The digital age has brought numerous advances to health care, including the proliferation of online pharmacies and telemedicine, which have revolutionised how patients interact with medical services. Accelerated by the COVID-19 pandemic and the resulting lockdown measures, patients are now increasingly using online services for medical consultations and access to prescription and over-the-counter medications. The digital pharmacy market is estimated to be growing at a rate of about 14% year on year and telehealth uptake has risen sharply, with consumer adoption reported to have increased from 11% in 2019 to 46% in 2021, in the USA. Although these platforms can offer clear benefits to patients, they also present some substantial public health risks.
Perhaps the greatest benefit of online pharmacies and telemedicine is the vastly simplified access to treatment. These services allow patients to consult with health-care providers and receive medications from their home, which is a particular advantage for people living in remote areas or those with mobility issues. Additionally, online pharmacies can offer greater privacy for patients who might feel embarrassed about seeking treatment for conditions that are associated with stigma, such as overweight or obesity, sexual health issues, and dermatological conditions. Another reason that patients are turning to online services is cheaper prices for medications in some countries, as overheads are reduced and generics are frequently offered. Additionally, the costs associated with seeing a physician to obtain a prescription might be reduced. Together, these benefits can lead to improved adherence to treatment regimens when using mail-order services rather than in-person visits, potentially improving outcomes and reducing risks of complications from missed doses.
However, one of the greatest concerns in this space is the prevalence of unlicensed pharmacies. According to the US National Association of Boards of Pharmacy, almost 95% of websites that sell prescription-only drugs operate illegally. Online pharmacies might be able to avoid the standards set by authorities for physical pharmacies. According to inspections by the UK General Pharmaceutical Council (GPhC), online pharmacies frequently operate from overseas or jurisdictions with weak regulatory frameworks, meaning they can avoid GPhC or Care Quality Commission regulations. A UK study published in 2024 assessed 116 online pharmacies and found that 55 (47%) were confirmed as rogue and only 47 (41%) were verified as legitimate by the GPhC. Moreover, only 23 (20%) of the 116 online pharmacies assessed required a prescription to access prescription-only medications. Access to medications without a prescription could pose major risks to patients and public health; for example, unnecessary use of antibiotics leading to adverse effects and the development of antimicrobial resistance.
The US Centers for Disease Control and Prevention have stated that there is a potential public health risk for individuals ordering what they believe to be prescription medications from online pharmacies. Even if drugs are obtained with a prescription, the lack of oversight and regulations in some of these services means that patients might unknowingly purchase medications that are counterfeit or expired, or have been improperly stored. WHO have reported that at least one in ten medicines in low-income and middle-income countries are substandard or falsified, and these products are often sold online. A study found that semaglutide (a glucagon-like peptide-1 [GLP-1]receptor agonist) products were being sold without prescription by illegal online pharmacies, often with lower purity than advertised (7–14% vs 99%), or sometimes substantially exceeding the labelled concentration in samples by 29–39%, meaning that patients could receive ineffective amounts or too much drug per injection. This could have dangerous consequences, as GLP-1 receptor agonists can cause some uncommon but serious adverse effects, such as severe dehydration and pancreatitis, which might have increased frequency at higher doses. Furthermore, due to off-label prescriptions of semaglutide for weight loss leading to increased demand, there has been a continued shortage of the drug, and the UK National Pharmacy Association has suggested there could be a rapid rise in counterfeit versions and the unlicensed sale of medication online as a result.
Lack of personalisation and professional guidance is also a substantial risk when patients turn to online pharmacies. Self-diagnosis and self-medication are possible when using these platforms, and patients might seek drugs without a valid medical need or without a prescription. Absence of personalised advice and follow-up could lead to misuse of medication, dangerous drug interactions, or unexpected adverse effects. Sharing details between the online prescription service and the patient's general practitioner is often recommended but not an absolute requirement, meaning that care might be fragmented between providers who do not have access to a comprehensive medical history, including concurrent medications. In an investigation reported last year, the BBC was able to buy prescription-only medicines (an anti-anxiety drug, a painkiller, and a sleeping medication) from 20 regulated online pharmacies in the UK without checks, such as general practitioner approval. Other medications with serious side-effects, such as finasteride for hair loss, were frequently available after completing a simple questionnaire but without having to provide evidence of the condition, and often did not include the patient alert card that warned of the possible adverse effects including suicidal thoughts and sexual dysfunction.
In February, 2025, the GPhC published updated guidance that proposes new measures to improve patient safety in response to concerns relating to inappropriate supplies of medicines from online pharmacies. The guidelines state that identity-verification services, such as in-person or video consultations, will be required to access some medications, and prescription information should be shared with the patient's general practitioner. If the patient has not given consent to share this information with their doctor, the guidance states that “the prescriber must then decide whether it is safe to prescribe”. These are steps in the right direction, but there remains potential for unsafe prescriptions despite this guidance.
Other potential methods have been suggested to monitor online pharmacies, including use of a mystery shopper style system where professional regulators would use the service to check that standards are being met, but there remains an urgent unmet need to protect patient safety, especially as there is an absence of proposed methods to deal with unlicensed pharmacies and for enforcement of accountability when it is found that the required standards have not been met.
Governments and regulatory bodies worldwide must act to ensure all online pharmacies operate in accordance with national and international standards for safety and quality. Advanced verification systems and improved quality assurance should be developed, implemented, and enforced. Combined efforts from health-care providers, pharmacists, and regulators are necessary to make online pharmacies a safe and reliable option for patients. By finding a balance between innovation and regulation, the benefits of online pharmacies can be harnessed while minimising the risks to public health.