No question has divided more patients, pharmacists and doctors in recent times than “Do you want the generic?”, writes Angelo Pricolo
The question has intensified, as more expired patents have become fair game for financial opportunity. Many rambling conversations have sprawled into ideological banter as health professionals struggle to explain the phenomenon of the same active drug in a different colour box.
Sometimes it provokes conflict between doctors and pharmacists. The doctor can tick a box on a script that overrides any generic substitution. Some pharmacists and patients have been known not to spot this.
An argument can start as to why the box was ticked in the first place. The doctor may be encouraged by a persuasive medical representative. The pharmacist may be encouraged by an equally persuasive pharmacy representative.
I was once told that all the amoxicillin dispensed in Australia comes from one hopper and the filled capsules just go in different packets. If that is correct, and it wouldn’t surprise me if it was, then surely there is little value in choosing the streamlined pack with a fancy colour scheme.
It has also been proposed that Australia’s generic drug policy has been more detrimental to patients than in most other countries. On examination this statement could make some sense.
Using amoxicillin as the example again, if a patient chose the original brand when getting their prescription dispensed they could expect to pay the concessional subsidised price of about $6.
But when a generic competitor enters the market, say at a cost price of $2 less, the charge to the patient for the original brand increases. Instead of paying $6, the price jumps to $8.
The consumer bridges the gap between the two medicines deemed equivalent. So preferring this original brand, the new price to the patient would be higher than before, even though the generic was supposed to reduce the price to the consumer.
Why not take the generic/cheaper brand instead of the more expensive original brand and continue to pay the $6? Maybe it is tied up in the word ‘cheaper’.
One generic company used a clever phrase to help win market share from big pharma. They suggested referring to the ‘best priced brand’ when offering their generic. Surprising how favourable the uptake to generic medicine is by removing the word ‘cheap’.
It’s interesting that some are attracted to the word ‘cheap’, while others find it close to offensive. Many businesses base their entire marketing campaign and name around words like cheap and discount.
Some have likened pharmacy to the discount Persian rug stores that always seem to be closing down (but never do) and routinely sell at 95% discount. Unfortunately these ‘strap-line’ words have become synonymous with many parts of the pharmacy industry.
There is also the puzzling way our system allows for policy discrepancies depending on your situation. If you are an in-patient at a public hospital you usually have no choice which brand of medicine you receive.
Hospitals are rationalising their stock holding to simplify inventory, save time and optimise financial benefits. More money to buy new defibrillators for the wards. It makes sense.
If we look over at our neighbours in New Zealand, we can examine what they have adopted. In a system where choice has all but been eliminated, no doubt they have created price advantages for many patients. They have also achieved savings for the country’s budget, similar to our hospitals.
This has created friction with big pharma and sometimes has had ramifications influencing which new drugs are launched in NZ. It has also changed the generic market and who competes in it. Again choice has been the victim for patients, pharmacists and doctors.
Looking further abroad and speaking to a GP who worked for the World Health Organization, spending many years in third world countries, we discussed medicine availability and brands. He explained that he always chose the cheaper/generic brand when travelling because it was less likely to be a counterfeit medicine than the more expensive name brand. After all, there is more money in copying an Eames chair than an Ikea replica!
He was also once astonished to see a table piled with pre-loved prescription medicines (labelled with directions and someone else’s name) at an outdoor market on an Asian visit. But he was even more astounded when he noticed that one bottle had my pharmacy label and his name on it as the prescriber. It was a generic and he bought it!
When it comes to generics, language itself can be a barrier for some and not just people speaking different tongues. Sometimes we may speak the same language but miss the meaning. Like the ‘try to keep a straight face request’ that leaves you wondering how best to respond, when someone asks specifically for ‘the genetic one’.
Many struggle with the whole concept of having a choice as they just expect to hand over a prescription and in return receive their medicine as prescribed. The classic example I often see is when English is not the patient’s first language.
On occasions the legal obligation attached to giving people a choice is the cause of much confusion and anxiety. Maybe professional discretion could be employed here?
There is no doubt that multiple generic brands or too much choice has created dangerous situations, as different packaging can cause confusion. Some struggle with these variants and the risk always exists of double dosing with the same active. It is especially problematic and well documented with the elderly.
Then there’s the heated debate that continues around biologics versus biosimilars. Biologic drugs are large, complex proteins made from living cells. Unlike generic drugs, which are copies of chemical drugs, biosimilars are copies of a biologic medicine that is similar, but not identical to the original.
What is clear is the amount of money that can be saved by governments that invest in these cheaper alternatives of very expensive, highly specific medicines. But for now traditional western medicines still make up the bulk of the budget.
So we continue to work with the system we have, grapple with the dialogue around brands and their various advantages or annoying packaging differences. The generic question continues to occupy much of some people’s time and absolutely none for others who happily swap between brands satisfied with Australian bioequivalence data. Many disregard the trade name and the influence of drug companies or other vested interests.
It is impossible to shift some from a particular brand, be it originator or generic. To the extent that I have witnessed patients travel 100km to pick up the same capsule in a different box. If only they knew!
No matter how I try to explain it or which angle I pursue (and I’ve tried them all) is it that some people are sceptics or they just don’t enjoy change?
Angelo Pricolo is an addiction medicine pharmacist and former National Councillor of the Pharmacy Guild of Australia.