Analysis of Unregulated Sale of Lifesaving Prescription Drugs Online in the United States | Clinical Pharmacy and Pharmacology | JAMA Internal Medicine | JAMA Network
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Table 1.  Frequency of Advertisements for Albuterol and Insulin on Craigslist and Difference in Advertised and Retail Price From Drugs.com
Frequency of Advertisements for Albuterol and Insulin on Craigslist and Difference in Advertised and Retail Price From Drugs.com
Table 2.  Thematic Categories and Sample Text From Craigslist Advertisements
Thematic Categories and Sample Text From Craigslist Advertisements
1.
Gilmore  C. Rising insulin prices push woman to buy medicine on Craigslist. NBC DFW. https://www.nbcdfw.com/news/health/Rising-Insulin-Prices-Compel-Woman-to-Buy-Medicine-on-Craigslist-490807341.html. Accessed January 7, 2020.
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United States Congress. H.R. 3298 (82nd): An Act to Amend Section 503(b) of the Federal Food, Drug, and Cosmetic Act. United States of America; 1951. https://www.govtrack.us/congress/bills/82/hr3298/text. Accessed January 7, 2020.
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Craigslist.com. Prohibited. https://www.craigslist.org/about/prohibited. Accessed January 7, 2020.
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United States Postal Service. Publication 52- Hazardous, Restricted and Perishable Mail. USPS.com. https://pe.usps.com/text/pub52/pub52c4_019.htm. Accessed January 7, 2020.
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Guest  G, MacQueen  KM, Namey  EE.  Applied Thematic Analysis. Thousand Oaks, California: SAGE Publications; 2012. doi:10.4135/9781483384436
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Office  USGP. U.S.C. Title 21- Food and Drugs. United States Code, 2011 Edition. https://www.govinfo.gov/content/pkg/USCODE-2011-title21/html/USCODE-2011-title21-chap13-subchapI-partD.htm. Accessed January 7, 2020.
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    Research Letter
    Health Care Policy and Law
    February 17, 2020

    Analysis of Unregulated Sale of Lifesaving Prescription Drugs Online in the United States

    Author Affiliations
    • 1College of Engineering, University of Delaware, Newark, Delaware
    • 2Cooper Medical School of Rowan University, Camden, New Jersey
    • 3Jefferson College of Population Health, Philadelphia, Pennsylvania
    • 4The Value Institute, ChristianaCare, Newark, Delaware
    • 5Department of Medicine, ChristianaCare, Newark, Delaware
    JAMA Intern Med. 2020;180(4):607-609. doi:10.1001/jamainternmed.2019.7514

    Reports in the lay press suggest that patients who cannot afford prescription medications seek out discounted products in online marketplaces such as Craigslist.1 The unregulated sale and purchase of prescription medication is prohibited by law and Craigslist policy.2-4 We sought to quantify and characterize advertisements on Craigslist in the United States for 3 potentially lifesaving medications: insulin, albuterol, and epinephrine (EpiPen).

    Methods

    We undertook a mixed-methods, cross-sectional analysis of Craigslist advertisements in the United States. One research assistant (A.A.) individually entered the search terms “insulin,” “albuterol,” and “Epipen” in the Craigslist search engine for each city in each state listed on the Craigslist site. The search was completed in 12 days (June 12, 2019 to June 24, 2019). A 20% sample of collected data was verified by a second researcher (J.N.G.).

    Advertisements were categorized by drug type. The price per unit was calculated as the total price divided by the total number of units for sale (ie, $100 for 10 vials of insulin = $10/unit). Mean advertised prices on Craigslist were calculated for all categories of drugs. The difference between the retail price (listed on Drugs.com) and the advertised Craigslist price was calculated. All information was recorded into a REDCap database and all analyses were performed using Excel and SPSS statistical software (version 20, IBM Corp). Content analysis was performed to identify dominant themes of the advertisement text using the approach described by Guest, MacQueen, and Namey.5 One member of the research team (K.C.K.) coded the entire database and a 30% sample was double coded by a second researcher (R.F.). Discrepancies were resolved by consensus. Intercoder reliability was calculated with NVivo statistical software (version 12, QRS International). This study was deemed exempt by the ChristianaCare institutional review board because all data used were in the public domain.

    Results

    During the study period, all 50 US states were searched, and 432 advertisements for insulin and albuterol were found representing 240 cities in 31 states. No advertisements were identified for EpiPens. We identified 105 (24.3%) advertisements for albuterol and 327 (75.7%) advertisements for insulin. Analog insulin was the most commonly advertised product, with 311 posts (71.9%). Of the analog insulins for sale, the most common were Lantus (n = 91, 27.8%), Humalog (n = 90, 27.5%), and Novolog (n = 70, 21.4%). When compared with the retail price listed on Drugs.com, the Craigslist price for an albuterol inhaler was, on average, $18.77 more expensive than retail, whereas the price per vial of analog and human synthetic insulin were $372.30 and $123.19 less expensive, respectively (Table 1). Content analysis of the text of advertisements revealed 3 dominant themes: (1) motivation of sellers, (2) quality and safety of the products, and (3) sales and shipping details. Sellers were frequently motivated by altruism and aversion to wasting medication. The content of many advertisements raised safety concerns about the quality and safety of the medications being sold (Table 2).

    Discussion

    In this cross-sectional analysis we found that analog insulins were the most commonly advertised prescription drugs and were being offered at a fraction of their retail price on Craigslist. Unregulated resale of prescription medications is illegal6 and in the case of insulin, may be dangerous because improper storage can lead to loss of potency or contamination of the product. Although we were unable to obtain the exact details of Craigslist’s regulatory mechanisms, the site does allow users to report or “flag” inappropriate or illegal posts, which are subsequently considered for removal by site administrators. Our findings may not be representative of all advertisements on Craigslist at all times and there is no way to verify whether advertisements resulted in sales of prescription medications. However, this study provides evidence that patients are seeking and likely finding medication, in particular analog insulin, in unregulated and unmonitored online marketplaces.

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    Article Information

    Corresponding Author: Jennifer N. Goldstein, MD, MSc, ChristianaCare, 4755 Ogletown Stanton Rd, Ammon Education Center, Ste 2E70, Newark, DE 19718 (jgoldstein@christianacare.org).

    Accepted for Publication: December 28, 2019.

    Published Online: February 17, 2020. doi:10.1001/jamainternmed.2019.7514

    Author Contributions: Dr Goldstein had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Study concept and design: Kullmann, Frasso, Goldstein.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: All authors.

    Critical revision of the manuscript for important intellectual content: Ahamed, Frasso, Goldstein.

    Statistical analysis: All authors.

    Administrative, technical, or material support: Ahamed, Frasso, Goldstein.

    Study supervision: Frasso, Goldstein.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: Mr Ahamed and Dr Goldstein were funded in part by the Delaware IDeA Network of Biomedical Research Excellence program, with a grant from the National Institute of General Medical Sciences (8 P20 GM103446-16) from the National Institutes of Health.

    Role of the Funder/Sponsor: The Delaware IDeA Network of Biomedical Research Excellence and the National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Additional Contributions: We thank Julianne LaRosa, MPH, Jefferson College of Population Health, for her support with thematic analysis of qualitative data. She did not receive any compensation.

    References
    1.
    Gilmore  C. Rising insulin prices push woman to buy medicine on Craigslist. NBC DFW. https://www.nbcdfw.com/news/health/Rising-Insulin-Prices-Compel-Woman-to-Buy-Medicine-on-Craigslist-490807341.html. Accessed January 7, 2020.
    2.
    United States Congress. H.R. 3298 (82nd): An Act to Amend Section 503(b) of the Federal Food, Drug, and Cosmetic Act. United States of America; 1951. https://www.govtrack.us/congress/bills/82/hr3298/text. Accessed January 7, 2020.
    3.
    Craigslist.com. Prohibited. https://www.craigslist.org/about/prohibited. Accessed January 7, 2020.
    4.
    United States Postal Service. Publication 52- Hazardous, Restricted and Perishable Mail. USPS.com. https://pe.usps.com/text/pub52/pub52c4_019.htm. Accessed January 7, 2020.
    5.
    Guest  G, MacQueen  KM, Namey  EE.  Applied Thematic Analysis. Thousand Oaks, California: SAGE Publications; 2012. doi:10.4135/9781483384436
    6.
    Office  USGP. U.S.C. Title 21- Food and Drugs. United States Code, 2011 Edition. https://www.govinfo.gov/content/pkg/USCODE-2011-title21/html/USCODE-2011-title21-chap13-subchapI-partD.htm. Accessed January 7, 2020.
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