Despite concerted efforts by various drug regulatory agencies to monitor drug distribution, the prevalence of fake and substandard drugs in the nation’s open drug markets has continued to threaten the nation’s health system and present challenges to public health.

The recent increase in the price of drugs has led to increased patronage of fake and substandard drugs in the country as people hunt for affordable drugs to ease their medical issues and these actions could have immediate and future health consequences.

Statistics by the Pharmaceutical Society of Nigeria (PSN) show that there are over two million unregistered pharmaceutical premises and 35 open drug markets, making Nigeria a fertile ground for fake and substandard drug products. About two billion people around the world lack access to necessary medicines, vaccines and other health products, which creates a vacuum that is too often filled by substandard and falsified products.

World Health Organisation (WHO) said the problem is growing as global supply chains become more complex, meaning products manufactured in one country may be packaged in a second country and distributed across borders to be marketed or sold to consumers in a third, leading to an increase in disease prevalence, exacerbate antimicrobial resistance with adverse health effects and waste resources resulting in economic loss and increase out-of-pocket spending on medical treatment.

A recent tweet on X (formally known as Twitter) by a digital health entrepreneur, Slava Sazhin with the username @slavasazhin83 attracted a lot of controversies on the issue surrounding inadequate regulation of prescription drugs in open drug markets in the country.

The post, which now has over 1.9 million views reads, “I went to the Idumota market in Lagos, where drugs are sold. I bought Xarelto 10 mg from Bayer from Turkey without a Nigerian registration mark for $10 and Viagra 50 mg from Pfizer from France with a Nigerian registration mark for also $10…both without prescriptions and not expired. Viagra costs five times more in Russia, while the price of Xarelto is the same. I sent them to Russia through friends for laboratory verification to check if they’re genuine.”

However, the National Agency for Food and Drug Administration and Control (NAFDAC) revealed that registered distributors of Xarelto did not distribute the drug to Idumota market and therefore, NAFDAC concluded that it’s most likely a parallel importation.

Reacting to the health risk of the unregulated sale of prescription medications, NAFDAC Director, Drug Registration and Regulatory Affairs, Mrs Uche Sonny-Afoekelu, said these products are usually stored under temperatures that do not comply with the required specifications, thus affecting product stability, reduction in efficacy, and increase in degradation products.

She said steps are being taken by the agency to address the issue, adding that the agency’s Enforcement Directorates consistently raid markets, undertake seizures, arrest, and prosecute those involved and trace such marketers to the importation sources. “Also, we undertake vigilance at the port of entries – port, land, and air – so that parallel/unapproved importation is seized at the points of entry,” she said.

Experts said the level of sophistication associated with fake drugs has made it impossible to identify so many of them. They warned against the unrestricted use of Xarelto, without a doctor’s prescription.

The Managing Director, Merit Healthcare Limited, Dr Lolu Ojo told The Guardian that it is not safe to buy these drugs without a confirmed medical need or prescription. Ojo, who is also a former Chairman, Association of Industrial Pharmacists of Nigeria said, Xalreto is an anticoagulant, that is used to prevent blood clotting.

“This is an indication beyond the level of having a headache or pain. There is a risk of blood clots if you take the medicine too soon and bleeding is one of the common side effects. This is a drug that must be handled by a qualified and registered pharmacist. Viagra on the other hand, is used to treat erectile dysfunction, but people have turned it to ‘sports’. It is now used for manpower with attendant consequences on the cardiovascular system,” he said.

The pharmacist, who is also a fellow of the Pharmaceutical Society of Nigeria (PSN) emphasised that the level of sophistication associated with fake drugs now has made it nearly impossible to distinguish one from the other. Reacting to the X (formerly Twitter) post he said, “The man purchased his drug from a source that cannot be verified. Therefore, we are not sure if the drug is genuine or not. It may be wrong to conclude that one is cheaper than the other.”

He continued, “There are so many registered pharmaceutical premises where you can get genuine drugs in Lagos. There are over 2, 000 of these premises in Lagos alone. Getting a fair price is relative, especially at this time of swinging forex rate.”

Ojo advised Nigerians to source their medicines from registered pharmaceutical premises and to consult with pharmacists in charge.

The Managing Director, Engraced Pharmacy, Jonah Okotie, pointed out that poor structure; organisation, accountability and irresponsibility contribute to the current situation in the country. “In a civilised or standard environment, what happens is before people have access to some of these medications, they would have gone to the hospital, gotten a prescription, which is taken to the pharmacy. There will also be the necessary counseling that should follow the dispensing or the collection of those prescriptions,” he said.

According to him, “The way things are in Nigeria, everything is commercialised. There are multiplicities of issues that if we begin to look at them, we wonder where we are going to start from but then, it is a matter of will. So, if NAFDAC can take that step to say, we are not going to turn a blind eye and do something about it, I believe there is hope.

“It is a matter of the concerned parties doing the needful. Whether NAFDAC, Pharmacist Council, Medical and Dental Council of Nigeria(MDCN), the Pharmacist Society of Nigeria, and Association of Community Pharmacists of Nigeria, as well as the civil society groups, and even, the media, every one of us is involved, because when anything happens to anybody who takes some of these medications; they are members of our family one way or the other, then we all will be affected,” Okotie said.

Reacting to the post, he said, “If it is happening with Xarelto, it can happen with narcotic drugs, it can happen with any other kind of drug because it is an open market where people go to buy vegetables or buy tomatoes and go home. It is also about the storage condition. Some medicines are sensitive and need to be stored properly. It is an international embarrassment for us. They will be laughing at us. So, it is an insult to our collective sensibilities as a people. It is as if we don’t have regulators or a system in place, which is also a wake-up call for every one of us, including the professionals themselves.”

He maintained that Xarelto is not a drug that can be given to anybody off the shelf and so should not be dispensed casually. He further warned against the unrestricted use of Xarelto, saying that it is a medication that should only be given after a doctor performs a series of tests to determine if it is suitable for the patient.