Trends in Medication Importation by U.S. Adults over Time

Abstract

Background:

Few data are available about how personal prescription drug importation behavior has changed over time in tandem with increases in the U.S. prices of many medications, or how importation has varied over time as a function of access to licensed prescribers.

Objective:

The study objective was to examine trends in personal drug importation by U.S adults over time and assess these trends stratified by access to a provider.

Methods:

This cross-sectional study used 2011–2018 National Health Interview Survey data on adults ≥18 years of age. Using procedures that accounted for the complex survey design, linear trends in the prevalence of importation were assessed using linear regression models fit with ordinary least squares. Prevalence ratios with 95% confidence intervals (CIs) comparing other survey years to 2015 were estimated using log-binomial regression models.

Results:

Between 2011 and 2015, the percentage of U.S. adults importing medications from foreign countries decreased from 1.91% to 1.28%, an average decrease of 0.19% per year (95% CI 0.14–0.24, p<0.0001). However, in 2016, the percentage of adults importing medications increased to 1.49%. The percentage remained stable in 2017 at 1.50%, and then increased slightly to 1.57% in 2018. Compared to 2015, the prevalence ratio for importation was 1.50 (95% CI 1.31–1.73; p-value<0.0001) in 2011, 1.17 (95% CI 0.96–1.42; p-value=0.12) in 2016, and 1.23 (95%CI 1.01–1.50; p-value=0.05) in 2018. Individuals who had difficulty finding a licensed prescriber were consistently more likely to import medications than those who had no difficulty across all years, with no difference in trend by prescriber access.

Conclusion:

Medication importation and its relationship to provider access should continue to merit the attention of legislators, clinicians, and researchers.

Background

Prescription medications are significantly more expensive in the U.S. than in foreign countries.^1,2 In response to high costs, U.S. patients import medications for personal use from Canada or elsewhere.^1,3,4 Personally importing drugs from Canada appears to be safe since drug-safety standards are similar to those of the U.S. Personal importation of medications from other countries with more lenient drug-safety standards (e.g., Myanmar) may increase the risk of exposure to counterfeit (i.e., falsified, fraudulent), adulterated, or otherwise substandard medications.^1,5–7 Difficult-to-read, inaccurate, or insufficient foreign drug product labeling may also increase the risk of medication errors and subsequent harms. High drug costs and the risks of importation from some foreign countries are thus important public health concerns.^1,2 An additional related concern is that many people cannot gain access to a licensed prescriber who can write them a valid prescription, so they order medications online from unsafe foreign pharmacies without a prescription and take the risk that it might not be a legitimate drug.³ Few data are available about how importation behavior has changed over time or as a function of access to prescribers.^1,2,4

Objective

The objective of this study was to examine trends in personal drug importation by U.S adults over time and assess these trends stratified by access to a prescriber.

Methods

Data from the cross-sectional 2011–2018 National Health Interview Survey, a nationally representative in-person survey, were analyzed.⁸ The study population was adults ≥18 years of age. Additional details about the data and study population can be found in prior publications.^3,4 This study used de-identified publicly available data and did not require institutional review board approval.

Personal prescription drug importation was measured as a self-reported binary indicator of whether an individual imported one or more prescription drugs for personal use from a foreign country to save money. Provider access was a binary indicator of whether an individual had any trouble finding a “general doctor or provider” who would see them. The implied focus of the provider access variable is licensed prescribers, not pharmacy providers or access.

The overall prevalence of importation was plotted for each of the eight years of the study period. For analyses stratified by licensed prescriber access, 2017 was the last year of the study period because the question about difficulty accessing a licensed prescriber was removed from the 2018 survey. Using procedures that accounted for the complex survey design, linear trends in the prevalence of importation were assessed over time using linear regression models fit with ordinary least squares. Prevalence ratios with 95% confidence intervals (CIs) were estimated comparing other survey years to 2015, the nadir for importation prevalence, using log-binomial regression models.

Results

Between 2011 and 2015, the percentage of U.S. adults personally importing medications from foreign countries decreased from 1.91% to 1.28% (Figure 1), an average decrease of 0.19% per year (95% CI 0.14–0.24, p<0.0001). However, in 2016, the percentage of adults importing medications increased to 1.49%. The percentage remained stable in 2017 at 1.50%, and then increased slightly to 1.57% in 2018. Compared to 2015, the prevalence ratio for importation was 1.50 (95% CI 1.31–1.73; p-value<0.0001) in 2011, 1.41 (95% CI 1.23–1.62; p-value<0.0001) in 2012, 1.18 (95% CI 1.03–1.36; p-value=0.02) in 2013, 1.08 (95% CI 0.93–1.25; p-value=0.34) in 2014, 1.17 (95% CI 0.96–1.42; p-value=0.12) in 2016, 1.17 (95% CI 0.97–1.41; p-value=0.10) in 2017, and 1.23 (95%CI 1.01–1.50; p-value=0.05) in 2018. Individuals who had difficulty accessing a licensed prescriber were consistently more likely to import medications than those who had no difficulty across all years (Figure 2). There was no difference in trend by prescriber access, though there was a notable decrease in importation from 5.56% in 2013 to 2.99% in 2017 among those with difficulty accessing a prescriber.

Figure 1.

Time Trends in Medication Importation by United States Adults from Foreign Countries, 2011–2018. The shaded regions represent the 95% confidence intervals estimated using survey procedures to account for the complex survey design. The double black line on the y-axis indicates that the axis scale does not start at zero.

Figure 2.

Time Trends in Medication Importation by United States Adults from Foreign Countries Stratified by Access to a Licensed Prescriber, 2011–2017. The shaded regions represent the 95% confidence intervals estimated using survey procedures to account for the complex survey design. The double black line on the y-axis indicates that the axis scale does not start at zero.

Discussion

Personal drug importation decreased from 2011 to 2015, but began increasing slightly in 2016, held stable in 2017, and then increased slightly further in 2018. Further surveillance and investigation into whether the increase is meaningful and what factors (e.g., increasing drug prices; prescriber access) may be contributing to the upward trend are warranted. It is important to note that all observed absolute differences are small in magnitude. Nonetheless, these data suggest that lack of access to prescribing physicians or other health professionals may play a role in patients deciding to purchase or import medications from foreign countries (without a prescription).^1,3,7

Formalizing the importation of medications from countries with more patient-friendly pricing through legislation is being considered; however, legislators should also explore how to improve patient access to prescribers and pharmacies to obtain needed prescriptions and medications as well as appropriate provider monitoring to reduce or prevent drug-related harms.^1,9 Proponents of importation have stated that importation from Canada will largely solve the issues around access to affordable medications, but may have underappreciated the reality that importation from Canada still requires a valid prescription, which people cannot obtain if they are unable to access a licensed prescriber to write one. If patients attempt to import without a valid prescription, they may increase their likelihood of importing medications from an illegal pharmacy that is not in compliance with U.S. laws and standards. Such pharmacies likely confer an increased risk of exposure to harmful substandard, adulterated, and counterfeit medications.¹⁰

Conclusion

Individuals who had difficulty accessing a licensed prescriber were more likely to import medications than those who did not have such difficulty. Personal medication importation and its relationship to prescriber and pharmacy access should merit the attention of legislators, clinicians, and researchers.