This is such a great example to highlight how information asymmetry and choice overload act to undermine markets.
> The difference in price between brand names and generics accounts for tens of billions of dollars "wasted" every year by Americans in pharmacies, according to the economics researchers.
> Consumer confusion, or misplaced trust, is compounded by the fact that a drug store is likely to have upwards of 300 cold-and-flu products
> One myth is that "brand-name drugs are made in modern manufacturing facilities, and generics are often made in substandard facilities." But, the FDA counters with the reminder that it "won't permit drugs to be made in substandard facilities."
Imagine how much consumers would overspend on branded medications if they couldn't count on the FDA as a backstop.
EDIT: By "backstop" I mean the FDA's role in ensuring that generics are bioequivalent and meet manufacturing standards. Imagine how much more effective brand advertising would be if some of the choices on the shelf really were manufactured in a dirty factory in Mexico.
The FDA does try, but it's ineffective and totally overwhelmed. Here's a recent story[1]:
In January, FDA inspectors paid a surprise
visit to the facility in Toansa, in a rural
area north of New Delhi, and found broken
equipment, windows stuck open and flies
“too numerous to count,”
...
Workers ran quality tests over and over
until they got the results they wanted
Just google around and you will find many many many stories like this. It's been an ongoing problem with generics (mostly from India) for quite some time.
I don't know if brand-name drugs are any better, probably many of the same ingredients are sourced from the same suppliers. But at least the brand-name drug has a reputation, i.e. a "brand name" to protect.
Edit: Just wanted to add: RTFA I linked to. My one quote doesn't do the situation justice. The culture at some companies is IMO really really bad.
Stores like CVS and Walgreen's do have their store brand to be concerned about. So if brands do provide some guarantee of quality, buying from those stores is likely not worse than the branded products.
Agree with everything about your comment, except I wouldn't characterize the FDA as "overwhelmed". Read the expose 'Dirty Medicine' on Forbes and you might choose a different adjective. :-/
It is indeed an interesting example of information asymmetry. An economic historian at LSE who I know actually traces the origins of modern advertising to the rise of "brand-name" medicines. Back in the late 17th century, early newspapers started running early ads for proprietary drug recipes that cured things like plague and gout. These were the earliest products to be sold via mass media and to be "branded" using the name of the preparer. I.e. in a world where a consumer would simply go to "Shoe Street" to buy shoes, these early apothecaries pioneered the idea of using mass media to persuade consumers not to buy a generic gout cure, but instead to go specifically to, say, Mr. Merck's shop to buy "Merck's gout elixir" (I use that example because the Merck corporation actually does trace its origins to a late 17th century apothecary).
While the FDA does a fantastic job of reminding the population of the process it uses to ensure generics deliver the same experience, there is still a ton of waste in the system due to brand-name drugs being chosen over generics. Part of the problem is the massive marketing efforts by pharma trying to convince patients and doctors that their brand-name drug is better. For details see:
Part of the problem is that the name brand drug is sometimes better than the generic, and one generic brand is sometimes better than another. I have experienced this as a patient.
There have been a few examples where the FDA received complaints, looked at the data and asked the generic manufacturer to rest test/reformulate their drug since it wasn't therapeutically equivalent.
The best example is generic Wellbutrin[1]. Many patients complained of side-effects from generics that they didn't experience with the brand-name drug. The FDA did testing and realized that the generic Wellbutrin extended-release resulted in much high blood concentrations than the branded version. The generics in questions were withdrawn from the market.
The interesting thing is that to get approval for an "AB-rated" (therapeutically equivalent) generic drug, you don't have to be identical. The FDA only requires that the generic drug deliver 80-125% of the drug the branded drug does[2]. Normally that range is fine, but for some drugs (antiepileptics are a good example) the differences can produced a less than equivalent therapeutic outcome.
Problematic generics seem to come up often about extended release formulations when hanging around ADHD communities. Judging from this latest one I remember, it takes a big push for the FDA to start looking into it and ask questions:
As consumers, we don't really have much of a way to test for placebo effects or when generics are actually subpar other than complaining until someone listens... so... it's a bit of a chicken/egg problem.
I think that's my question, as an individual, you can't say that one is more effective than the other because, as an individual, you can't account for the placebo effect. Personally, if it works, it works, placebo or otherwise.
If you search online, you can find isolated regulatory incidents, patient anecdotes, and even statements by doctors that they prefer patients not switching brands when something works for them. Beyond that, I'm not sure what is really known, or how you would go about studying this phenomenon in a scientific fashion.
Even if it is a placebo, if two medications that are supposedly the same cause different effects on me, e.g. one has much more manageable side effects than the other, then why shouldn't I take the one that makes my life better?
The information asymmetry and confusion factor are worst in that all these products have just a few ingredients, in my opinion. While the branded/generic price difference is an important issue, I think a larger one is that the huge volume of products takes attention away from the fact that there are only a few basic components, leading many to buy inappropriate products or products with too many components that can cause side effects that could easily be avoided.
People without some prior knowledge of the basic drugs must have a very difficult time walking into a store and choosing the product with the drugs they need without some of the ones they don't. I imagine many people are totally overwhelmed by the product selection and they just pick something, which they then turn to each time they're feeling sick. It's more difficult than normal to perform an assessment of products at the store when you're sick, and the store presentation only makes things more difficult. Even knowing something about these products and knowing exactly what I want, I sometimes find it time-consuming to locate the single-ingredient products among all the endless combinations, especially when they're out of stock.
Things would be so much simpler if stores posted some type of reference. I'm not an expert in the field, but it's such a pet peeve of mine that I've memorized the basics. Here's a start:
Fever/pain -> Relieve:
ibuprofin
acetaminophen [avoid if you have liver problems]
naproxen
aspirin
Nasal congestion -> Reduce:
pseudoephedrine [quite effective, but the pharmacy must be open; prepare to provide identification, sign, possibly be questioned / receive a dirty look, and have your purchase be entered into a federal database]
phenelyphrine [of questionable effectiveness]
Coughs -> Make more productive at clearing congestion:
guaifenesin
Coughs -> Suppress:
dextromethorphan
Trouble sleeping / allergic sensitivity -> Relieve:
doxylamine [slightly better for sleeping than allergies]
diphenhydramine [slightly better for allergies than sleeping]
The store could have a nice section of the products that contain just one of these drugs, making it easy to mix and match, with reference to the list.
I don't think there's anything inherently wrong with the combination products, but it really seems their general effect confuses rather than clarifies, which seems to me to be part of the reason for the design and proliferation.
The author of this piece seems to have similar feelings:
> ...I can't see myself using it, because I usually keep generic single-drug products around. A family, or a sickness-inclined person living alone, could very reasonably keep the five aforementioned individual generic medications in their medicine cabinet and address the symptoms as they arise. I think that's easier than messing with combination products, and usually cheaper. Especially if you consider that you're not taking medications you don't need.
> I tried to convince Angelotti that's the way to go, but she was adamant that many or even most people really like to take one pill that addresses all of their symptoms. "I don't know if people will be likely to have their own inventory of generic over-the-counter medications in their homes," she said.
I think a simple list like this, preferably easily visible in the store, and some better organization in stores would do people a much greater service than the app the article discusses.
My problem with this approach: As I'm quoted as saying in Jim's article, I just think it's a non-starter for most people to do this, ie keep an inventory of sorts in their medicine cabinet and recombine them as needed. Jim is thinking like a doctor, not like your average, non-medically-trained person. There's a reason pharma makes combo products — people do like getting multiple ingredients in one pill. It's convenient! Most people have neither the patience nor the medical education to recombine individual generic ingredients on their own. And trying to do so could actually put them at higher risk for drug interactions or other human error. You have to read and reconcile warnings and directions labels from 3 or 4 different product packages, instead of just one.
>"And trying to do so could actually put them at higher risk for drug interactions or other human error. You have to read and reconcile warnings and directions labels from 3 or 4 different product packages, instead of just one."
I don't see how "combined" pills that are vetted by pharmaceutical companies or the FDA stop unwanted interactions from drugs. People don't read the entire huge and tiny-font booklet that comes with most medicine and cross-reference the ingredients from each with all the other medicine they're taking. Sure, they rely on doctors to help them out (if they know/can anticipate), but that's just as much a disaster waiting to happen as what you're arguing against.
So what ends up happening is that the drug interactions occur anyways even though people took approved combinations of ingredients. I'd rather we not promote this whole approved combinations prevent unwanted interactions as people mix different pills anyways.
Having your SOP for dealing with a cold being "select exactly one box from your medicine cabinet [or pharmacy shelf] and take the recommended dose" is likely to produce fewer unwanted interactions than if your SOP is "select 1 to N boxes from your medicine cabinet and take the recommended dosage of each of those medications", especially when the person selecting is far from their peak mental performance due to the cold symptoms they're experiencing.
Many (likely most males under 60) people take zero pills on a given day when not sick.
I certainly agree with you that some people are not going to keep a small inventory of common drugs, others can't be bothered to take more than one pill, and a few cannot successfully manage that sort of combination.
On the other hand, though, I think there are a lot of people who would like to learn more in order to make the best choice about what drugs they take, and the branded combination solutions really end up muddying their conceptions of these medicines. I know a number of people who just buy whatever they've decided is their favorite variety of DayQuil when they're feeling sick during the day (you're quoted relating similar experience in the article), and I know a number more who don't realize there are major differences between traditional Alka Seltzer and the proliferation of their cold products. The brands and the proliferation undermine people's ability to concentrate on the drugs they're taking, and they mentally give up on figuring the situation out and determining the best medical choice (especially if they also consider the cost and branded/generic elements of the equation).
The identification with brands rather than the actual drugs is likely the largest problem, especially now that each long-existing drug manufacturer sells combinations of the various drugs under their own name. I wouldn't mind seeing these companies have to devote the top 1/3 of the front of their boxes to a large, unadorned list of the product's active ingredients.
I think people who would like to be more informed consumers, but who struggle because of the current setup, are underaccounted for. I think there are many people who would love an inexpensive pack of 50 of each of these generic drugs to keep a small inventory at home, and who would be perfectly capable of managing it.
While it may be easy for a doctor who is familiar with these medicines to erroneously assume that they are very familiar to others, I think it is also easy for a doctor to not give patients enough credit in being engaged with their health treatment and being willing to spend a small amount of time and effort becoming familiar with a few extremely common drugs.
How often are people, on average, mildly sick in their adult lives? About once per year? How often do they care for others who are sick? These drugs are incredibly common, they are relatively simple, and people are likely to have a lot of contact with them over a lifetime. I think greater familiarity with them would be very useful in the average life, and I think an education effort would provide a lot of health value, even so little as starting with a simple reference in the store.
I am not a medical doctor or a pharmacist, and my list above is from memory (except for spelling). Perhaps I have engaged in the care of illness slightly more than average, but it didn't take a medical text to learn this stuff. It just took some concern over what I was giving myself/others and whether it was appropriate for me/them, and then a small bit of reading. This is an issue I care about because it seems to me the ill are victims in a corporate marketing game where the outcome is often someone sick ending up with an inappropriate product.
Another part of what bothers me about the combination setup is that many people are getting acetaminophen when they don't need it, or even when it could be bad for them. For instance, when I enter "stuffy nose" and "trouble sleeping" into the site, I get products with diphenhydramine, phenylephrine, and... acetaminophen, even though it's not needed for the symptoms. When it is needed for the symptoms, I bet a lot of people take extra tylenol when they have a headache, anyway. Many would be better off with ibuprofin, but in many combinations it's not an option.
I think your project is a very helpful improvement over the status quo, and I'm glad you made it and that it's available! I'll certainly recommend it to my "DayQuil" friends, and someone looking for relief in the store is much more likely to find it with your site than by a first-time confrontation with the cacophony on the cold shelf. My suggestion would be not to discount that people might like--and be capable of--getting down to the basics of each medicine. It's really not hard, and I hold out hope that, contrary to Internet rumors, some people still have some patience and the ability to remember a few things!
> The difference in price between brand names and generics accounts for tens of billions of dollars "wasted" every year by Americans in pharmacies, according to the economics researchers.
> Consumer confusion, or misplaced trust, is compounded by the fact that a drug store is likely to have upwards of 300 cold-and-flu products
> One myth is that "brand-name drugs are made in modern manufacturing facilities, and generics are often made in substandard facilities." But, the FDA counters with the reminder that it "won't permit drugs to be made in substandard facilities."
Imagine how much consumers would overspend on branded medications if they couldn't count on the FDA as a backstop.
EDIT: By "backstop" I mean the FDA's role in ensuring that generics are bioequivalent and meet manufacturing standards. Imagine how much more effective brand advertising would be if some of the choices on the shelf really were manufactured in a dirty factory in Mexico.