The History of Buying Viagra Online: In Pfizer We Don’t Trust

For 20 years, from the late 1990s until it lost patent protection in the U.S. in 2017, Viagra (sildenafil citrate) was an extraordinary cash cow for drug company Pfizer. It has generated about $34 billion worldwide. Viagra’s beginnings also marked the beginning of the Internet’s rise as the primary tool of global communication and commerce. Since brand name drug prices are much higher in the U.S., including for Viagra, Pfizer recognized early on the commercial threat it faced from the Internet because it empowered consumers in the U.S. to communicate with and order Viagra from Canadian pharmacies and later from pharmacies in other countries with lower prices - including generic versions in India. 

Those international and imported Viagra sales were on top of a growing international pharmacy retail trade in many patented drugs at the time, mostly ones prescribed for health maintenance, such as Fosamax, Lipitor, Norvasc, and Zoloft. Pfizer -- and consumers -- also faced threats of criminal counterfeiters peddling fake -- and in some cases dangerous -- counterfeit Viagra via rogue online pharmacies.

Pfizer had a big problem on its hands: The federal law prohibiting personal medicine importation under most circumstances was not stopping international Viagra sales due to the FDA’s policy of enforcement discretion to either permit personal imports or not take action against patients availing themselves of lower foreign drug prices. To protect its profits in the U.S., Pfizer wanted to scare people away from buying cheaper Viagra online from other countries. One way to accomplish this was to conflate real Viagra sales and savings from licensed pharmacies in Canada with counterfeit drugs sold by rogue online pharmacies. And on that note...

If you're not interested in the history of online Viagra sales and simply want to affordably fill a prescription, you can check out The Cheapest Place to Find Viagra Online. Quick takeaway for my fellow Americans reading this: Canada is not the way to go for sildenafil savings. For those of you guys “in the know,” you might be thinking Indian online pharmacies are cheapest. Not necessarily. In some cases, you could find a lower price from a safe Indian pharmacy but only on the margins. PharmacyChecker sildenafil price comparisons will probably lead you into your local pharmacy with a discount coupon, in part because there’s no shipping fee! For the punchline: 

• 100 pills of 100mg brand name Viagra in the U.S. could cost you over $9,000 at the average retail price. 

Want to save $8,950? 

• 100 pills of 100mg generic Viagra in the U.S., in conjunction with a U.S. pharmacy discount coupon, could cost you only $50. 

The $34 billion accident

In the mid-1990s, Pfizer was not exactly trying to create a drug to treat impotence. Rather, they were testing the active pharmaceutical ingredient called sildenafil citrate as a treatment for pulmonary arterial hypertension (PAH). Participants in clinical trials began reporting a sexy side effect: erections. That accident has improved the sex lives of potentially billions of people worldwide spanning over two decades - and grossed Pfizer $34 billion in global sales.*

The Human and Economic Gravitational Pull of the Internet 

The cost of Viagra combined with the human desire to save money and avoid embarrassment - even when people should not feel that way - drove people to look for Viagra on the Internet. To meet that demand was a cornucopia of websites ranging from traditional pharmacies that required valid prescriptions, to remote consultation or “online prescribing” websites, to rogue websites that sold counterfeit Viagra -- and a lot in between. As stated, Viagra sales online also led Americans to find that Viagra was much cheaper in Canada and even cheaper farther abroad. Now that the generic version is available in the U.S., the Viagra consumer paradigm has turned on its head. 

When Viagra launched in 1998, the Internet was still in a toddler phase: the two would quickly and aggressively grow together. Upon its launch, Viagra was instantly sold over the Internet, accompanied by safety concerns, mostly pertaining to nonexistent or shady prescription requirements among drug-selling websites. The conclusion of an academic paper published in 1999 captures the traditionalist position of the medical establishment at the time. The conflict was not so much about mail-order Viagra, since mail-order pharmacies predated the Internet. It had more to do with the importance of medical oversight via legitimate prescriptions for patients seeking Viagra online. The authors stated: 

A clear distinction exists between online prescriptions and pharmacies. While it may be acceptable for sildenafil to be sold over the Internet given current technologies, it must be done within the confines of a traditional doctor-patient relationship. Online prescriptions must be limited to patients who live in states in which the prescribing physician is licensed. Failure to establish a doctor-patient relationship in this context breaches ethical standards, and may give rise to potential civil and criminal liabilities.”

The Many Types of Online Viagra Sales

When our company, PharmacyChecker, began surveying the spectrum and safety of online drug sales in 2002, we classified online pharmacies into three main categories having to do with prescription requirements. There were traditional online pharmacy sales offered by U.S. and Canadian pharmacies that required valid, original prescriptions based on face-to-face consultations with licensed prescribers. A category of online pharmacies we referred to as remote consultation sites offered a process in which an interested consumer would answer medical questions that were used by medical doctors to write or decline to write a prescription. Finally, there were no prescription sites -- often referred to as “rogue online pharmacies.”

The medical establishment was not concerned with online pharmacies with traditional prescription requirements, as noted above. For legitimate Canadian online pharmacies that fell into that category, the laws restricting drug importation were a separate issue, one discussed below. Clearly ‘no prescription’ sites were viewed as dangerous. 

The remote consultation or “online prescribing’ sites posed the biggest dilemma. For a long time, the medical and pharmacy establishments frowned upon remote medical consultations as a basis for prescribing medications. The conventional wisdom was that a face-to-face doctor-patient examination was necessary as the basis for a legitimate prescription. When the practice of online prescribing started, there were no laws that effectively banned it, as relevant federal and state statutes predated popular use of the Internet. The question at hand was whether or not an online consultation, especially one where a patient merely filled out a questionnaire reviewed by a doctor, formed the basis for a valid doctor-patient relationship. 

Initially, there was hostility from the American Medical Association. In 1999, an AMA meeting directly addressed the issue, including online Viagra websites. Its report stated:

Typically, a Web site will advertise the advantages of obtaining Viagra via the Internet, require the purchaser to acknowledge a liability waiver, select a quantity of Viagra to be purchased and ask the purchaser to fill out a short questionnaire...Clearly, there essentially is no medical assessment at all, and there is no follow-up to determine whether the medication has been effective or if there are side effects.”

Pfizer probably viewed U.S. online pharmacies that offered online prescribing as commercially advantageous: more Viagra sales at the world’s highest prices. In contrast, doctors had a commercial reason to oppose them: fewer visits to the doctor meant less income. Pfizer’s greater concern, shared by U.S. pharmacies, was that online sales would lead to more importation from Canada and other countries with lower prices. 

Regardless of the myriad interests opposed to it, online prescribing sites proliferated in the early part of the century and they were geared toward so-called “lifestyle” drugs, such as products that treat ED, hair loss, sexually transmitted disease, etc. 

For much of the early 2000s, online prescribing sites were often looked at with derision but generally permitted by regulators to operate, except those selling controlled prescription drugs, such as OxyCodone, Percocet, Vicodin, and other opioid-based prescription drugs; or benzodiazepines, such as Valium and Ativan. With the passage of the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, online prescribing sites offering such services for controlled drugs were expressly banned, with the exception of sites granted special licenses by the U.S. Drug Enforcement Agency. 

As late as 2015, the AMA remained on the fence over what constitutes a valid doctor-patient relationship. Sticking points included whether an initial face-to-face consultation was required; disclosure requirements among providers who have a commercial interest in the outcome of the decision to write a prescription or not; patient privacy; and determining which drugs are suitable for remote consultations vs. those that are not.

Often, when serious money and venture capitalists hop on the bandwagon, even in a highly regulated, health-related area, especially if they can get entrenched big business interests behind them, like Big Pharma, the regulations will magically conform to meet the needs of the new business. Alas, this has happened for remote consultation online pharmacies, with Viagra online prescribing sites a ubiquitous presence. Leading online pharmacy and health certification company, LegitScript, designates many such sites as legitimate. Some household names include Lemonaid, Roman, and Hims. 

Email Spam Marketing of Viagra 

Over two decades ago, sophisticated and large-scale email spam marketing campaigns were created for the purpose of selling Viagra, real and counterfeit, over the Internet to men without a prescription. Depending on how old you are, you might know what I’m talking about. Email inboxes inundated with a call to “get Viagra now,” “no prescription required,” “lowest prices,” etc. Those emails linked people to online pharmacies, often dangerous ones, on which purchases created real risks for patients. People with certain conditions, especially those with heart conditions and taking nitrates, should not take Viagra. For them, following up on an email solicitation to get Viagra without a prescription is dangerous. Even people not at any risk from taking Viagra face the risk of receiving counterfeit Viagra or substandard sildenafil citrate from rogue online pharmacies filling orders generated by spam email. 

These spam-generated sales proliferated when sildenafil citrate was approved for sale in India. In many cases, this was not counterfeit Viagra, but real, lawfully manufactured Indian generic medication. This did not remove the threats to patients. Yes, many got what they had ordered and wanted, but in buying prescription drugs online where a prescription is not required - even Viagra - people face a much greater likelihood of getting a fake or otherwise bad medication, not to mention entrusting their financial information with rogue actors. 

Viagra email spam is still around but much less prevalent due to stronger spam filter technology; greater consumer awareness to avoid such emails; and market forces -- the availability of low-cost generic Viagra from sites that don’t require you to have an original prescription. 

For an interesting history of the Viagra email spam, see: Ever Wondered Who’s Behind Those Viagra Emails? The dark and deadly world of pharma spam

Big Pharmacy/PBM Online Pharmacies

Big pharmacy retailers and pharmacy benefit manager mail-order pharmacies of course also sell Viagra online. That includes U.S. pharmacy chains such as CVS and Walgreens; retailers like Walmart, Target, and Costco; and online pharmacies of large pharmacy benefit managers including CVS Health, Cigna, and Optum. 

There are very few U.S. online pharmacies that fall into the traditional prescription requirement camp that also do not have a brick-and-mortar presence. The pioneer of such online pharmacies was Drugstore.com. It was launched in 1998, was acquired in 2011 by Walgreens, and four years later was closed down by Walgreens. Today, the most notable such U.S. online pharmacy is Healthwarehouse.com.

Canadian pharmacies and other international online pharmacy personal importation options

Like most brand-name prescription drugs, brand Viagra is insanely less expensive in other countries than in the United States. You can compare Viagra prices online to see for yourself. You'll find that the lowest Viagra per pill costs among online pharmacies accredited by PharmacyChecker or through local U.S. pharmacies using a discount card are about $75 in the U.S.; $25 in Canada $20; and as low as $7 in other countries.

Despite federal laws prohibiting imports of prescription drugs, tens of millions of Americans have availed themselves of these lower-cost options. They do so because patients are never arrested, let alone prosecuted, for filling prescription orders internationally. Federal law actually instructs the FDA that it should permit personal drug imports that are not an unreasonable risk to patients. 

It’s probably impossible to make a case that imported Viagra from Canada, or pharmacies in other countries, poses an unreasonable risk to people in the U.S., but Pfizer has done a lot, in my opinion, to make it seem that way. Unlike telemedicine in the U.S. for the purpose of getting more prescriptions into the hands of Americans to purchase drugs at the world’s highest prices, Big Pharma does not want Americans to access Canadian pharmacies or pharmacies in other countries for lower prices. 

The Empire (“Pfizer”) Strikes Back 

At the beginning of this century and leading up to the present, to deter online Viagra sales that undermine Pfizer’s business model, the company has funded many “public education” campaigns, often operated by “non-profit” organizations that were essentially created by drug companies, used private investigators, and lobbied and contributed money to politicians. Its campaigns were not all bad, but only to the extent that they fought against dangerous counterfeit drug peddlers and rogue online pharmacies. Sadly, Pfizer’s efforts developed into what I believe was and remains a propagandist campaign that has simply scared and continues to scare patients away from not just Viagra, but essential medicines sold online internationally that help Americans and patients worldwide afford treatments that are out of reach domestically.

The key to Pfizer’s efforts was making sure to disseminate information to the public that showed online purchases of lower-cost or generic versions of Viagra from abroad were dangerous. As part of that work, Pfizer funded research exploring the dangers of counterfeit drugs sold online. But, according to Gary Warner, director of research in computer forensics at the University of Alabama at Birmingham (UAB) such research was conditioned upon an agreement that the results would only be made public if the Viagra orders turned out to be bad:

Pfizer said they wanted to work with us on this project as long as they had the right to shut the thing down if it turned out the drugs were real...I told them that we’re big on academic freedom and that we wouldn’t be able to live with that condition...I told him that we’d want to be able to say, for example, ‘Okay, so in 25 percent of pharmacy orders we got, we got the real thing.’ They said, ‘No, no, you can’t do that. We only want you to publish about the fake pills.’”

Among its efforts to shape the public message about online Viagra and prescription drug sales overall, Pfizer funded a program of the National Association of Boards of Pharmacy (NABP) called the Internet Drug Outlet Identification Program, which places certain online pharmacies on a Not Recommended List. Sure enough, that list of about 13,000 contains many really bad, no prescription requirement, untrustworthy rogue sites -- even some that sell addictive prescription drugs without requiring a prescription. But it also includes licensed Canadian pharmacies, not to mention most, if not all, PharmacyChecker-accredited international online pharmacies. Taking it a step further, NABP has placed this very website -- PharmacyChecker.com -- on that list. We have sued them. That’s right: Big Pharma doesn’t like us either. 

Pfizer, along with other drug companies (Eli Lilly, Merck, and others), funded the NABP’s campaign to operate .Pharmacy (think dot com, dot org, but in this case dot pharmacy). How might this help Pfizer? In its operation of this program, the NABP excludes any online pharmacy, for example, that sells Viagra internationally to a customer in the United States from obtaining the .Pharmacy registration. The NABP along with other groups funded by drug companies, such as the Alliance for Safe Online Pharmacies, then “educates” the public that websites with .Pharmacy at the end (such as www.walgreens.pharmacy, www.cvs.pharmacy, etc.) are trustworthy and safe, whereas those that are not eligible for .Pharmacy, including any safe international online pharmacy that sells prescription drugs to patients in the U.S., should not be trusted. You can see those drug-company-funded efforts in action here. 

In 2013, Pfizer actually hopped on the “if you can’t beat them, join them” bandwagon by deciding to sell Viagra online itself. Can a drug company do that? Drug companies are not pharmacies. The answer is yes because they can team up with a pharmacy -- and in this case, Pfizer teamed up with CVS. The public relations conducted as part of Pfizer’s decision to sell Viagra online aligned with the same objectives for funding the NABP’s programs mentioned above: Present it to the public as two choices: 

1) Buy expensive brand name Viagra in the U.S.; or 

2) Die from counterfeit drugs sold on the online black market.

Sure enough, the headline in the New York Times was: “Facing Black Market, Pfizer Is Looking Online to Sell Viagra.” That article reports that Pfizer may be losing hundreds of millions of dollars “to a prolific black market of online pharmacies that cater to men too embarrassed to buy the drug through traditional means.” The article briefly explains that people also buy real Viagra online from licensed pharmacies in Canada and other countries that require legitimate prescriptions. It included an interview with Roger Bate, whose research has demonstrated the safety of properly credentialed international online pharmacies -- including those accredited by PharmacyChecker. However, Pfizer’s PR people were probably pleased with the article, which quotes its personnel in glowing terms as saving the world from counterfeit drugs. 

The website’s main claim was that you can buy “real” Viagra. Apparently, it didn’t work out so well since the Pfizer online pharmacy page is gone. See this link to see what that page looked like. 

Indian Generic Viagra: Very Real and Very Cheap

In terms of men looking for affordable Viagra, the emergence of a generic version sold online was a saving grace. Due to its different patent laws, lawful and genuine generic Viagra was manufactured and sold in India as early as 2001. Soon thereafter, it was sold over the Internet and internationally. When brand name Viagra was selling for as little as $15/pill in the U.S., generic sildenafil citrate was going for not much more than $1/pill. Pfizer wanted Americans and people in other high-income countries to view these generic versions as fake, counterfeit, or bad by definition. But they were and are not. 

In terms of public health, there’s a big difference in selling counterfeit Viagra vs. real, regulated sildenafil citrate, such as the generic versions approved for sale in India. Today, many, if not most, of the FDA -approved generic Viagra that you can buy at your local CVS, Walgreens, or Walmart are manufactured by Indian drug companies.

The Evergrowing Price of Viagra Over the Years

The price of Viagra in the U.S. has gone up over 1000% since its launch, compared to overall inflation of only 65% during that same time period. The launch price of Viagra in 1998 was about $7/pill: $700 for 100 mg pills. By 2009, it had more than doubled to $1457.61 for 100 pills, which is about $14.50/pill. Today, the prices at big chain pharmacies and retailers for 100 pills range from about $8,200 to almost $10,500. With a coupon available at GoodRx, people can pay about $6,700. 

Did Pfizer really worry about people getting Viagra without a prescription online?

I don’t think so. Pfizer may have funded public information campaigns to deter men from getting Viagra over the Internet without a prescription. Those campaigns often expressed the dangers of doing so based on the fact that a prescription is needed. Yet, Pfizer has tried to sell Viagra over-the-counter, arguing that a prescription is not needed. In 2017, Pfizer applied to the European Medicines Agency to sell Viagra without a prescription only to withdraw its application after the EMA expressed concerns. In 2017, however, the UK approved the sale of Viagra 50mg without a prescription. 

Pfizer wanted to sell VIagra OTC in the U.S., too, with the company’s excuse being that men are already getting it without a prescription online. 

Anyway, today you can get it online legally and, in my opinion, safely through legitimate telemedicine - without having a face-to-face medical consultation. Moreover, who needs Canada or India, not to mention black market criminal enterprises, when FDA-approved generic Viagra is less than $1/pill at your local U.S. pharmacy? 

*I came to the number $34 billion, by consulting Statistica for 2003-2019. For the other years, I looked at Pfizer’s annual reports, except two years, 2020 and 1998, on which I relied on other sources, per the information below.

2020: est. $0.4 billion: https://www.globaldata.com/viagra-fights-off-strong-resistance-display-q3-growth-says-globaldata/. 

2002: 1.7 billion: http://people.stern.nyu.edu/jbilders/Pdf/pfizer2002ar.pdf 

2001: 1.5 billion: http://people.stern.nyu.edu/jbilders/Pdf/pfizer2001ar.pdf 

2000: 1.3 billion: http://pages.stern.nyu.edu/~jbilders/Pdf/pfizer00ar.pdf 

1999: 1.0 billion: https://sec.report/Document/0000930413-00-000548/

1998: .75 billion: https://www.sellingpower.com/2010/02/02/5023/pfantastic-pfizer