Brand Name vs. Generics — Again and Again

Okay, let me get this straight.

A study, done by people who at least in part are employees of the CVS pharmacy chain, has established to a wildly impressive level of significance that prescriptions for (cheaper) generic drugs are more likely to get filled than prescriptions labeled “brand name only.”

Brand-name only prescriptions are 50 to 60% less likely to get filled.  This is the summary of the article on CVS website.

Of course there is a little more info in the first article linked above — like specialists being more likely to write “dispense as written,” and such.

The fact of the matter is that once again, we are all upset by the high cost of health care in these United States, and see the prescription of cheap generics as a way to bring it down for the consumer.  As far as I can check, all states seem to have laws and regulations to encourage more generic prescriptions.

No troubles so far.

My first question; who is making money from the prescription of generic drugs?  Could it be chain pharmacies like CVS?

Our friends at CBS Money Watch nailed this one.  Although generic drugs are less expensive to the consumer, they do not have a lower price margin for the pharmacy.  They seem to have a larger one.

Here is a quote in the CBS article from the CVS annual report is correct.  If you want to read it, the link will open a PDF file of the annual report. (You must have the free Adobe Acrobat Reader installed to access this)

CVS makes more money when generic drugs are prescribed.

They do not seem to be alone in this.

The state of West Virginia seems to be challenging this practice.  I am neither lawyer nor politician and can only cheer them on.

The other important thing I can do is to answer the question that everyone ought to be asking.

What the hell is the difference between brand names and generics anyway, and why might a specialist prefer to prescribe a brand name under some circumstances?

This is knowledge I use everyday — something that I learned early in my (American) training, that has not changed.

A brand name drug is the same drug as a generic, and a generic pill has the same amount of drug as the brand.

They differ in “excipient,” which is the non-biologically active portion of the drug.  Most contain some kind of milk solids or chalk and/or coloring or a capsule made of algae or gelatin or whatever.

These constituents affect what is called the “bioavailability” of the drug.  That means, the ability of the amount of drug taken to be absorbed by the body and thus ultimately, to do what it is supposed to do.  According to federal law, this means that the bioavailability can be 20% more to 20% less than the brand name drug of reference.

Now since I would NEVER ask you to do anything too difficult, let me do the arithmetic for you:

The patent on the Brand-Name drug Razzmataz (I just made that up) has expired and now many companies rush to cash in by making generics available.

Company A makes a generic equivalent but it has a bioavailability that is 20% more that good ole Razzmataz.  So a 100mg tablet of generic is as effective as 120mg of Name Brand.

You take this generic for a few months, and then the pharmacy gets a low-bid from Company B who makes a generic equivalent of good ole Razzmataz.  But this new generic has a bioavailability that is 20% less than Name Brand.  That means your 100mg tablet of generic is as effective as 80mg of Name Brand.

OK – if you stuck with me this far – you can see that you have gone from 20% more to 20% less – a total of 40% difference.

If you are now only getting 60% of the bioavailability (the effect) of what you were taking before, you might start showing symptoms that you thought were treated.  Your depression or anxiety or obsessiveness or – whatever! It’s come back!  You don’t know what happened.

And believe me, the major pharmacies (and minor ones too!) are all doing you a favor by saving you money – taking bids on who can sell these generics to them cheapest.

Low bids rule the world (at least the world involved in saving you money – and thus keeping “competitive”).

Astronaut Gus Grissom, who died (along with fellow astronauts Ed White and Roger Chaffee when Apollo 1 burned up on the launch pad in 1967) was once asked in a radio interview:

How does it feel to be up there in space?

And he replied:

“How would you feel if your life depended on a million different parts, each one of which was provided by the lowest bidder on a government contract?”

For some people – the variation in medicine strength can be life-threatening too.

This does not mean there is anything wrong or horrible about generics.  It does mean you need — and deserve– to know what is going on with your prescription.

Drugs can differ widely in their “therapeutic index.”  There is generally a lower limit below which there is not enough drug around to do very much good.  There is an upper limit above which the drug becomes toxic.  In general the drugs with a lower therapeutic index are the ones for which a “blood level” is required to insure safety — things like lithium and valproic acid.

For a drug with a wide therapeutic index, a generic may be the world’s greatest deal — if it works for you.

But add to this picture the fact that many chain pharmacies renegotiate their genetic providers as often as monthly, and we can have that 40% change in effective drug potency every time you refill your prescription — which can be a recipe for disaster.

Just with the two drugs mentioned here; lithium and valproate, I have seen wild mood swings and (albeit rarely) a couple of hospitalizations with changes in generics.

As with any loophole, corporations are standing by to make money.  The frequency and consistency with which companies make money off human system is a cause for shame to our country and the human race.  I am really starting to believe that animals of the same species do more to help each other than we do.

Just yesterday I wrote a brand-name only prescription for valproic acid (Depakote) for a manic-depressive patient who had been sensitive enough to ride a mood-exploding roller-coaster with different generics.

I always advise patients to note and check if their pharmacist comes up with a pill different in color and/or shape from what they are used to taking.  This generally means the pharmacy has changed the generic provider and may be enough indication for a drug blood level to be repeated.

Of course in our “Cost savings are more important than life-saving” medical milieu, you may not be allowed to get a blood test because your insurance or the state/federal program won’t pay for it.  But that is a different problem and the topic for another one of my rants.

However, I am heartened by the small voices, like that of West Virginia, perhaps not the most affluent of states, but some people trying to speak truth in the face of the corporate greed that is a corruption of free enterprise past the boundaries of ethics.  I believe that the openness of information fostered by the internet fans such flames.

My ambition is to be not a still, small voice, but a loud and angry one.

I write truth – and I do it for you.