10 Reasons Why Pharmacists Are Silent about Generic Drug Quality:
Two recently published books (Katherine Eban’s Bottle of Lies and Rosemary Gibson’s China Rx) spell out in graphic detail the shortcomings of the FDA and the generic drug industry abroad. One might think that there would be an outcry from the world of pharmacy. After all, pharmacists are ultimately responsible for the products we sell. Why have we heard nary a peep from pharmacists about generic drug quality?
In my opinion, if you were to ask a pharmacist at a chain drug store whether he feels generic drugs are always as good as brand name, he/she is most likely to say yes. Whenever customers asked me that question, rather than open a huge can of worms, I would typically say that the FDA approves generic drugs. I said this knowing full well that the FDA is quite lax in checking generic drug quality. Instead, the agency naively relies on generic manufacturers to submit truthful data.
I have never worked in a hospital pharmacy so I am not very familiar with the attitudes of hospital pharmacists. I worked my entire career for chain drug stores. So my opinions may be more applicable to pharmacists who work at chain drug stores and independent pharmacies in comparison to those who work in hospital pharmacies.
What Do Pharmacists Think about Generic Drugs?
If I were to discuss generic drug quality privately with other pharmacists, their first reaction would probably be that customers who complain about the effectiveness of generic drugs are kooks, or those customers are simply imagining a difference between generics and brand name drugs. Their second reaction would be that I am a troublemaker for raising this question.
I agree that some fraction of pharmacy customers who complain about the quality of generic drugs are imagining a difference. But I don’t know what that fraction is. I believe that all pharmacists have been confronted with some number of customers who question the effectiveness of generic drugs. Are all of these customers imagining such a difference in effectiveness? Or could some of them be correct in their criticism?
[1] Ninety percent of prescriptions are filled with generic drugs.
You need to realize that the utilization of generic drugs is the primary strategy employed by state and federal governments and private insurance companies to hold down drug expenditures. Because pharmacists fill 90 percent of prescriptions with generic drugs, pharmacists fear that the financial viability of the pharmacy would be in jeopardy if serious questions were raised about the equivalence of generics to brand name drugs. When you’re talking about 90 percent of the business of a pharmacy, this is an extremely important subject.
[2] Most pharmacists trust the FDA to assure generic drug quality.
The biggest reason that pharmacists do not criticize generic drugs is because pharmacists believe the assurances from the FDA that generics are as good as brand name. I believe that most pharmacists and pharmacy educators assume that the FDA is very thorough in examining the quality of generic drugs that are manufactured abroad. I do not believe that most pharmacists and pharmacy educators know that the FDA largely depends on the honor system. The FDA largely depends on foreign manufacturers to submit truthful data to the FDA. As Katherine Eban points out in Bottle of Lies, that is clearly not happening in a shocking number of instances.
[3] Federal and state drug expenditures would skyrocket if fewer generic drugs were dispensed.
If the quality of generic drugs were acknowledged to be frequently inferior, the federal government and state governments’ budgets would explode because they would have to pay for many more brand name drugs. It seems evident that many brand name manufacturers are engaged in a game of price gouging to see how much they can increase their profits. Thus, the expenditures for drugs for people on Medicare or Medicaid or the Veterans’ Administration would skyrocket.
Some pharmacists have a negative attitude toward customers on Medicaid, which is medical assistance for the poor. Many pharmacists feel that state Medicaid expenditures for drugs are quite generous and that many of these Medicaid customers don’t seem to appreciate the generosity of taxpayers while hard-working people often have difficulty paying for the same drugs. And, to make matters worse, sometimes people on Medicaid are rude or impatient pharmacy customers. Thus many pharmacists dislike many Medicaid customers and don’t want to see their own taxes increase to pay for people who are sometimes seen as rude, impatient and unemployed slackers. That definitely does not apply to all Medicaid customers. Many Medicaid customers are very fine people living under difficult circumstances.
[4] Generic drugs save taxpayers and insurance policyholders lots of money.
Many or most pharmacists believe that customers who complain about generic drugs simply don’t like the fact that Medicare or Medicaid or private insurance seem to be coercing people to use generics. If state governments are struggling to pay for drugs for Medicaid patients, those costs would increase tremendously if many generic drugs were removed from the market. In addition, if the FDA were to be stricter with foreign manufacturers, drug shortages in this country would become even more acute and widespread.
[5] The cost of the pharmacy inventory would explode with more brand name drugs.
The average drug store has something like 2,000 or 3,000 drugs in the pharmacy department. Reducing the number of generic drugs for quality reasons would mean that the cost of the pharmacy inventory would skyrocket, potentially causing many independent pharmacies to go out of business.
[6] Generic drugs increase patient adherence and compliance.
Pharmacists know that the cost of prescription drugs is a big factor in determining whether patients will have their prescriptions filled. The two most common questions that customers ask pharmacists are “How long will it take?” and “How much will it cost?” Thus, pharmacists know that a customer is more likely to decide against having a prescription filled if it is very expensive. The customer then goes back to the doctor who prescribed the drug and says he/she didn’t have the prescription filled because it was so expensive. Consequently, generic drugs increase what’s commonly known in the profession as “compliance” or “adherence” (i.e., faithfully taking the drugs one’s doctor has prescribed).
[7] Pharmacists have no way of knowing whether customers who complain about generic drug quality are telling the truth.
There is no way for pharmacists to definitively tell whether our customers are telling the truth when they say that the generic did not work as well as the brand name. It’s not like having a mechanic fix our car air conditioner. Anyone can sit in a car and easily determine whether the air conditioner is working well. In contrast, pharmacists have no way of verifying that a generic blood pressure pill is adequately lowering the patient’s blood pressure. We don’t have time to physically take the blood pressure of all of our customers who take drugs for that condition, nor would customers or physicians stand for pharmacists acting like policemen to see whether our customers are truthful about generic drugs. Likewise, pharmacists have no way of objectively determining whether a patient’s anti-depressant is relieving the patient’s depression, whether a diuretic is adequately getting rid of fluid, whether the generic version of Ritalin works as well in controlling children’s behavior, and so on. We have to accept the patient’s word.
[8] Understaffing means there’s not enough time for thoughtful conversations with customers about generic drug quality.
Pharmacists who work for chain drug stores simply don’t have enough staffing that would allow them to have thoughtful and detailed conversations about the controversies surrounding the quality of generic drugs. These conversations simply take too much time and cause other customers to have to wait longer. This results in negative comments submitted by customers to corporate or regional headquarters. With the growth of production metrics which rely heavily on how much time it takes to fill prescriptions, pharmacists simply want to get customers out of the store as quickly as possible. Asking your pharmacist “Are generic drugs as good as brand name?” is a short question but it requires an answer that is often quite time-consuming.
Pharmacists working for the big chains are certainly less likely to question quality control with generic drugs if the district supervisor is standing nearby. Supervisors want pharmacists’ conversations with customers to be as positive as possible. I am now retired, but there is no way that I would have had a detailed conversation with a customer about quality control with generic drugs if my district supervisor were standing nearby.
Many pharmacists feel it is their job to be deferential to physicians. The profession of pharmacy is in many ways subservient to the medical profession. We depend on physicians to write prescriptions. Thus many pharmacists have decided to keep their heads down and be team players rather than troublemakers. Unfortunately, this conformity may keep many pharmacists from being independent thinkers.
[9] Many pharmacists feel that criticizing generic drugs is bad for business.
Pharmacists downplay criticism of generic drugs for the same reason that pharmacists and doctors downplay side effects. Pharmacists who are employed in “retail pharmacy” work in a business. Businesses don’t survive unless they are profitable. Criticizing drugs is simply bad business for pharmacists and doctors. Doctors write prescriptions and pharmacists fill those prescriptions. It is bad for the financial well-being of both pharmacists and doctors when the public has a negative view of pharmaceuticals. Therefore pharmacists and doctors tend to downplay the potential adverse effects of pharmaceuticals. Perhaps physicians are more open to discussions about generic drug quality because physicians have little economic benefit in defending generic drugs, but pharmacists clearly do.
Dispensing generic drugs causes the public to feel that pharmacists are concerned about drug prices. If pharmacists were to question the quality of generic drugs made abroad, our customers would probably assume that is because we want to dispense brand name drugs to make more money. But, in fact, the profit margin on generic drugs is usually better than on brand name drugs.
[10] Many retail pharmacists feel they must be positive about pharmaceuticals.
Pharmacy is largely a conservative profession. Pharmacists who question the safety or effectiveness of drugs are seen as troublemakers and disloyal to the profession. Working for chain drug stores for my entire career, I have seen a very definite emphasis from corporate management to be positive in our interactions with customers. As pharmacists are increasingly monitored by production metrics, it is easier to be positive when answering customers’ questions about drugs. When pharmacists say anything negative, the customer typically wants (and deserves) a detailed explanation from the pharmacist for our negative comment.
The subject of generic drug quality is one that pharmacists don’t really want to discuss. Likewise, pharmacists were not interested in discussing the cardiovascular and cancer risks associated with the once widely popular hormone replacement therapy. Pharmacists are not eager to discuss the muscle pain and weakness associated with statin therapy. They would rather not discuss the tendon damage associated with fluoroquinolone antibiotics such as Cipro and Levaquin. Similarly, pharmacists are not eager to discuss the growing number of side effects associated with very popular proton pump inhibitors (PPIs) such as Prilosec, Prevacid, Protonix, Nexium and Aciphex. In my opinion, the subject of adverse effects of pharmaceuticals is the Achilles Heel of pharmacy. It makes pharmacists uncomfortable.
Are Pharmacists Scientists or Business People?
I do not view most retail pharmacists as unbiased scientists whose primary loyalty is to scientific truth. I view most retail pharmacists as very protective of pharmaceuticals. Those who are critical of the pills we dispense are seen as troublemakers and disloyal to the profession. Consumer activists like Sidney Wolfe, M.D., formerly head of the Public Citizen Health Research Group, are not, in my experience, admired by the majority of retail pharmacists. Such consumer activists are typically viewed as troublemakers by pharmacists.
The absence of discussion of important books about the quality of generic drugs (Bottle of Lies and China Rx) is similar to the absence of discussion of books that are critical of Big Pharma:
- Marcia Angell MD, The Truth About the Drug Companies
- Jerry Avorn, MD, Powerful Medicines
- Thomas J. Moore, Prescription for Disaster
- Melody Petersen, Our Daily Meds
- John Abramson, MD, Overdosed America
- Armon Neel, PharmD, Are Your Prescriptions Killing You?
- Jennifer Jacobs, MD, MPH, Do You Really Need That Pill?
In my opinion, the pharmacists I know are not particularly attracted to or interested in books that critically examine the world of pills. Pharmacists are busy raising families, paying school loans, making car payments and house payments, and saving for their kids’ education, etc. They don’t seem to want to be bothered with big questions that complicate their lives and cause our customers to have less confidence in pharmaceuticals. Pharmacists seem to want reality to be simpler than it is. They seem to want to believe that all pharmaceuticals are wonderfully safe and effective. This makes us feel better about our job.
How Do We Know Generic Drugs Are as Good as Brand Name Drugs?
The equivalence of generic drugs to brand name drugs is simply the narrative that pharmacy staff recites robotically in drug stores today. It resembles the long-standing narrative that margarine is safer than butter, even though that claim has recently been seriously challenged.
Many pharmacists proudly wear their white coats in the pharmacy and nothing seems to shake their rock-solid belief in the pill-for-every-ill approach of modern medicine. Many pharmacists don’t seem to know or care how corrupt the pharmaceuticals industry is. Many pharmacists do not seem to know or care that the FDA functions as an enabler rather than a regulator.
In my opinion, most pharmacists are much more concerned about their income than the safety and effectiveness of the drugs they dispense. I haven’t seen that the safety and effectiveness of drugs is at the top of the list of things that pharmacists worry about. In my opinion, the primary reason that students go to pharmacy school is because they know that pharmacists make a nice income. That was the primary reason I became a pharmacist.
The process of filling prescriptions is extremely monotonous and tedious, in many ways resembling the filling of hamburger orders at McDonald’s. The main difference is that a mistake in the pharmacy can be infinitely more serious than a clerk’s error in filling an order at a fast food outlet. A nice salary is all that keeps many pharmacists in the profession and silent about many things that trouble us every day. Many pharmacists say they would leave the profession today if they were able to do anything else that pays as well as filling prescriptions.
