Millions of Europeans turn to Google to find medicines, but a study spanning 30 countries raises troubling questions about which online sellers appear in search results and whether national pharmacy regulations are protecting consumers.
Study: Exposure to legitimate and illegal online medicine vendors via search engines in 30 European countries. Image Credit: MAYA LAB / Shutterstock
In a recent study published in the journal npj Digital Medicine, researchers conducted the first pan-European comparison of legitimate and illegal online medicine sellers appearing in Google search results.
The study examined 9,000 organic Google results across 30 European countries to assess associations between national online medicine sales policies, drug classifications, and the visibility of illegal sellers.
The researchers found that while legitimate pharmacies predominated overall, more than one in three retail links directed users to illegal vendors lacking recognized legal authorization, raising concerns about potential access to unsafe medicines.
For controlled substances, the prevalence of illicit sellers exceeded 76%, and illegal vendors were generally more visible among highly ranked results in countries prohibiting online medicine sales. The results could inform future public health policies aimed at reducing exposure to illegal medicine vendors.
Background
Advances in internet access and digital health services have enabled the rapid expansion of telemedicine and mail-order pharmacy services, providing consumers with convenient remote access to medications.
To address risks associated with online medicine sales, including falsified and substandard products, the European Union (EU) introduced the Falsified Medicines Directive (EU FMD), along with an official common verification logo that links consumers to authorized national registries.
The growth of online medicine sales has also attracted rogue operators dispensing prescription medicines without requiring a valid prescription. Purchasing unverified medicines may pose clinical hazards, including adverse reactions, therapeutic failure, and drug interactions.
Previous research has examined illicit vendors through regulator watchlists and targeted searches, but it has not systematically compared the visibility of unlicensed sellers to ordinary consumers conducting routine internet searches across countries with different online pharmacy regulations.
About the study
The study aimed to address this knowledge gap and inform international digital healthcare policy by simulating everyday consumer search behavior across 30 European countries (the 27 EU member states, plus Norway, Switzerland, and the United Kingdom). The researchers scraped the top 50 organic search results on Google between March 2023 and April 2024 using purchase queries translated into each country's primary language. Sponsored results and personalized searches were excluded.
The study evaluated different degrees of regulatory control by tracking six tracer active pharmaceutical ingredients (APIs), which were divided into three clinical categories: controlled substances (alprazolam and clonazepam), other prescription-only medicines (POMs; amoxicillin and omeprazole), and over-the-counter products (OTCs; paracetamol and ibuprofen). Medicine classifications can vary by dose and country; for example, low-strength omeprazole may be available without a prescription in some markets, while higher-dose ibuprofen may require a prescription in many countries.
The classification of retailers as legitimate or illegal was achieved by checking licensing details, verification logos, official national pharmacy registries, and databases identifying rogue vendors. Statistical analyses examined associations between drug categories, national sales policies, and the number and ranking of illegal-vendor links.
Study findings
Of the 9,000 search results examined, the researchers identified 3,839 links that directed users to retail medicine platforms, representing 42.6% of all results. Of these links, 63.7% led to legitimate pharmacies and 36.3% to illegal vendors.
Among illegal-vendor links, 56.6% were affected by "search engine poisoning", an unethical cyber manipulation technique in which compromised third-party websites redirect visitors to rogue pharmacy domains. Illegal-vendor links were more prevalent for medicines subject to tighter prescribing controls.
While over-the-counter searches yielded few illicit links (1.4% for paracetamol and 5.5% for ibuprofen), rogue vendors accounted for 55.1% of retail links for amoxicillin, 76.2% for alprazolam, and 77.5% for clonazepam. Across controlled substances, links to illegal sellers were more than three times as common as links to legitimate pharmacies.
The analyses also identified an association between national online medicine sales policies and search rankings. Compared with countries that prohibit online sales, countries that permit online sales of both prescription and over-the-counter medicines had approximately 69% fewer illegal-vendor links among the top 10 search results in the adjusted analysis. In these countries, the highest-ranked medicine-selling link was also less likely to lead to an illegal vendor.
In Croatia and Greece, illegal vendors outnumbered legitimate pharmacies among the top 10 results, while no legitimate pharmacy links appeared in Cyprus. The researchers suggested that limited competition from authorized pharmacies may explain this pattern. Sweden and Norway permitted online prescription medicine sales but still had the highest overall proportions of illegal-vendor links. The analysis did not show the same regulatory-policy association across all 50 search results.
Conclusions
Illegal online medicine vendors appeared in Google search results across all 30 countries, particularly when searching for controlled substances such as benzodiazepines. The findings describe potential exposure through search results, rather than actual purchases or verified medicine quality.
The authors suggested that authorized sellers may limit illegal-vendor visibility through competition, but the cross-sectional study could not establish that sales bans caused these differences.
The findings reflect organic Google results for six medicines collected in 2023 and 2024, so they may not represent other search platforms, sponsored listings, or medicines experiencing sudden demand increases. The researchers recommended that health authorities pursue coordinated regional e-pharmacy policies, strengthen consumer verification of authorized online pharmacies, and collaborate directly with search engine providers to demote poisoned domains and reduce exposure to illegal vendors.
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