title: Illicit Internet availability of drugs subject to recall and patient safety consequences.
abstract: BACKGROUND
  Permanently recalled drugs are a public health concern if they remain accessible in violation of applicable regulation. Illicit online pharmacies act as an alternative form of access and have been associated with the sale to patients of counterfeit/falsified/fraudulent/substandard drugs. We wished to determine if permanently recalled and significantly restricted drugs were illegally marketed for sale online.
  
  
  OBJECTIVE
  The study was conducted in two phases with two objectives. The first phase attempted to identify drugs subject to permanent recall in certain major pharmaceutical markets as well as those listed as recalled or significantly restricted by the United Nations. We also examined the market authorization status of identified drugs in China and India. The second phase used structured searches on the Internet to determine if identified drugs were marketed for sale online.
  
  
  METHODS
  The World Wide Web.
  
  
  METHODS
  After identification of permanently recalled and restricted drugs we conducted Internet searches for illegal "no prescription" marketing events. We assessed the form of marketing, whether a site offered direct-to-patient sale, use of social media marketing, and the site's compliance status with external monitoring bodies.
  
  
  RESULTS
  Number of recalled drugs marketed as available for purchase on the Internet.
  
  
  RESULTS
  We identified 16 class I equivalent permanently recalled or restricted drugs, 56.3 % (n = 9) of which maintained market authorization in either China or India. Half (n = 8) were marketed for sale online without a prescription direct-to-patient. Use of social media marketing was mixed, with only 18.8 % (n = 3) of recalled drugs having a presence on Facebook, though 50.0 % (n = 8) had content on Twitter. We also found the majority (68.8 %, n = 11) were available and marketed for sale by vendors on the wholesale/business-to-business website alibaba.com primarily as active pharmaceutical ingredient.
  
  
  CONCLUSIONS
  Despite efforts in several countries to restrict access to these drugs or permanently remove them from the market, our study indicates that various sources actively market recalled drugs for sale online. Drug regulators, public health agencies, and law enforcement officials should act with urgency to appropriately restrict and regulate these sales to protect global patients and consumers.
authors.affiliation: Department of Anesthesiology, University of California, San Diego School of Medicine, San Diego, CA, USA. tmackey@ucsd.edu.|Division of Global Public Health, Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA, USA. tmackey@ucsd.edu.|Global Health Policy Institute, 8950 Villa La Jolla Drive, Suite #A204, La Jolla, CA, 92037, USA. tmackey@ucsd.edu.
authors.forename: Tim K
authors.initials: TK
authors.lastname: Mackey
authors.affiliation: Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, San Diego, CA, USA.
authors.forename: Phyo
authors.initials: P
authors.lastname: Aung
authors.affiliation: Global Health Policy Institute, 8950 Villa La Jolla Drive, Suite #A204, La Jolla, CA, 92037, USA.
authors.forename: Bryan A
authors.initials: BA
authors.lastname: Liang
mesh_terms: D002681:China; D011307:Drug Prescriptions; D056736:Drug Recalls; D004335:Drug and Narcotic Control; D006801:Humans; D013287:Illicit Drugs; D007194:India; D020407:Internet; D040541:Marketing; D060946:Pharmaceutical Services, Online; D061108:Social Media
chemical_list: D013287:Illicit Drugs
keywords: Drug recalls; Drug withdrawals; Internet pharmacies; Market removal; Online pharmacies; Public health; Social media marketing