A Day In the Life of Illegal Online Drug Sellers Using Social Media by Tim Mackey, Alsberg Fellow

Direct-to-Consumer Advertising Social Media and DrugsSocial Media Platforms • Growing Use of Internet: 2 billion people currently access the Internet and 51% of US users access Internet for health information • High traffic-high volume: Facebook has some 900 million + users, Twitter 250 million +, many of whom visit site frequently • Rise in Direct-to-Consumer Advertising: Legal DTCA has increased 330% from 1996-2005, twice as fast as other forms of promotion Partnership for Safe Medicines Interchange 2012

Direct-to-Consumer Advertising Risks and Vulnerabilities Unregulated and Unchecked • Limited regulation by FDA: FDA has yet to issue meaningful regulations on social media DTCA • Adverse Events: Patients may report adverse events or provide inaccurate information to other users • Others: How to deal with patient interaction, privacy of PHI, misleading information about products • Illicit Activity: Online pharmacies now heavily populate accessible and low cost social media Partnership for Safe Medicines Interchange 2012

Rise of Illicit Digital Health Digital Dangers for PatientsTop 20 DTCA drugs and illicitsocial media online pharmacy link • 90% of Top 10 DTCA spend drugs have illicit eDTCA links • 60% and 50% prevalence on Facebook among top 10 and top 20 DTCA advertised drugs respectfully • High prevalence of use of eDTCA 2.0 by illicit online pharmacies Liang BA, Mackey TK. Prevalence and Global Health Implications of Social Media in Direct-to-Consumer Drug Advertising. J Med Internet Res. 2011 Aug 31;13(3):e64. Partnership for Safe Medicines Interchange 2012

Rise of Illicit Digital Health Digital Dangers for Patients Partnership for Safe Medicines Interchange 2012

Rise of Illicit Digital Health Digital Dangers for PatientsOther Risks Include Online availability and safety of drugs in shortage: a descriptive study of internet vendor characteristics. • Drugs that are Currently in Shortage: Liang BA, Mackey TK. IHLS research shows 94% of identified J Med Internet Res. 2012 Feb 9;14(1):e27. FDA shortage drugs online Risks of online direct-to-consumer tumor • Vaccines Online: All FDA Biologic markers for cancer screening. Drug Shortage list vaccines available Lovett KM, Liang BA, Mackey TK. J Clin Oncol. 2012 May 1;30(13):1411-4. Epub online, many WHO EML vaccines 2012 Feb 21 available online Vaccine shortages and suspect online • Contraception: All contraceptives pharmacy sellers. available online, many OTC, with Liang BA, Mackey TK. YouTube videos showing Vaccine. 2012 Jan 5;30(2):105-8. Epub 2011 administration/use (i.e. IUDs) Nov 15. • Screening Tests: A number of Suspect online sellers and contraceptive access. screening tests, including tumor markers Liang BA, Mackey TK, Lovett KM. for cancer available online Contraception. 2012 May 25. [Epub ahead of print] Partnership for Safe Medicines Interchange 2012

Research Question Scope and Accessibility of Social Media Research Question •Digital DTCA is Global: Digital DTCA crosses borders even though it is only explicitly allowed in the USA and New Zealand. Illicit actors may engage in digital marketing. •Social Media DTCA has Risks: Social media is high traffic, not limited to geographical boundaries, is largely unregulated, and is easily accessible by questionable users. •Question: How accessible is illicit online social media-based pharmaceutical marketing and does it really go global? Partnership for Safe Medicines Interchange 2012

IHLS Research Methods and MaterialsSocial Media Illicit Marketing Risk Assessment Partnership for Safe Medicines Interchange 2012

IHLS Research Methods and MaterialsSocial Media IHLS Ad Anatomy Advertisement for “No Prescription” and “Safe” Drugs Fake Seal Advertising “Lowest Price Promise” Stock image of “medical professional” purchased from website Picture of various medicines shot with SRL at home Partnership for Safe Medicines Interchange 2012

IHLS Research Methods and Materials Partnership for Safe Medicines Interchange 2012

IHLS Research Significant Findings IHLS Research Social Media Websites • Active: 3 of our 4 illicit online social media ad sites are still available • Traffic: In period of 10 months of data collection, we generated an average range of 78-97 unique user visits (w/out working site) • Accessibility: Sites were easily registered under suspect names (e.g. “no prescription”) • Low Cost: Total project including hosting/marketing of $80p/site Partnership for Safe Medicines Interchange 2012

Research Results Site Links and Stats Partnership for Safe Medicines Interchange 2012

Research Results Global Scope and High Traffic CountriesEmpirical Evidence of GlobalReach • The United States ranked highest with 54.3% of total visitors • Emerging markets, China and Russia ranked 2nd (26.0%) and 4th (6.5%) respectively • In total, illicit ads generated users from 18 diverse countries Source: Intensity map visualization using Google Fusion Tables Partnership for Safe Medicines Interchange 2012

Research Results Unique User Traffic Trends 140 120 100 Facebook Unique User Traffic 80 Twi er 60 Myspace 40 20 0 ch l June May July er er er uary ber ary Apri b emb emb Mar Octo Ja n u em Febr Sept Nov Dec Partnership for Safe Medicines Interchange 2012

Research Results Global User Traffic Trends

Research Results Study LimitationsOpportunities for Improvement • Google+ Suspension: We are not aware of the reasons for the suspension of our study site. However, this provides evidence that suspension/enforcement is possible from the service provider • User Types: We did not conduct detailed examination of user/visitor types (could include in addition to human users, web bots, web crawlers, indexing services) • Relatively Low Traffic: Since we did not have a working site, we did not generate significant traffic. This might be due to the fact that we had a high level of competition! Partnership for Safe Medicines Interchange 2012

Research Results Lessons LearnedSummary of Findings Ways Forward… • Easy: Illicit social media online • Accountability: Make social pharmacy ads are easy to create, media content providers even for those in academics! accountable for illicit ads • Domestic Threats: Highest % of • Surveillance: Content/service visitors were from USA, consistent providers should easily be able to with main purchasers of online surveil for questionable pharmacy products ads/accounts • Source Countries: Emerging • VIPPS: Possible VIPPS markets of China and Russia had integration/utilization into social high % and are known source media sites? countries for counterfeit drugs • Cooperation: Enforcement • It is possible with little experience, requires the cooperation of Internet expertise or money to create your service sector, regulators and law own illicit social media online enforcement pharmacy ad that can go global! Partnership for Safe Medicines Interchange 2012

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A Day In the Life of Illegal Online Drug Sellers Using Social Media by Tim Mackey, Alsberg Fellow

by The Partnership For Safe Medicines on Sep 27, 2012

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