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When asked why they turned to underground exchange, lack of affordability and accessibility were frequently mentioned. These comments supported statistics showing that over half of participants in the study engaged in underground exchange activities out of financial necessity. People donated and traded with family, friends, and strangers who could not get supplies themselves, despite most having health insurance.

In other instances, bureaucracy got in the way. Delays in approval, filling a prescription, or shipping prevented some individuals from getting supplies by the time they were medically needed. As a result, some resorted to making trades or accepting donations in order to meet their needs quickly and avoid hospitalization.

"I most likely would have ended up with ketoacidosis but I was lucky enough to get insulin from another person," wrote one survey participant.

Listen to an interview with Litchman about how people with diabetes are foregoing basic needs and taking part in underground trading just to stay healthy.

"People with diabetes resort to underground exchange of diabetes supplies and medications not because they want to, not to turn a quick profit, but because their needs aren't being met," says the study's senior author Sean Oser, M.D., �����г���Ƶ of Colorado, Denver. "Some turn to others to get what they need to feel safe."

Many weren't engaging in underground trading for themselves, but rather had excess items they knew others could use. "I… donate supplies to people who need them because it's not fair for me to have excess while they struggle to survive, or even die, because our healthcare system is broken," wrote another participant. In fact, altruism was a prevailing motivation behind underground exchange. Some reported feeling a strong desire to help others within the diabetes community but at the same time were aware that circumstances are volatile. Someone who is in a position to donate supplies on one day could become a person in need on the next.

A downside to acquiring medications and supplies outside the traditional health care system is lack of safety oversight, the study's authors say. However, fewer than 1% of study participants who made transactions through underground markets reported safety concerns. Those that occurred included receiving faulty equipment and unrefrigerated insulin, although recipients did not experience ill effects.

Still, the authors indicate there is plenty of room for additional error. Poor shipping conditions could spoil medications without the recipient knowing. Another risk could be someone taking the wrong medication if it were inadvertently provided to them. Despite these risks, people continue to use underground exchanges because, at this stage, few alternatives exist, says Litchman.

Participants of the survey were mostly Caucasian women with a college education. Next steps will be to carry out larger studies that sample individuals across the country, including participants with varied income levels and of different ethnicities to provide a more comprehensive picture of underground exchange and its impacts on the public. In any case, Litchman says that the black market for medications doesn't appear to be going away soon.

"Underground trading of medications and supplies isn't ideal,"Litchman says. "But what other real solutions exist so that people can actually get what they need without increasing bureaucratic delays and burden? Our study points to an urgent need to improve access to medications that are essential for life."

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In addition to Litchman, co-authors are Sarah E. Wawrzynski, and Heather R. Walker from U of U �����г���Ƶ and Tamara K. Oser and Sean Oser from �����г���Ƶ of Colorado, Denver.

The research published as "The Underground Exchange of Diabetes Medications and Supplies: Donating, Trading, and Borrowing, Oh My!" and was funded by the U of U �����г���Ƶ College of Nursing and the �����г���Ƶ Equity Resilience and Education Research Equity Team.