Illicit online pharmacies—and there are 35,000 of them around the world—are a significant and growing threat, and nearly all are being operated illegally. These pharmacies distribute counterfeit medicines, which pose a significant health risk to consumers. The illegal pharmacies employ sophisticated deceptive practices to mimic legitimate pharmacies, contributing to the widespread availability of unregulated and potentially harmful drugs while undermining public health and safety. As reported by the Office of the United States Trade Representative, more decisive regulatory actions and international cooperation must be demanded to shut down these destructive entities.

The U.S. Trade Representative’s annual report, “2024 Review of Notorious Markets for Counterfeiting and Piracy,” shined a spotlight on these counterfeit pharmacies spanning the globe. The report noted that 96 percent of online pharmacies were found to be violating laws and regulations, with many counterfeit pharmacies offering prescription drugs without requiring valid prescriptions, which, of course, is a clear indicator of illegitimacy. These fake drugs often contain incorrect, substandard, or harmful ingredients, which have led to severe health consequences, including death.

The 58-page report covers examples of counterfeit medications for numerous illnesses, including cancer, which, according to the CDC, saw 1.8 million new cases reported in 2021. These fake cancer drugs coming from illegal pharmacies often lack active ingredients and are ineffective and dangerous. For example, Avastin, a regularly prescribed cancer medication, was found counterfeited in online pharmacies and contained no active ingredients. Because the patients received no active ingredients and thus no therapeutic benefit, their cancer was free to progress unchecked. Without a doubt, this misleading confidence in treatment can delay necessary interventions. Even when the counterfeit drug contains the correct active ingredient, it may be mixed with harmful substances or manufactured in unsanitary conditions, thereby posing a significant health risk to consumers.

Fake ADHD medications are also high on the list of drugs regularly counterfeited. In the U.S., counterfeit Adderall was discovered containing the wrong active ingredients, including harmful substances like methamphetamine. As with cancer and other drugs, incorrect active ingredients in ADHD medications can lead to severe side effects, overdose, or ineffective management of conditions, leading patients to potentially experience dangerous health effects like heart arrhythmias or neurological symptoms.

It gets worse. Counterfeit versions of drugs like OxyContin or Xanax have been found laced with deadly fentanyl, a synthetic opioid that is 50 to 100 times more potent than morphine. Fentanyl-laced drugs have infiltrated countless cities and states in America and have been the cause of thousands of overdoses globally. Even a tiny dose of fentanyl can be lethal, especially for unsuspecting users. These criminal fake opioid pharmacies are primarily operated internationally, with many based in countries that have weaker regulatory environments or lenient enforcement against counterfeit pharmaceuticals.

What countries are involved? It should come as no shock that China and Mexico play a significant role in nefarious online pharmacy practices. China is a major supplier of precursor chemicals used to make fentanyl and other synthetic opioids. Indeed, many counterfeit pills come from Chinese manufacturers, which ship raw materials and finished products globally, with regulatory loopholes making it difficult to enforce international laws. For its part, Mexico is also a significant hub for fake opioids, including fentanyl pills. Drug cartels use precursor chemicals from China to produce and distribute counterfeit pills, especially to the United States. Weak governance in certain regions allows these deadly activities to flourish.

Beyond China and Mexico, the report notes that India is well known for producing counterfeit medications, including opioids, and shipping them globally through online pharmacies, all while enjoying little to no robust regulatory enforcement over its pharmaceutical exports. Likewise, Eastern Europe and Russia are home to many rogue online pharmacies that distribute fake opioids around the globe. Limited cross-border enforcement cooperation and sophisticated methods to evade detection are key challenges to addressing this illegal activity. Many counterfeit opioid pills enter the United States through smuggling routes from Mexico or through international mail. Domestic rogue pharmacies in the U.S. often serve as intermediaries, selling the fake pills online, through the dark web, or social media platforms.

According to the report, these fake opioid pharmacies masquerade as legitimate pharmacies, completely deceiving consumers. They employ obfuscation techniques such as fake identities, offshore hosting, and encrypted transactions to evade detection while ensuring global distribution by shipping pills directly to consumers, bypassing regulatory safeguards. Enforcement efforts face significant challenges, including cross-border complications due to the international nature of these operations, the anonymity provided by the dark web, and the use of sophisticated websites and advertisements that mimic legitimate pharmacies, further hampering efforts to identify and dismantle them.

While fake opioids are certainly one of the more popular drugs to counterfeit, the report highlights the myriad of other drugs being compromised by online pharmacies. Counterfeit antibiotics, such as fake versions of amoxicillin and ciprofloxacin, are also a global concern. These counterfeit drugs often contain incorrect dosages or, like so many others, no active ingredients, leading to treatment failure, prolonged illness, and serious complications. The report states they also contribute significantly to antimicrobial resistance, posing a critical public health crisis by effectively undermining efforts to combat infections.

Moreover, bogus antimalarial drugs, particularly counterfeit versions of artemisinin-based combination therapies (ACTs), are prevalent in Africa and Asia. These fraudulent treatments allow malaria to progress unchecked, resulting in severe complications or death. Additionally, the availability of such counterfeit drugs erodes public trust in legitimate health systems, further complicating malaria control efforts. Likewise, substandard erectile dysfunction drugs, including counterfeit versions of Viagra and Cialis, often contain harmful substances such as talcum powder or toxins. These fake drugs can cause extreme health issues, including heart problems, allergic reactions, or permanent damage to reproductive organs. Their misuse can also lead to dangerous drug interactions, again, putting consumers at significant risk.

And like the United State’s own Big Pharma, counterfeit online pharmacies around the world took advantage of the opportunities to scam humanity during the COVID-19 pandemic. Indeed, counterfeit treatments and vaccines, including fake versions of remdesivir and hydroxychloroquine, proliferated online. Like the others, these fraudulent products robbed patients of effective treatment and exposed them to harmful substances. Moreover, the widespread distribution of fake COVID-19 vaccines undermined public confidence in government-run vaccination efforts (that lack of confidence has been exposed to be fully warranted), further complicating its agenda-driven pandemic response. Besides imitation drugs used during COVID-19, counterfeit vaccines, including fake meningitis or flu vaccines, are often sold in low-income countries. Providing no immunity, the report states these fraudulent products leave populations vulnerable to preventable outbreaks and undermine global vaccination efforts.

And, of course, as our nation battles obesity, counterfeit weight-loss medications are another significant concern, as they often contain banned substances like sibutramine or undeclared stimulants. Fake diet pills can lead to severe health effects, such as heart attacks, strokes, or psychiatric issues like anxiety and psychosis, posing significant risks to unsuspecting users. The report adds that tampered hormonal medications, including counterfeit birth control pills, have been found to contain incorrect hormone levels or no active hormones at all, increasing the risk of unintended pregnancies. They also cause hormonal imbalances, leading to adverse health effects for users.

Even over-the-counter drugs are not secure. Fake pain relievers, such as counterfeit acetaminophen or ibuprofen, often include substandard or harmful fillers. These counterfeit drugs can cause organ damage, such as liver or kidney failure, and fail to provide adequate pain relief, prolonging suffering and reducing the quality of life for affected individuals. Misbranded diabetes medications, including counterfeit insulin, often contain diluted or incorrect formulations. These substandard products can lead to poorly controlled blood sugar, resulting in serious complications such as ketoacidosis, coma, or even death.

The overall global impact of counterfeit drugs is profound. Lacking proper oversight, these illegal drugs delay effective treatment, worsen health outcomes, and expose patients to severe side effects, including toxicity, organ failure, and death. On a broader scale, they exploit gaps in international regulations by avoiding legal safeguards, thus enabling the proliferation of unverified drugs across countless borders. While also facilitating organized crime, financial fraud, and cybersecurity risks, counterfeit drugs from illegal pharmacies erode public trust in an already doubtful healthcare system, encourage drug resistance, and exacerbate global public health challenges.