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Generic Drugs

category_bug_geriatrician.gif [EDITORIAL NOTE: The TGB Geriatrician is a bi-weekly column written by Dr. Bill Thomas (bio) for Time Goes By to give us the information we need to help us navigate the health issues of aging. Dr. Thomas also writes his own blog at Changing Aging.]

I know you are out there. I know that there are still some people who see generic medications as being somehow inferior to brand name drugs. This is a big issue, worth billions of dollars to major corporations, but I do have a funny story to tell you about generics.

A few years back, the anti-anxiety medicine Xanax™ lost its patent protection and became available as a generic called Alprazolam. A patient of mine who was, I'll admit, a very anxious person, called me at home on a Saturday after seeing me in the office on a Friday. "Hey Doc," he said, "this new medicine you put me on doesn't work!"

I asked a few questions and slowly came to understand that when he had refilled his prescription, the pharmacist had supplied him with the just-released, lower-cost generic version of the drug.

I explained this to him and he continued to insist that something was wrong. He'd taken the new pills as prescribed and they "didn't work at all. Nothing." I learned early on in my medical career that it is never a good idea to argue with patients, so I told him I would talk to the pharmacist and then call him back.

I was living in a small town then and was friends with the pharmacist (I'll call him John since that is his name.) John confirmed that he had supplied our patient with the generic version of Xanax. Then came the kicker. "You know Pfizer* makes the brand name (called Xanax) and the generic (called Alprazolam) on the same production line in the same factory." In fact, the only difference was the shape and color of the pill.

I called my patient back and explained all this - that it was the same medicine made in the same place by the same people with the same machines. It just looked different and cost less. He didn't care. He wanted the Xanax that he knew and nothing else. What could I say? I called John back and made the switch.

So what was going on here?

  1. Pill colors and shapes are designed by marketing teams, not doctors. Color and shape are related to sales. That's why Viagra is a blue football and not a pink softball. Drug companies spend billions trying to persuade Americans that color and shape matter. Remember the "purple pill?"
  2. The chemical compound inside brand name drugs and their generic equivalents are exactly the same. It's like the salt in salt shakers, you can pay big money for engraved silver salt shakers or you can save money and buy simple glass salt shakers. But, in the end, the salt inside the shaker is exactly the same - it is sodium chloride.
  3. Drug companies have the right to force generic drug makers to make their pills a different color and shape. They rely upon the confusion sown by this difference to support sales of the brand name drug. As you can see in the case of my Xanax loving patient, it works.

  4. Generics are manufactured according to the same rigorous standards that govern the manufacture of brand name drugs. They are Cadillac drugs for sale at Chevrolet prices.
  5. The big, brand name drug makers have started to make what are called "reverse payments" to generic drug makers. Because of the huge profits that they make on the brand name drugs, they are able to pay generic drug makers to NOT MAKE GENERICS. Keeping competition from an equally good product that can be sold for less is good for the drug makers' profit-and-loss statements and bad for the health and healthcare of Americans.

Clear? Not as clear as you might think. Very soon after this post goes up someone is going to write a comment that reads something like: "Generics don't work on me. My doctor says that I have to have the brand name versions." Here is what I love about blogging at TGB, I get to tell you the story behind the story.

First, your doctor doesn't think that "generics don't work on you." She knows that your body reacts to generics the same way that it reacts to brand name drugs because, inside the body, brand name drugs and generics are the same thing.

Fillers and colorings are often blamed when patients say generics don't work, but generics use the same fillers as the brand names and the amount of food coloring in a pill is incredibly tiny. Problems with fillers and colorings are theoretically possible but the fact is, they are tremendously rare. Brand name drugs and generics are equivalent inside the body.

Second, your doctor has the same policy I do. She has explained that generics are just as good and that the only real difference is the price. You were not convinced and she is not going to waste time arguing with you. End of story.

Third, you should choose generics whenever you can. Why? I think that it is a matter of intergenerational fairness. Every dollar spent on brand name drugs that are no longer under patent and thus have a generic equivalent, is a dollar fewer for childhood immunizations, prenatal care, school health clinics and all the rest.

We all share an obligation to be thrifty with the health care resources we use. We are a rich nation, possibly the richest nation in history, but we are not so rich that we can afford to spend money foolishly on expensive pills simply because we are accustomed to a certain shape and color.

I look forward to reading this comment thread.

* The drug was developed by Upjohn before it merged with Pfizer.

[At The Elder Storytelling Place today, Herchel Newman attempts to exorcise the evil demons of modern life in Utter Frustration. ADDITIONAL NOTE: Today is the last day to vote in the Excellence in Storytelling Award. Polling closes at midnight eastern U.S. time. Links to nominated stories are here.]

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I only need to look at the difference in price between generic Ibuprofen and the branded versions to get a very good reason for choosing generics!

I do recall seeing someone arguing with the pharmacist when given generics - he was concerned however about fake drugs rather than generics.

I wish all my medications could be generic! Our family pays literally hundreds of dollars monthly in drug copays. Unfortunately, only three of the 15 medications I take daily is generic.

I know that the drug companies spend a lot of money developing drugs, and they deserve a profit on their products. But "reverse payments?" That sounds little short of illegal; it's certainly unethical in my book.

I'd like to think nicely of Big Pharma, since their research dollars make up the difference for our government's woefully-underfunded medical research grants. But "reverse payments" is just another reason to lump them in with all the other money-grubbers like Big Oil and Big Insurance.

Dr. Thomas, thank you for putting these words down and talking straight. So many people see drugs as a Pepsi/Coke dilemma, which is obviously ridiculous. As long as the standards are the same, the drugs are the same. A chemical solution is a chemical solution regardless of colour or shape.

Isn't there also the aspect that by supporting generics, the companies that produce these drugs have the possibility of selling these less expensive drugs in developing countries?

This explains something I thought a bit curious about a year ago: one of my prescription meds (a brand name as it were) changed in color. The first time I picked up the new version, the clerk took pains to warn me it was the same, not to worry, just a color change, etc. OK. But I got that warning the next month, and the month after, for several months. I wondered why they were making so big a deal out of what I thought a minor matter, but now I understand.

I confess to being one who goes for the brand name of products. Mostly out of ignorance or unsurity, if that’s a word. I’m lucky enough not to have lots of meds in my life, so have never had a doctor explain the generic thing to me. But I’m beginning to see the light! Thanks for writing about this.

Thank you for posting this!!! I always ask for generics and get miffed when I can't get them on the rare occasion that my doc prescribes something that doesn't come in a generic.

I know people who can ill-afford it who say they can't take generics and I just want to shake them and scream, "Are you nuts? It's the same damn stuff?"

Barnum was right.

Thank you for clearing this up for the non-believers. I always ask for generic.

I think there is something else going on here. If people maintain the generic doesn't work, isn't that proof that the mind comes into play in the healing process? Haven't they proven in tests that the placebos often work as well as the drug when patients don't know the difference? Maybe "it's all in your mind" isn't so crazy after all.

I wish ALL meds were available in generics. I just purchased some Leviquim, which is an antibiotic.
I have no prescription insurance, so I paid $60. for 5 tablets!!

tnwoman: Wow. Levaquin (I assume that you just misspelled it) is a massively effective antibiotic.

It should also be used in cases where the bacteria being addressed is highly resistant to other drugs, as this is broad spectrum. Your doc should make some attempt to figure out if you have a gram pos or gram neg bacterial infection. Or that you have a bacterial infection AT ALL.

There are certainly cases where this drug is appropriate, but I get prescriptions for this all the time for 'colds'. That's why we have antibiotic resistant strains of bacteria. (Or at least one of the big reasons.)

I'm not a doctor, I'm a pharmacist and chuckled out loud at the doctor's story. I'll tell you flat-out that most people should not be treating their chronic conditions with drugs.

That's where you end up with 15 prescription drugs, treating something that will not respond anyway, that causes a side effect that you need yet another drug to 'cure', etc., etc., etc. See it all the time.

Doc, what I see are a lot of elderly patients that are almost proud of the number of meds they are taking. It is as though they are treating it as a badge of honor.

nobody, but nobody should be taking 15 prescription drugs.

I had to beg and insist that my Dr. give my husband Warfarin instead of coumadin which is much higher......He says you cannot "trust" the warfarin to all ways be the same quality!!!!!!!!!!! He finally gave in and we see no problems with his protime being irregular.......

I have heard of one exception. My psychiatrist said that it has been found that clonazepam (that's the generic) works somewhat better/differently as the brand name than the generic. Of course, when I tried to get the brand name, noone had it, and I had to go with the generic, which for me works ok.

I just wish they would deal more with drug interactions and requiring the posting of all reported side effects, even when rare. After being treated for hypertension for years, I found out after regulations required changes in the posting of side effects that not just one but TWO of my other medications could contribute to hypertension! After dropping those drugs, my blood pressure is now far more stable.

I also took Vioxx for some time, which led to a suit over heart attacks, While I did not have a heart attack, and so couldn't benefit from the suit, I suspect it also contributed to the hypertension problems.

I also see doctors prescribing a drug way too often when lifestyle changes or diet changes would be far more effective. Omega 3 supplements, Co-Q10 and eating more salmon have helped my mood and my blood pressure stability considerably, along with other dietary changes. Better to only take what you need, and not just blindly take whatever the doctor suggests. Patients need to learn to research their medications, along with the effects of their diet and lifestyle, and not just blindly accept what they are given. Some of my doctors have been great about listening to my suggestions about what works for me, others not so much. It is extremely frustrating to me when a doctor won't listen. I had to switch doctors when one refused to believe I did not simply have white coat hypertension. Given how dangerous untreated hypertension can be, this was really unacceptable behavior, and I even reported him to my insurance company and wrote a scathing review of him.

So yes, if a patient believes a generic is more effective for them and is willing to pay for it, that's fine. It may not be true, but psychological factors are often important as well, especially with a drug that is used to treat mental health. I talked my shrink into trying lamictal with me for my bipolar disorder when nothing else was working, even though it was not yet approved to treat bipolar but only under study. Since then I've had zero depression or hypomanic episodes, and am extremely stable. He has many other patients who use it now and thanks me constantly for doing the research and talking him into trying it. Sometimes patients do know what they are talking about.

Generic products are great and most of the time they are exactly the same thing. But changing to a generic without warning could easily lead someone to believe they aren't getting the same thing. Better to explain carefully that there is now a generic version available and ask if the patient wants to try it before changing a prescription or simply substituting the generic if a doctor has requested a specific brand. My pharmacies have always asked me first if the generic was available, and it's always been fine. Insurance companies often force this issue and it can lead to problems in dealing with patients. Still, a phone call first could save pharmacists, doctors and patients a lot of confusion.

Thanks so much for this. Sometimes I have had my doubts, but the difference between $100.00 bucks and $5.00 is huge in my budget. I'll take all the generics offered, I would just like to take less of everything.

Dr. Thomas, I respect you greatly (my wife and I recommend your book to many people) and I agree with you in theory about generics. But, as I see it, it's not that simple.

For years I used the same argument when talking to our daughter. She's a "name brand" person -- always has the 'right brand' of jeans; her husband drinks only imported beers. Likewise, they buy the most heavily advertised cars. My daughter insisted on buying Advil, Tylenol and Benadryl, while I insisted that 'store-brand' ibuprofen, acetominophen and diphenhydramine were every bit as good and much less expensive. But then last year, I read an Associated Press article about a recall of 'store-brand' acetominophen, as I recall, from Safeway and Shoprite, among other grocery chains. Several customers had reported finding small chunks of metal in the tablets. Upon investigation, they were able to determine that the tablets had come from one of several non-US sources, and that the raw materials they were made from may have come from Eastern Europe, Indonesia, or China -- they couldn't be traced for sure. The AP article said that such recalls happen numerous times a year, more than once a month.

I figure that the makers of Tylenol and Advil have to stake their reputation on the purity and quality of their products, but generic medications are a drop in the bucket for Safeway and Shoprite. I now buy only name-brand over-the-counter medications. With the FDA overstretched and understaffed, I have no assurance of the quality or efficacy of prescription medications not made in the US. And of course, even if the generic has a US label, that's no guarantee of place of manufacture. If one chooses to go generic, one has to be really SURE about what they're getting and where it's really coming from. (And don't get me started on counterfeits packaged to look like those made by the original developers.) I believe (correct me if I'm wrong) that generics are a big enough business, because of insurance companies and state governments wanting to cut costs, that unscrupulous manufacturers overseas are willing to sell counterfeit generics which are actually non-efficacious and possibly even dangerous. The bottom line -- buy generic if you will, but be aware that you may get bitten.

I wish for generic to be available for all my meds. And I agree, generics are just as good as the original.

(For Ronni)
I don't know what incantation or voodoo I have called upon that is allowing me to comment but I don't look a gift horse in the mouth. :)

Unless one has been told that a different shape/color/size of "pill" is the same as one's previous "pill", one should check the identity of the medication with the pharmacy that filled the prescription. Mistakes do (thankfully, rarely) happen!

You're not going to get an argument from me. Right on sister! Get those generics as SOON as the patent has expired. They are exactly the same! (I work in the pharma industry)

On the whole I agree, generics are a great idea. Three of the prescription drugs I take are generics, and I have absolutely no problems with them - or the generic painkillers which I buy by choice.

However, I was switched to an unknown brand of generic thyroxine about two years ago. I took these new pills without concern. Within a very short time I was having problems with palpitations which were keeping me awake at night and limiting my activities during the day and my heart was racing at odd times too. The doc checked me out and found an arrythmia, and I was sent to a cardiologist who said my heart was just fine, not to worry.

But the symptoms continued, and they were very uncomfortable and draining. Eventually, after much thought I got around to wondering about those thryoxine tabs and asked my doctor if, as an experiment, I could go back onto the named brand I had been using before. She agreed, and within the month, my heart had settled down and I was able to get back to my normal daily life, including exercising three times a week, dog walking twice a day.

I can only assume that somehow this particular generic drug was responsible. Whether they'd been made in a another country without sufficient checks I have no idea. Whether they contained something I can't cope with, I have no idea. I can only tell you that in this case, they caused me huge problems.


No doubt commenting twice in one day counts for some kind of narcissism. But I just found this on TV Guide channel. Airing on the Toon network this morning is Codename: The Kids Next Door: Operation Z.E.R.O.

TV Guide describes the cartoon flm this way: “The kids face their greatest challenge ever when they must thwart an ancient evil that threatens to turn the world’s population into ‘Senior Citizombies.’”

SENIOR CITIZOMBIES? That's right up there with feminazis for cultural troglidytism. Then again, maybe I am insulting the troglidytes by the comparison.

Thanks for shedding some light on generic vs prescription drugs. I'm wondering if the possible concerns of some who perceive differences between generics and prescription drugs may be minimized here. Any number of problems are considered rare until they happen to me.

Certainly, I've understood prescription meds and generics must share the same active ingredients, though in years past I've read reports where there have been discrepancies discovered. I trust our FDA makes certain that is a past problem.

But these other filler items can vary considerably. I think people would be well-advised to be aware of such possibilities if they think they're experiencing a different response from their generic. A quick search turned up this link which is not alarmist, but adds some specifics about brand names vs generics:

I think a common mistake is to discount older people's concerns as all being in their head as some of those have experienced for whom I've had to advocate on their behalf with the medical community.

I experienced an exception, showing generics act the same as the branded drugs in most, but not all, cases. My pharmacist switched me to the generic form of Ambien and I began to have sleeping problems again. My psychiatrist suggested we do an experiment and see if I had any difference going back to branded. Lo and behold, sleep returned—and it wasn't simply the power of positive suggestion. I wasn't even aware that I was taking the generic or there could even be a difference in performance between generic and branded. Apparently, I'm not the first of her patients who has had problems with generic Ambien. In this case, the drug isn't manufactured in the same fashion. It does hurt the pocketbook to pay over $60 a month with the copay for branded, though.

I too experienced an exception using a generic. And, I was unaware at the time that I was using a generic, the difference in colour, shape and size was so small that it was only when I showed the pills to my doctor that she noticed that it was a generic. Going back to the name brand medication fixed the problem.

I have no problem with generics. I'm thinking though that it would be worth paying more money to get different colors and shapes so that I could identify the many pills I'm taking. Right now I have so many white round ones I have to be very careful! The past two days I took an generic version of ambien in the morning, mistaking it for topriamax. Not Good! I have my pills divided into day and night boxes and this still can happen. We need different colors and shapes!

I always have suspected that generics might be inferior. When I take a certain brand name pain reliever the pain relief is of a much higher quality than the same quanity of a generic. This I believe is not my imagination. One theory I have is thaty the more expensive brands use higher, and more expensive, ingredients.

You are assuming that generics DO come from the Parent Company and not some Fly-By-Night company in Mexico for example.

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