Canadian ePharmacies and the American Public: Mutualistic, Parasitic or Commensal Symbiosis?

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Things are heating up on the cross-border prescription front.  Hardly a day goes by without hearing from the opponents and proponents of those Canadian online pharmacies that sell prescription drugs to American consumers at lower prices than their United States (US) pharmacy counterparts.  Unfortunately, its hard to get past the rhetoric when investigating this issue.  The very vehicle that has fueled the latest explosion of prescription business is now bloated with information (and misinformation) on this topic.  Conduct a Google search using the keywords "online pharmacy" and you'll get no less than 4.5 million hits.  That's about one hit for every $100 US in Canadian pharmaceutical sales to American consumers in 2002.  Or one hit for every 15 Americans who live without health insurance to support prescription drug costs.  Staggering numbers that reflect the true magnitude of health care system issues to the south.

In this issue, I join four PharmD students from the University of British Columbia as we attempt to capture some of the arguments for and against Canadian online pharmacies. (1)  During our investigation of this topic, it became apparent that things just aren't as simple as they first appeared.  Opinions differ widely about the legality of this practice, an issue partially obscured by the presence of unscrupulous unlicensed pharmacies capitalizing on the public demand for less expensive drugs.  Claims of Canadian drug shortages resulting from the redirection of drugs to American customers have been made, although direct evidence appears to be lacking.   Fears have been voiced about the safety of drugs entering the United States from Canada, including claims of unapproved products, medications that are not stored properly and medicines that may be dispensed in the wrong amounts or without proper labeling.  While certainly valid concerns, these potential problems are not exclusive to the cross-border prescription business.  Concern has also been expressed about the impact of online pharmacies catering to US citizens in an era of Canadian pharmacist shortages, although lucrative business opportunities such as these can have positive spin off benefits to the profession.  And the list goes on. 

Underlying the debate on this topic is the significant loss of profits to the pharmaceutical industry resulting from increased product sales at lower Canadian prices.  While Canada comprises only 2.6% of world pharmaceutical sales, the US has a voracious appetite for medications and accounts for 53.4% of the global market. (2)  A 20-fold difference in sales for a 9-fold difference in population.  Theoretically, the industry should be supportive of any activity that increases the likelihood that a prescription will actually be filled and their product will be purchased.  After all, more prescriptions translates into more profit.  However, when those are US prescriptions that will be filled at lower Canadian prices, profits will suffer and that's contrary to the primary objective of these huge corporations and the shareholders they represent. There is one aspect of this issue for which there is absolutely no debate.  It's all about money. 

Symbiosis is an intimate association between two entities.  When both partners benefit, we have mutualism.  When there is a negative effect on one, we have a parasitic symbiosis and if no beneficial or negative effect exists, we have a commensal relationship.  I invite you to read the review  and decide for yourself what type of association this situation represents. 

P. Jewesson, Ph.D. FCSHP
Publishing Editor

J Inform Pharmacother 2004;15:1-2.


  1. Makowsky MJ, Legal GM, Buchkowsky SS, Koshman SL, Jewesson PJ.  Canadian online pharmacies servicing U.S. citizens: patient care or profits? J Informed Pharmacother 2004;15:300-318.
  2. Anon.  Patent Medicines Price Review Board. Annual Report 2002. www.pmprb.com/CMFiles/ar2002e21LEF-6252003-6142.pdf (Accessed December 12, 2003)

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