication usage. The pharmacist answers the queries, providing evidence-based medicines information and using consumer-friendly language, during the specific 1-hour period. The most popular questions in the past 12 months were related to adverse effects, treatment options for conditions, and drug interactions. The service had a mean number of engagements (defined as a like or share of the Pharmacy Hour post) of 38 (SD 19) people and a mean 5 (SD 3) questions per session. Conclusions: The Pharmacist Hour Facebook service addresses the medicines information needs of consumers and indirectly promotes other appropriate and relevant NPS MedicineWise products and services to further assist consumers. The service offers a new medium for a quality use of medicines organization committed to promoting awareness about the correct and safe use of medicines in Australia. ",
doi="10.2196/jmir.4161",
url="http://www.jmir.org/2015/11/e265/",
url="http://www.ncbi.nlm.nih.gov/pubmed/26596328"
}


@Article{info:doi/10.2196/jmir.2606,
author="Fittler, Andras
and B?sze, Gergely
and Botz, Lajos",
title="Evaluating Aspects of Online Medication Safety in Long-Term Follow-Up of 136 Internet Pharmacies: Illegal Rogue Online Pharmacies Flourish and Are Long-Lived",
journal="J Med Internet Res",
year="2013",
month="Sep",
day="10",
volume="15",
number="9",
pages="e199",
keywords="online pharmacies",
keywords="Internet pharmacy",
keywords="online pharmaceutical services",
keywords="online medicines",
keywords="counterfeit medicines",
keywords="patient safety",
abstract="Background: A growing number of online pharmacies have been established worldwide. Among them are numerous illegal websites selling medicine without valid medical prescriptions or distributing substandard or counterfeit drugs. Only a limited number of studies have been published on Internet pharmacies with regard to patient safety, professionalism, long-term follow-up, and pharmaceutical legitimacy verification. Objective: In this study, we selected, evaluated, and followed 136 Internet pharmacy websites aiming to identify indicators of professional online pharmacy service and online medication safety. Methods: An Internet search was performed by simulating the needs of potential customers of online pharmacies. A total of 136 Internet pharmacy websites were assessed and followed for four years. According to the LegitScript database, relevant characteristics such as longevity, time of continuous operation, geographical location, displayed contact information, prescription requirement, medical information exchange, and pharmaceutical legitimacy verification were recorded and evaluated. Results: The number of active Internet pharmacy websites decreased; 23 of 136 (16.9\%) online pharmacies ceased operating within 12 months and only 67 monitored websites (49.3\%) were accessible at the end of the four-year observation period. However, not all operated continuously, as about one-fifth (31/136) of all observed online pharmacy websites were inaccessible provisionally. Thus, only 56 (41.2\%) Internet-based pharmacies were continuously operational. Thirty-one of the 136 online pharmacies (22.8\%) had not provided any contact details, while only 59 (43.4\%) displayed all necessary contact information on the website. We found that the declared physical location claims did not correspond to the area of domain registration (according to IP address) for most websites. Although the majority (120/136, 88.2\%) of the examined Internet pharmacies distributed various prescription-only medicines, only 9 (6.6\%) requested prior medical prescriptions before purchase. Medical information exchange was generally ineffective as 52 sites (38.2\%) did not require any medical information from patients. The product information about the medicines was generally (126/136, 92.6\%) not displayed adequately, and the contents of the patient information leaflet were incomplete in most cases (104/136, 76.5\%). Numerous online operators (60/136, 44.1\%) were defined as rogue Internet pharmacies, but no legitimate Internet-based pharmacies were among them. One site (0.7\%) was yet unverified, 23 (16.9\%) were unapproved, while the remaining (52/136, 38.2\%) websites were not available in the LegitScript database. Contrary to our prior assumptions, prescription or medical information requirement, or the indication of contact information on the website, does not seem to correlate with ``rogue pharmacy'' status using the LegitScript online pharmacy verification standards. Instead, long-term continuous operation strongly correlated (P<.001) with explicit illegal activity. Conclusions: Most Internet pharmacies in our study sample were illegal sites within the definition of ``rogue'' Internet pharmacy. These websites violate professional, legal, and ethical standards and endanger patient safety. This work shows evidence that online pharmacies that act illegally appear to have greater longevity than others, presumably because there is no compelling reason for frequent change in order to survive. We also found that one in five websites revived (closed down and reopened again within four years) and no-prescription sites with limited medicine and patient information are flourishing. ",
doi="10.2196/jmir.2606",
url="http://www.jmir.org/2013/9/e199/",
url="http://www.ncbi.nlm.nih.gov/pubmed/24021777"
}


@Article{info:doi/10.2196/jmir.2810,
author="Dasgupta, Nabarun
and Freifeld, Clark
and Brownstein, S. John
and Menone, Mark Christopher
and Surratt, L. Hilary
and Poppish, Luke
and Green, L. Jody
and Lavonas, J. Eric
and Dart, C. Richard",
title="Crowdsourcing Black Market Prices For Prescription Opioids",
journal="J Med Internet Res",
year="2013",
month="Aug",
day="16",
volume="15",
number="8",
pages="e178",
keywords="opioids",
keywords="black market",
keywords="economics",
keywords="drug abuse",
keywords="surveillance",
keywords="crowdsourcing",
keywords="Internet",
keywords="Silk Road",
keywords="StreetRx",
keywords="RADARS System",
keywords="police",
keywords="law enforcement",
abstract="Background: Prescription opioid diversion and abuse are major public health issues in the United States and internationally. Street prices of diverted prescription opioids can provide an indicator of drug availability, demand, and abuse potential, but these data can be difficult to collect. Crowdsourcing is a rapid and cost-effective way to gather information about sales transactions. We sought to determine whether crowdsourcing can provide accurate measurements of the street price of diverted prescription opioid medications. Objective: To assess the possibility of crowdsourcing black market drug price data by cross-validation with law enforcement officer reports. Methods: Using a crowdsourcing research website (StreetRx), we solicited data about the price that site visitors paid for diverted prescription opioid analgesics during the first half of 2012. These results were compared with a survey of law enforcement officers in the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System, and actual transaction prices on a ``dark Internet'' marketplace (Silk Road). Geometric means and 95\% confidence intervals were calculated for comparing prices per milligram of drug in US dollars. In a secondary analysis, we compared prices per milligram of morphine equivalent using standard equianalgesic dosing conversions. Results: A total of 954 price reports were obtained from crowdsourcing, 737 from law enforcement, and 147 from the online marketplace. Correlations between the 3 data sources were highly linear, with Spearman rho of 0.93 (P<.001) between crowdsourced and law enforcement, and 0.98 (P<.001) between crowdsourced and online marketplace. On StreetRx, the mean prices per milligram were US\$3.29 hydromorphone, US\$2.13 buprenorphine, US\$1.57 oxymorphone, US\$0.97 oxycodone, US\$0.96 methadone, US\$0.81 hydrocodone, US\$0.52 morphine, and US\$0.05 tramadol. The only significant difference between data sources was morphine, with a Drug Diversion price of US\$0.67/mg (95\% CI 0.59-0.75) and a Silk Road price of US\$0.42/mg (95\% CI 0.37-0.48). Street prices generally followed clinical equianalgesic potency. Conclusions: Crowdsourced data provide a valid estimate of the street price of diverted prescription opioids. The (ostensibly free) black market was able to accurately predict the relative pharmacologic potency of opioid molecules. ",
doi="10.2196/jmir.2810",
url="http://www.jmir.org/2013/8/e178/",
url="http://www.ncbi.nlm.nih.gov/pubmed/23956042"
}


@Article{info:doi/10.2196/jmir.2464,
author="Mackey, K. Tim
and Liang, A. Bryan
and Strathdee, A. Steffanie",
title="Digital Social Media, Youth, and Nonmedical Use of Prescription Drugs: The Need for Reform",
journal="J Med Internet Res",
year="2013",
month="Jul",
day="26",
volume="15",
number="7",
pages="e143",
keywords="non-medical use of prescription medications (NUPM)",
keywords="eHealth",
keywords="Internet",
keywords="social media",
keywords="youth and adolescents",
keywords="drug abuse",
keywords="substance abuse",
doi="10.2196/jmir.2464",
url="http://www.jmir.org/2013/7/e143/",
url="http://www.ncbi.nlm.nih.gov/pubmed/23892156"
}


@Article{info:doi/10.2196/jmir.2610,
author="Mackey, Ken Tim
and Liang, A. Bryan",
title="Global Reach of Direct-to-Consumer Advertising Using Social Media for Illicit Online Drug Sales",
journal="J Med Internet Res",
year="2013",
month="May",
day="29",
volume="15",
number="5",
pages="e105",
keywords="health policy",
keywords="pharmacies",
keywords="social media",
keywords="Internet",
keywords="social marketing",
keywords="marketing of health services",
keywords="online pharmaceutical services",
abstract="Background: Illicit or rogue Internet pharmacies are a recognized global public health threat that have been identified as utilizing various forms of online marketing and promotion, including social media. Objective: To assess the accessibility of creating illicit no prescription direct-to-consumer advertising (DTCA) online pharmacy social media marketing (eDTCA2.0) and evaluate its potential global reach. Methods: We identified the top 4 social media platforms allowing eDTCA2.0. After determining applicable platforms (ie, Facebook, Twitter, Google+, and MySpace), we created a fictitious advertisement advertising no prescription drugs online and posted it to the identified social media platforms. Each advertisement linked to a unique website URL that consisted of a site error page. Employing Web search analytics, we tracked the number of users visiting these sites and their location. We used commercially available Internet tools and services, including website hosting, domain registration, and website analytic services. Results: Illicit online pharmacy social media content for Facebook, Twitter, and MySpace remained accessible despite highly questionable and potentially illegal content. Fictitious advertisements promoting illicit sale of drugs generated aggregate unique user traffic of 2795 visits over a 10-month period. Further, traffic to our websites originated from a number of countries, including high-income and middle-income countries, and emerging markets. Conclusions: Our results indicate there are few barriers to entry for social media--based illicit online drug marketing. Further, illicit eDTCA2.0 has globalized outside US borders to other countries through unregulated Internet marketing. ",
doi="10.2196/jmir.2610",
url="http://www.jmir.org/2013/5/e105/",
url="http://www.ncbi.nlm.nih.gov/pubmed/23718965"
}


@Article{info:doi/10.2196/jmir.2236,
author="Cicero, J. Theodore
and Ellis, Stephen Matthew",
title="Health Outcomes in Patients Using No-Prescription Online Pharmacies to Purchase Prescription Drugs",
journal="J Med Internet Res",
year="2012",
month="Dec",
day="06",
volume="14",
number="6",
pages="e174",
keywords="prescription drugs",
keywords="health care quality",
keywords="access",
keywords="evaluation",
keywords="health policy",
keywords="substance-related disorders",
abstract="Background: Many prescription drugs are freely available for purchase on the Internet without a legitimate prescription from a physician. Objective: This study focused on the motivations for using no-prescription online pharmacies (NPOPs) to purchase prescription drugs rather than using the traditional doctor-patient-pharmacy model. We also studied whether users of NPOP-purchased drugs had poorer health outcomes than those who obtain the same drug through legitimate health care channels. Methods: We selected tramadol as a representative drug to address our objective because it is widely prescribed as an unscheduled opioid analgesic and can easily be purchased from NPOPs. Using search engine marketing (SEM), we placed advertisements on search result pages stemming from the keyword ``tramadol'' and related terms and phrases. Participants, who either used the traditional doctor-patient-pharmacy model to obtain tramadol (traditional users, n=349) or purchased it on the Web without a prescription from their local doctor (ie, nontraditional users, n=96), were then asked to complete an online survey. Results: Respondents in both groups were primarily white, female, and in their mid-forties (nontraditional users) to upper forties (traditional users). Nearly all nontraditional users indicated that their tramadol use was motivated by a need to treat pain (95\%, 91/96) that they perceived was not managed appropriately through legitimate health care channels. A majority of nontraditional users (55\%, 41/75) indicated they used NPOPs because they did not have access to sufficient doses of tramadol to relieve pain. In addition, 29\% (22/75) of nontraditional users indicated that the NPOPs were a far cheaper alternative than seeing a physician, paying for an office visit, and filling a prescription at a local pharmacy, which is often at noninsured rates for those who lack medical insurance (37\%, 35/96, of NPOP users). The remainder of participants (16\%, 12/96) cited other motivations (eg, anonymity) for using NPOPs. In terms of health outcomes, nontraditional users experienced a significantly (P<.01) greater number and severity of adverse events, including life-threatening seizures: 7\% (7/96) of nontraditional users reported seizures, while none of the traditional users reported seizures. Conclusions: Although online pharmacies can offer distinct advantages in terms of convenience and cost, users of these ``rogue'' pharmacies that offer drugs with no prescription or doctor supervision do so at great risk to their health, as evidenced by much higher rates of adverse events. The most logical explanation for these findings is that the lack of physician oversight of dosage schedules, contraindicated conditions, and concomitant medications, were responsible for the increased intensity and frequency of adverse events in the nontraditional users. Although we only examined tramadol, it is logical to postulate that similar results would be observed with dozens of equally accessible prescription drugs. As such, the geometric growth in the use of online pharmacies around the world should prompt intense medical and regulatory discussion about their role in the provision of medical care. ",
doi="10.2196/jmir.2236",
url="http://www.jmir.org/2012/6/e174/",
url="http://www.ncbi.nlm.nih.gov/pubmed/23220405"
}


@Article{info:doi/10.2196/jmir.1999,
author="Liang, A. Bryan
and Mackey, K. Tim",
title="Online Availability and Safety of Drugs in Shortage: A Descriptive Study of Internet Vendor Characteristics",
journal="J Med Internet Res",
year="2012",
month="Feb",
day="09",
volume="14",
number="1",
pages="e27",
keywords="Illicit online pharmacies",
keywords="FDA drug shortage",
keywords="gray market",
keywords="drug supply",
keywords="social media",
keywords="direct-to-consumer advertising",
keywords="Internet pharmacies",
keywords="health policy",
abstract="Background: Unprecedented drug shortages announced by the US Food and Drug Administration (FDA) have severely affected therapeutic access, patient safety, and public health. With continued shortages, patients may seek drugs online. Objective: To assess the prevalence of online marketing for current FDA shortage drugs and potential patient safety risks. Methods: We performed a descriptive study of the prevalence of online marketing for shortage drugs---that is, offers for sale of each drug, including characteristics of online drug sellers and intermediary sites marketing these drugs. Results: Of the 72 FDA shortage-listed drugs, 68 (94\%) were offered for sale online. We found 291 offers for these drugs, the vast majority (n = 207, 71.1\%) by online drug sellers selling direct to consumers. Intermediary sites included data aggregators (n = 22, 8\%), forum links (n = 23, 8\%), and personal page data links (n = 34, 12\%), as well as Flickr social media links (n = 5, 2\%), all advertising drugs without a prescription. Of the 91 online drug sellers identified, 31 (34\%) had more than 1 shortage drug offered for sale, representing most (n = 148, 71\%) of all online drug seller sales offers. The majority of these online drug sellers (n = 21, 68\%) were on the National Association of Boards of Pharmacy (NABP) Not Recommended Sites list. Finally, for shortage drugs with an online drug seller (n = 58, 85\%), 53 (91\%) had at least one site on the Not Recommended list and 21 (36\%) had only sites on the Not Recommended list. Conclusions: FDA shortage drugs are widely marketed over the Internet. Suspect online drug sellers and intermediaries dominate these sales offers. As a critical risk management issue, patients, providers, and policymakers should be extremely cautious in procuring shortage drugs through Internet sourcing. ",
doi="10.2196/jmir.1999",
url="http://www.jmir.org/2012/1/e27/",
url="http://www.ncbi.nlm.nih.gov/pubmed/22321731"
}


@Article{info:doi/10.2196/jmir.1795,
author="Orizio, Grazia
and Merla, Anna
and Schulz, J. Peter
and Gelatti, Umberto",
title="Quality of Online Pharmacies and Websites Selling Prescription Drugs: A Systematic Review",
journal="J Med Internet Res",
year="2011",
month="Sep",
day="30",
volume="13",
number="3",
pages="e74",
keywords="Internet",
keywords="pharmaceutical preparations",
keywords="public health",
keywords="review",
keywords="online pharmacies",
abstract="Background: Online pharmacies are companies that sell pharmaceutical preparations, including prescription-only drugs, on the Internet. Very little is known about this phenomenon because many online pharmacies operate from remote countries, where legal bases and business practices are largely inaccessible to international research.  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 2011 and the gray literature on the Internet using the Google search engine and its tool Google Scholar. We also investigated the official websites of institutional agencies (World Health Organization, and US and European centers for disease control and drug regulation authorities). We focused specifically on online pharmacies offering prescription-only drugs. We decided to analyze and report only articles with original data, in order to review all the available data regarding online pharmacies and their usage. Results: We selected 193 relevant articles: 76 articles with original data, and 117 articles without original data (editorials, regulation articles, or the like) including 5 reviews. The articles with original data cover samples of online pharmacies in 47 cases, online drug purchases in 13, consumer characteristics in 15, and case reports on adverse effects of online drugs in 12. The studies show that random samples with no specific limits to prescription requirements found that at least some websites sold drugs without a prescription and that an online questionnaire was a frequent tool to replace prescription. Data about geographical characteristics show that this information can be concealed in many websites. The analysis of drug offer showed that online a consumer can get virtually everything. Regarding quality of drugs, researchers very often found inappropriate packaging and labeling, whereas the chemical composition usually was not as expected in a minority of the studies' samples. Regarding consumers, the majority of studies found that not more than 6\% of the samples had bought drugs online. 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. To enhance the benefits and minimize the risks of online pharmacies, a 2-level approach could be adopted. The first level should focus on policy, with laws regulating the phenomenon at an international level. The second level needs to focus on the individual. This approach should aim to increase health literacy, required for making appropriate health choices, recognizing risks and making the most of the multitude of opportunities offered by the world of medicine 2.0. ",
doi="10.2196/jmir.1795",
url="http://www.jmir.org/2011/3/e74/",
url="http://www.ncbi.nlm.nih.gov/pubmed/21965220"
}


@Article{info:doi/10.2196/jmir.1441,
author="Veronin, Michael",
title="Packaging and Labeling of Pharmaceutical Products Obtained from the Internet",
journal="J Med Internet Res",
year="2011",
month="Feb",
day="15",
volume="13",
number="1",
pages="e22",
keywords="Internet pharmacy",
keywords="online pharmacy",
keywords="drug importation",
keywords="drug label",
keywords="pharmaceutical packaging",
abstract="Background: For patients, the prescription container label may be the only source of instructions on how to take their medicines. In the United States, the legal requirements for a prescription label are set by federal law and state statutes. The container should be comparable to that which manufacturers use to package drug products and should preserve a product's identity, strength, quality, and purity and prevent contamination. Safety features such as a child-resistant closure should be provided. Pharmaceutical products purchased from international online pharmacies are not approved by the Food and Drug Administration (FDA) and may not meet US guidelines for labeling and packaging. Objective: The study objective was to determine whether commonly purchased pharmaceutical products obtained from international online pharmacies are comparable to products dispensed in the United States with regard to labeling and packaging. Methods: During March 2006 through January 2007, 41 pharmaceutical oral dosage form samples were obtained from international Internet pharmacy websites for evaluation: 18 generic simvastatin samples, 18 generic amlodipine samples, and 5 generic sildenafil samples. Contents for each package were observed and recorded and comparison of the prescription labeling and packaging of these products was made with prescription labeling and packaging requirements in the United States. Results: Of the 41 drug products obtained from online pharmacies from 12 different countries, only 1 product (from Canada) would meet both labeling and packaging guidelines for products dispensed in the United States. Of those not meeting the requirements, 7 were dispensed in paper envelopes with label affixed that was either handwritten or typed and contained missing information such as name and address of dispenser, name of prescriber, name of patient, and directions for use. Another 3 products did not have a label affixed to the drug product, but information was printed on a paper document enclosed in the shipping package, while 28 products did not have labels affixed to the drug product. In all, 39 of the 41 drug products' packaging would not meet the US guidelines. Aside from the Canadian product, only 1 product from Mexico was dispensed in a container that would meet guidelines established in the United States. In total, 35 products were not dispensed in plastic vials but were dispensed in unit dose packages, paper envelopes with loose dosage forms, blister packs of drugs held together with rubber bands, or a combination of these packaging forms. Conclusions: Results suggest that labeling and packaging standards for international generic drug products are not equivalent to labeling and packaging standards in the United States. This suggests dissimilar and substandard distribution processes compared with those in the United States, which in turn presents a challenge to patient comprehension and health literacy and may affect patient adherence to drug treatment regimens. These findings have strong implications for drug product quality, patient outcomes, therapeutic effectiveness, and safety. ",
doi="10.2196/jmir.1441",
url="http://www.jmir.org/2011/1/e22/",
url="http://www.ncbi.nlm.nih.gov/pubmed/21324833"
}