Search

BackgroundOver the past 4 decades, obesity has escalated into a global epidemic, with its worldwide prevalence nearly tripling. Pharmacological treatments have evolved with the recent development of glucagon-like peptide 1 agonists, such as semaglutide. However, off-label use of drugs such as Ozempic for cosmetic weight loss has surged in popularity, raising concerns about potential misuse and the emergence of substandard and falsified products in the unregulated supply chain. ObjectiveThis study aims to conduct a multifactor investigation of product quality and patient safety risks associated with the unregulated online sale of semaglutide by examining product availability and vendor characteristics and assessing product quality through test purchases. MethodsWe used a complex risk and quality assessment methodology combining online market surveillance, search engine results page analysis, website content assessment, domain traffic analytics, conducting targeted product test purchases, visual quality inspection of product packaging, microbiological sterility and endotoxin contamination evaluation, and quantitative sample analysis using liquid chromatography coupled with mass spectrometry. ResultsWe collected and evaluated 1080 links from search engine results pages and identified 317 (29.35%) links belonging to online pharmacies, of which 183 (57.7%) led to legal pharmacies and 134 (42.3%) directed users to 59 unique illegal online pharmacy websites. Web traffic data for the period between July and September 2023 revealed that the top 30 domains directly or indirectly affiliated with illegal online pharmacies accumulated over 4.7 million visits. Test purchases were completed from 6 illegal online pharmacies with the highest number of links offering semaglutide products for sale without prescription at the lowest price range. Three injection vial purchases were delivered; none of the 3 Ozempic prefilled injection pens were received due to nondelivery e-commerce scams. All purchased vials were considered probable substandard and falsified products, as visual inspection indicated noncompliance in more than half (59%-63%) of the evaluated criteria. The semaglutide content of samples substantially exceeded labeled amounts by 28.56%-38.69%, although no peptide-like impurities were identified. The lyophilized peptide samples were devoid of viable microorganisms at the time of testing; however, endotoxin was detected in all samples with levels ranging between 2.1645 EU/mg and 8.9511 EU/mg. Furthermore, the measured semaglutide purity was significantly low, ranging between 7.7% and 14.37% and deviating from the 99% claimed on product labels by manufacturers. ConclusionsGlucagon-like peptide 1 agonist drugs promoted for weight loss, similar to erectile dysfunction medications more than 2 decades ago, are becoming the new blockbuster lifestyle medications for the illegal online pharmacy market. Protecting the pharmaceutical supply chain from substandard and falsified weight loss products and raising awareness regarding online medication safety must be a public health priority for regulators and technology platforms alike.

BackgroundThe online pharmacy market is growing, with legitimate online pharmacies offering advantages such as convenience and accessibility. However, this increased demand has attracted malicious actors into this space, leading to the proliferation of illegal vendors that use deceptive techniques to rank higher in search results and pose serious public health risks by dispensing substandard or falsified medicines. Search engine providers have started integrating generative artificial intelligence (AI) into search engine interfaces, which could revolutionize search by delivering more personalized results through a user-friendly experience. However, improper integration of these new technologies carries potential risks and could further exacerbate the risks posed by illicit online pharmacies by inadvertently directing users to illegal vendors. ObjectiveThe role of generative AI integration in reshaping search engine results, particularly related to online pharmacies, has not yet been studied. Our objective was to identify, determine the prevalence of, and characterize illegal online pharmacy recommendations within the AI-generated search results and recommendations. MethodsWe conducted a comparative assessment of AI-generated recommendations from Google’s Search Generative Experience (SGE) and Microsoft Bing’s Chat, focusing on popular and well-known medicines representing multiple therapeutic categories including controlled substances. Websites were individually examined to determine legitimacy, and known illegal vendors were identified by cross-referencing with the National Association of Boards of Pharmacy and LegitScript databases. ResultsOf the 262 websites recommended in the AI-generated search results, 47.33% (124/262) belonged to active online pharmacies, with 31.29% (82/262) leading to legitimate ones. However, 19.04% (24/126) of Bing Chat’s and 13.23% (18/136) of Google SGE’s recommendations directed users to illegal vendors, including for controlled substances. The proportion of illegal pharmacies varied by drug and search engine. A significant difference was observed in the distribution of illegal websites between search engines. The prevalence of links leading to illegal online pharmacies selling prescription medications was significantly higher (P=.001) in Bing Chat (21/86, 24%) compared to Google SGE (6/92, 6%). Regarding the suggestions for controlled substances, suggestions generated by Google led to a significantly higher number of rogue sellers (12/44, 27%; P=.02) compared to Bing (3/40, 7%). ConclusionsWhile the integration of generative AI into search engines offers promising potential, it also poses significant risks. This is the first study to shed light on the vulnerabilities within these platforms while highlighting the potential public health implications associated with their inadvertent promotion of illegal pharmacies. We found a concerning proportion of AI-generated recommendations that led to illegal online pharmacies, which could not only potentially increase their traffic but also further exacerbate existing public health risks. Rigorous oversight and proper safeguards are urgently needed in generative search to mitigate consumer risks, making sure to actively guide users to verified pharmacies and prioritize legitimate sources while excluding illegal vendors from recommendations.

BackgroundIllegal online pharmacies function as affiliate networks, in which search engine results pages (SERPs) are poisoned by several links redirecting site visitors to unlicensed drug distribution pages upon clicking on the link of a legitimate, yet irrelevant domain. This unfair online marketing practice is commonly referred to as search redirection attack, a most frequently used technique in the online illegal pharmaceutical marketplace. ObjectiveThis study is meant to describe the mechanism of search redirection attacks in Google search results in relation to erectile dysfunction medications in European countries and also to determine the local and global scales of this problem. MethodsThe search engine query results regarding 4 erectile dysfunction medications were documented using Google. The search expressions were “active ingredient” and “buy” in the language of 12 European countries, including Hungary. The final destination website legitimacy was checked at LegitScript, and the estimated number of monthly unique visitors was obtained from SEMrush traffic analytics. Compromised links leading to international illegal medicinal product vendors via redirection were analyzed using Gephi graph visualization software. ResultsCompromised links redirecting to active online pharmacies were present in search query results of all evaluated countries. The prevalence was highest in Spain (62/160, 38.8%), Hungary (52/160, 32.5%), Italy (46/160, 28.8%), and France (37/160, 23.1%), whereas the lowest was in Finland (12/160, 7.5%), Croatia (10/160, 6.3%), and Bulgaria (2/160, 1.3%), as per data recorded in November 2020. A decrease in the number of compromised sites linking visitors to illegitimate medicine sellers was observed in the Hungarian data set between 2019 and 2021, from 41% (33/80) to 5% (4/80), respectively. Out of 1920 search results in the international sample, 380 (19.79%) search query results were compromised, with the majority (n=342, 90%) of links redirecting individuals to 73 international illegal medicinal product vendors. Most of these illegal online pharmacies (41/73, 56%) received only 1 or 2 compromised links, whereas the top 3 domains with the highest in-degree link value received more than one-third of all incoming links. Traffic analysis of 35 pharmacy specific domains, accessible via compromised links in search engine queries, showed a total of 473,118 unique visitors in November 2020. ConclusionsAlthough the number of compromised links in SERPs has shown a decreasing tendency in Hungary, an analysis of the European search query data set points to the global significance of search engine poisoning. Our research illustrates that search engine poisoning is a constant threat, as illegitimate affiliate networks continue to flourish while uncoordinated interventions by authorities and individual stakeholders remain insufficient. Ultimately, without a dedicated and comprehensive effort on the part of search engine providers for effectively monitoring and moderating SERPs, they may never be entirely free of compromised links leading to illegal online pharmacy networks.