Okay, let’s get one thing clear from the get-go: I am an internist by training. We don’t make the bulk of our living by cutting with scalpels, inserting scopes into various orifices, or zapping people with x-ray machines. Our primary tools are the stethoscope and the prescription pad. So I am certainly not “anti-drug.” There are a number of pharmaceuticals that can be life saving, or can greatly improve one’s quality of life, and I have prescribed them often.
The problem is that, more and more, the pharmaceutical industry seems to be putting more effort into soaking the public for maximum profits than they are actually trying to advance the cause of medicine.
Here are a few “tricks of the trade” designed to make you spend far more money than you need:
1) The “Late-released, extended-release” pill. The makers of Namenda (memantine) were recently shot down in court for trying to switch their medication over to an extended release form, which would have given them a new patent and fought off a much cheaper generic version. Namenda was approved for use in Alzheimer’s disease a dozen years ago and has been available in a twice-daily form. Now that it’s going generic, the company suddenly announced a new, “better,” once-a-day extended-release pill.
The logic is compelling: if you have a condition that makes it hard to remember, then taking the pill less often has to be better, right? The problem is that the pill is not more effective; it just keeps the price high, due to the new patent that comes with the slow-release formulation. (And of all the people living with Alzheimer’s, the number who would successfully take a pill once a day without assistance, but would be totally unable to do so twice a day seems rather small.)
The giveaway here is that extended-release technology has been available for decades. So if this formulation is truly superior, why didn’t they just release the pill in XR form when it was first approved in 2003? The answer: it’s not better—it’s just a ploy to get a string of new patents and keep the price exorbitant for as many years as possible.
The same trick was recently pulled (successfully) with the new Aricept 23mg pill. A pair of researchers who tested that pill before its approval actually filed a complaint, saying that their research showed the larger pill to be no more effective than the old 10mg twice-daily dose, and to have more side effects. But the FDA approved it anyway and the price of Aricept stayed high. (As you can see, there is also a political aspect to drug approvals…)
2) The “Left-handed drug ploy.” Here’s an old chemistry lesson: Most organic compounds (including most drugs) are asymmetric-shaped molecules. That means they come in two forms that contain all the same atoms, but in mirror image, just like your left and right hand. These “left- and right-handed” compounds have varying activity in the body, depending on the drug; but in general, the left-handed forms tend to be more biologically active.
Most drugs are packaged simply as a mixture of left- and right-handed forms, because it’s easier to do so. Two examples of this are the antidepressant Celexa (citalopram) and the antacid pill Prilosec (omeprazole). Both of these have been around for a while, so there are now cheaper generic forms available.
In both cases, just as the drugs were about to come out in generic form, the companies obtained new patents for the old drugs by separating out only the left-handed molecules, so the pill could be claimed to be “new and different.” They even gave them new names. But there’s no difference; it works exactly the same way in the body.
You can tell these left-handed concoctions because they put an “es” (meaning “left”) onto the generic name of the pill: escitalopram and esomeprazole. Do you recognize them? They are Lexapro and that famous “purple pill,” Nexium! Same stuff, different day; but same high cost because they are new patents.
In Rochester, the cost for generic citalopram 20mg is $6 per month; for Lexapro 20mg, it’s $82. In other words, you can buy over a year’s supply of generic Celexa for what one month of Lexapro costs. (By the way, did you ever notice how many modern drugs have a “z” or and “x” in the name? There’s a psychological theory that such names look more powerful to the consumer.)
A related trick that’s kept the price of some old drugs high comes when a prescription drug is approved for over-the-counter (OTC) sales. When a pill goes straight to the public without a prescription, you will pay for the added convenience. When the prescription drug ibuprofen was first approved for OTC use (with brands such as Advil) in the 1980s, it was priced a lot higher than the prescription form. I used to write for the generic prescription version for my patients instead of telling them to buy the OTC version; they could get a higher dose than was allowed OTC, and still pay a fraction of the cost. (Now that Advil and similar brands have been out for a long time, there are cheaper OTC generics available, but the brand names had that market for many years.)
3) “Me too” drugs. Once a new drug hits the market and enjoys some success, many competitors will rush to produce their own variations on the original formula. This occurs with most medications, so you can choose from a wide variety of statins for high cholesterol, SSRI drugs for depression, cephalosporin-type antibiotics, etc.
In fact, this is simply good old free market competition: Glad Wrap versus Handi Wrap versus Saran Wrap. The problem is that many of the new brands offer no significant benefit, but are often touted as being better (see the aforementioned plastic wraps example). So it pays to be a smart consumer.
In some cases, the newer brand has some definite advantages. For example, the original beta-blocker drug, propranolol, was able to cross over into the brain and could cause depression and fatigue. Newer formulations, like atenolol and metoprolol, don’t do this and are better for people prone to those problems.
But in many cases, there is not a huge difference in the pills. The drug companies do a lot of sponsored research where they may measure a host of side effects and find one that seems to occur a bit less often than with their competitor. And then they claim their version is superior, when in fact it probably is not noticeably different for most people.
Keep in mind that everything I have described above is completely legal and part of any free market system. There are equivalent marketing tricks in most other industries, from banking to beer. But when it comes to your health, the ethics of maximizing profits without providing any additional benefit are a bit shady, to say the least. It was reported a few years ago that Big Pharma spends twice as many dollars on marketing as they do on research and development.
Caveat emptor—buyer beware!
