Before you buy medication from an online pharmacy, you may want to think twice.

And after listening to Butler University Associate Professor of Pharmacy Practice John Hertig, who studies the impact of counterfeit online drug distribution worldwide, rattle off the numbers, you may want to avoid medication sold on the world wide web all together.

“At any one time, there are between 35,000 and 45,000 illegal online pharmacies operating worldwide,” he says. “The issue with those illegal online pharmacies, in addition to not operating under the laws and regulations of the United States, is that about 50 percent of them sell counterfeit medications. So in addition to just being the criminals who now have your credit card data and home address, about half the time they’re going to ship you counterfeit product.”

Hertig is a board member of the Alliance for Safe Online Pharmacies (ASOP), whose mission is to protect patient safety. His research looks at why patients are going online (“No surprise, it’s because of cost, but it’s also because it’s an ecommerce world, and people are not aware of the risks”), and whether pharmacists, nurses, and physicians adequately educate their patients about the risks.

The dangers, Hertig says, are the possibility of getting either a substandard or falsified drug. Substandard could be counterfeit, meaning it might not have any of the active ingredient in it—it could be sugar pills—or there might not be enough, or too much, of the active ingredient. Sometimes, counterfeiters might cut 100 real pills into 1,000 pills by diluting them with sugar, brick dust, antifreeze, or chalk.

Falsified drugs are real, but they haven’t been labelled, stored, or handled appropriately.

Hertig says there are ways to tell if an online pharmacy is legitimate. The National Association of Boards of Pharmacy (NABP) owns the “.pharmacy” top-level domain, and there’s no way to obtain a dot-pharmacy web address without going through the association.

“If you go to cvs.pharmacy, you’re good,” he says. “If you go to walgreens.pharmacy, you’re good. If you go to bestdrugsever.com, even though the website might look legitimate, you need to second-guess that.”

The ASOP and NABP are both heavily involved in consumer education (more information is available at BuySafeRx.pharmacy), as is Hertig in conjunction with the Indiana Coalition for Patient Safety, and a network of hospitals. They’ve developed toolkits and are working to determine how much doctors, nurses, and pharmacists know about online pharmacies.

This summer, Hertig will be working on a Butler Summer Institute project with Kyla Maloney ’22, a Pharmacy student whose research will summarize the possible link between illegal online pharmacies and patient harm worldwide. She plans to do a comprehensive review of the available literature regarding this kind of patient harm and unearth data that can be used for patients and providers to make better-informed healthcare decisions.

Maloney says that during an introductory pharmacy class, she was exposed to the world of online pharmacies and the massive issue surrounding adulterated drugs from these sites.

“The impact these pharmacies have on the economy, health system, and patient well-being were quite intriguing to me,” she says. “Pharmacists have a professional responsibility to deliver exceptional care for our patients; in many cases, the ease and convenience of online pharmaceuticals may aid in that mission … I am hoping this literature review will allow me to help make the world of pharmacy just a bit safer for my future patients.”