Lately, there has been some controversy regarding brand name prescription medications and their generic equivalents. Anecdotal reports followed up by scientific inquiry suggests that for certain classes of medications (frankly heavy-duty stuff for blood pressure and seizures,) generics significantly under-perform compared to their brand name kin. This is interesting enough from a pharmacological standpoint but the following statement from the linked article also caught my eye:
A pharmacist is not required to notify the patient of the change (from brand name to generic), although some choose to do so.
Technically, the statement is correct. At the same time, it is implying that pharmacists are at least partially to blame for the confusion regarding generics because they are not legally required to counsel on generic substitution. Consider the following scenario though: Your doctor writes you a prescription for an antibiotic. You want to get over this infection quickly, so you head to the nearest drugstore and get your prescription filled. As the cashier gives you your receipt, he also asks if you have any questions for the pharmacist. You think about this for a quick second. You think that you remember enough of what your physician told you to take the medication correctly. Plus, the medication comes with a safety guide which has the directions printed on it in case you forget. You opt out of the free counseling session and head home. If you had spoken to the pharmacist you would have been notified that you were receiving a generic drug.
Obviously the situation is more complicated than, “oh the pharmacist is too lazy to counsel.” In fact, there are lazy pharmacists out there, I myself (like all technicians) having worked with some before. The vast majority; however, make an earnest effort to counsel, but may be genuinely predisposed, or the patient might decline being counseled as in the above scenario.
On the other hand, why would a patient decline free medication counseling? Where else can you find an expert in medication therapy providing free advice? You might argue that pharmacist counseling isn’t actually free and that the fee is covered by the cost of the prescription. What about when a patient asks for a recommendation on an over-the-counter medication? Counseling is virtually a pro bono affair compared to getting advice from other professionals (lawyers for example).
There are two issues at play here. Can generic medications be dispensed in place of brand name medications? If so, what is the responsibility of the pharmacist in alerting the patient to this switchover?
Based on my pharmacy technician experience, I used to think that generic substitution was a straightforward affair. When patients asked me why they should buy generic pseudo-ephedrine (Sudafed) versus the brand name stuff, I would answer that they were chemically identical. They would protest that that couldn’t be all there was to it, and I would continue explaining that the tablet would appear different because of different inactive ingredients which comprise the “fillers.” For a complete answer though I defer to the Food and Drug Administration.
It might help to better appreciate counseling from pharmacist perspective if you actually see how pharmacists counsel. This is actually something I learned in the very first semester of pharmacy school because counseling is central to the pharmacy profession. Counseling consists of three major questions. All three questions are open-ended and phrased to determine what you, as the patient, remember from talking to your physician:
- What did the doctor tell you this medication is for? Translation: Let me tell you the name of the medication, its strength, whether it’s brand or generic, and explain exactly what the drug is used for.
- How did the doctor tell you take the medication? Translation: Let me tell you about the drug dose such as how much of the medication you will be taking and how often.
- What did your doctor tell you to expect? Translation: Let’s go over side effects, drug interactions, and any drug allergies you might have.
The format of these questions is not cut and dry and will differ from one pharmacist to another. Knowing the questions will be helpful as a patient (which we all are at some point) because they allow us to anticipate when to voice our concerns so the pharmacist can tell us what we want to know and more importantly what we need to know.
One Comment
Thanks for this post.
From a pharmacist’s perspective, there are additional points. The history of generic substitution has taken place over little more than the past 20-25 years from the time with pharmacists filled prescriptions for hand-compounded drugs, then the era of brand name products–no generics, and at this time, the era of widespread generic manufacturing and concerns about pharmaceutically elegant generic products from foreign companies.
When I was studying laws in late 80′s, ink on state pharmacy legislation was still wet regarding generic drugs. We were still in in deep discussion of legal ramification and implementation of substitution and patient rights.
At this same time we were still learning filling placebos and debating whether we could talk to patients and how to handle physician orders to ‘do not label. There was a law that we could fill a generic drug prescription could not cost more than the original proprietary product as long as patient, prescriber, and pharmacist agreed to fill it.
The generics learning curve has taken everyone for the ride; pharmacy school instructors, older pharmacists, new grads, techs in ever-expanding roles (when I graduated there was no such a person), and general public. Some people are more flexible than others in adapting to new knowledge, and others need to ensure the waters have been thoroughly tested before ‘jumping in’. The ‘wait and see’ attitude is especially relevant to clinicians concerning narrow therapeutic window drugs.
I recall taking a widely available CE program in the early 90′s about warfarin and Coumadin dispelling dfferences between various generic products and then some time later, nullification of CE validity because its promoter misrepresented issues with Coumadin and warfarin substitution. As a pharmacist in an Anticoagulation Clinic, I can be sure of only one thing in my practice– use of oral anticoagulants requires monitoring.
Open-ended counseling questions were designed to understand what the patient was told about the drug, and assess patient knowledge-base in the most time-efficient, non-judgmental, and informational gleaning way possible.
Drugs are often prescribed off-label, and rather than risk erection of attitude barrier, the question is designed to obtain a mini-history (patients go to different pharmacies for different types of drugs–polypharmacy.) Without going into a lot of detail, the reply of the patient ‘I was prescribed this for my Parkinson’s disease (PD) because my tremors are getting worse’, tips off the pharmacist to review PD, its treatment options, options the patient might’ve been offered previously, new issues, and other considerations e.g. nutritional status, sleep needs, exercise, sex drive, social networking (there are a local PD support groups in my area). and so on.
The patient’s sentence allows the pharmacist to consider what might have been tried without success, what side-effects might have been encountered with previous agents, and why this the new drug has been prescribed particularly, and what new side-effects need to be addressed, etc. With that answer, a pharmacist can ensure the correct drug e.g. Mirapex, and dose has been ordered (the dose for restless legs syndrome is different than PD (as well as verifying correct prescriber –a dentist doesn’t write for Mirapex). Often, there’s a fleeting thought about whether the drug is expensive, and whether the patient can afford to take it as directed.
The pharmacist in his/her mind reviews accuracy of filling the prescription, package insert information, therapeutic issues, adherence, and many other considerations when the patient answers only those three question.
One of the biggest problems with therapy for chronic illness is ensuring the easiest way to be compliant, and a major reason why patients become non-compliant is when they perceive the ‘new’ drug causes unpleasant unanticipated side-effects.
Any conversation at this point helps the patient see how they are going to take charge of their own adherence. Needless to say if it seems that the patient learns how to fit it into their present regimen.
Basically, what I want to hear the patient SAY as the experimental rat when I’m counseling is that they are going to take the ordered medication in the best way possible to ensure the most beneficial outcome, and if it doesn’t go as expected, they know who, when, where, how to make it work out better. (Sometimes, it doesn’t work out for the best and has to be changed.)
As a pharmacist, then, this is why I am extremely irritated when I am too busy with inanities to talk with my patients. I am especially irritated when I am working with a technician or other pharmacist whose goal seem to be for me as pharmacist to keep me shooting my own foot, such as when techs are preoccupied with creating negativity barriers with patients, when I am forced spend time listening to diatribes, or when techs take it on themselves to dismiss patient’s questions, or tell the patient out-and-out lies i.e. attempt to counsel, the drug is not covered by insurance without offering for pharmacist to speak with physician, or telling the patient it’s too early to fill a blood pressure medication without finding out why the patient wants it.