▲ 103 points
back
114 comments
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
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.
[1] http://www.bloomberg.com/news/2014-03-06/flies-found-by-fda-...
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:
http://www.iodine.com/blog/do-people-prefer-under-patent-dru...
> information asymmetry and choice overload
In the industry, we call it "patient education."
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]
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.
The most pernicious recent development is the widespread use of phenylephrine to replace pseudoephedrine. Neither personal nor clinical evidence support the effectiveness of phenylephrine, but it is very clear that phenylephrine causes a dramatic increase in blood pressure in many people.
There are some pseudoephedrine products on the market which are supposed to be diversion-resistant for methamphetamine production but it seems if you stop people from making meth they will just order up some other sympathicomimetic amine from China.
Just get yourself an ephedra plant and steep your own tea. Pseudoephedrine itself does bad things to some people.
"The idea is to help everyone find exactly the right cold medication."
http://www.iodine.com/cold-and-flu
I work at Iodine (our Cold and Flu tool is featured in this article) and we're watching this thread. Feel free to ask medication related questions of our clinical team or technical questions of our engineering team.
Please look at your website with iPad for example. And then please get rid if of that share bar that annoyingly covers the content. Thanks.
There is actually an excellent reason to choose a brand name over a generic. People with gluten intolerance, allergies, or those who suffer from Celiac disease need some guaranty that the medicine they are purchasing does not use filler which may contain gluten. Many of the brand name makers actually do make an effort to test for gluten and indicate its presence, but (in my experience) that is less common among generic offerings. (This is particularly so for prescription generics, where you really don't see or think about the maker of the pill.)
Did you consider keying everything off of active ingredients (instead of the famous brands)?
503 Server Error. The service you requested is not available yet.
OK, it's back up. You tell people they can save money by buying generic, but your site is all about the brand names, not the active ingredients. I think you're going about it backwards. Then by adding reviews on top of it all -- it just perpetuates the entire brand-name mythos. What's there to "review" about a bottle of Guaifenesin?! It's Guaifenesin!
What people really need to be educated about is; 1) the only thing that matters is active ingredient, and 2) what active ingredients do I want to take for these symptoms?
To that end, I think you want to explain the difference between Guaifenesin and Dextromethorphan, and why you would take one over the other, or both at once. But on your site, I click 'Cough', and I'm just hit with big shiny brand names, and nothing to explain how to decide. So I'm sorry to say I think you're failing entirely on your stated goal.
Edit: OK, I'm basically echoing @maxerickson 12 hours late.
Heyas! Love the idea behind this, but a question about the product itself -
Is there going to be some way to ask for and filter out information for effectiveness etc. depending on the use that you're trying to address? For example, I just looked up gabapentin, which was basically ineffective for treating my non-shingles/diabetic neuropathic pain.. and I can only break down the info by age and sex. Same story with montelukast, great for my asthma but far from a one-pill wonder for my allergic rhinitis despite being marketed/approved for it. Would love to see data like that without having to dig around in the individual comments or for studies!
How does iodine.com (as a company) handle the problem of FDA regulation? Besides the statement on the web site, I mean:
Iodine doesn't provide medical advice, diagnosis, treatment, or prescriptions. Read our terms of use for more info.
What's the medical consensus on Cold-EEZE?
Really like the idea; what's your plan with respect to pediatric medicines?
My problem with buying the store brand generics is I don't know how well they are tested and regulated. If it says it is 200mg, how can I trust it?
But branding does have an impact on the effectiveness of some over-the-counter medicines (because of the placebo effect):
>The effect of branding--that is, the labelling and marketing--of a well-known proprietary analgesic used to treat headaches was studied in a sample of women given a branded or unbranded form with either an inert or an active formulation....The findings showed that branded tablets were overall significantly more effective than unbranded tablets in relieving headaches.
This reminds of of the time I sat the cold/flu aisle looking at cough medicine for so long... Through the haze of my head-cold I finally figured out that there were three different products by the same company that had the exact same dose method, dose size, and active ingredients. The only difference was the name of the product and the price.
*EDITED:
This is amazing- we hadn't noticed this! It feels like they are A/B testing different boxes. I particularly like the MLB logo in the corner of one of those boxes.
I wonder how much of that wasted money could be saved by taking an approach with brand-name drugs similar to the one taken with cigarette packages: require them to carry a big-ass label. Something to the effect of "THIS PRODUCT IS MEDICALLY EQUIVALENT TO [ insert name of generic here ]" in great big, bold type.
Of course that would cut into pharma's profits, so it would never in a million years actually happen.
Except generics aren't guaranteed to be equivalent. Indian pharma companies have been incredibly corrupt, outright lying about their products:
http://fortune.com/2013/05/15/dirty-medicine/
I'd be very hesitant about buying medicine from such companies. But I agree that if the regulators could assure quality, then yes, pointing out equivalence would help a lot of people.
Of course that would cut into pharma's profits, so it would never in a million years actually happen.
That's a cynically opinion.
When it comes to prescription drugs, most states have generic substitution requirements. That is, if your doctor writes a script for Lipitor, the pharmacist is required to fill it with the generic unless the doctor writes (DAW = dispense as written).
When it comes to OTC drugs, I think it's up to the consumer to educate themselves.
Here's another racket: "decongestants" containing phenylephrine as the active ingredient (most U.S. over the counter decongestant products).
"Phenylephrine was not significantly different from placebo in the primary end point, mean change in nasal congestion score at more than 6 hours (P = .56), whereas pseudoephedrine was significantly more effective than both placebo (P < .01) and phenylephrine (P = .01)"
yup, that data was very obviously suppressed to keep the DEA happy and prevent meth labs from easily obtaining large amounts of pseudo-ephedrine.
Ask any seasonal allergy sufferer, we all look to find out where the 24 hour pharmacies are so we can get access to the "good stuff" when sinus trouble inexplicably hits and you need the behind the counter pseudo-ephedrine to get through it.
If I actually trusted the FDA to do their job properly maybe I could spend less time staring at brand names in the cold aisle.
If we all trusted the FDA implicitly, then the next logical step could be to actually ban the entire concept of applying brand names to off-patent pharmaceuticals and rework the entire cold aisle into a patient-education + active ingredient grab bag. In such a world, phenylephrine is phenylephrine, guaifenesin is guaifenesin, and all shoppers would care about is the form factor and dosages.
I've read on HN about exactly how many fucks the FDA gives these days when billion dollar pharma is forging test results while they knowingly pump crap generic meds with zero quality control out of their dirty factories. See, for example, https://news.ycombinator.com/item?id=8468099. So that leaves us with the flimsy fallback of hoping brands like Mucinex believe good QC is absolutely essential to maintaining their market position.
TFA claims American consumers waste "tens of billions" on brand name pills. I'm sure this stat isn't just cold/flu meds, but probably including blockbusters like Lipitor vs generic as well. That's like a $10 billion tax because we can't fully trusted the quality and bio-equivalence reviews the FDA is tasked to enforce?! By comparison, the total FDA budget is $4.5 billion.
To give a specific example of where this works in practice, take buying a good piece of steak. While some chains try to brand their beef one way or another, all you really want to look for is "USDA Prime". The USDA... they really, really know how to grade a cut of beef. I trust them implicitly, when I see "USDA Prime" I know exactly what I'm going to get.
Now imagine having that same level of trust in the FDA. "Guaifenesin 1200mg 24 Hour - FDA Prime" would be all I need to see, and I'm grabbing that bottle. Spend a cool $5 billion setting up that program for the Top 100 generics, and you save Americans, what, maybe about a trillion dollars over the next 30 years?
Just like with beef, this isn't about controlling production, or subsidizing the factory, but simply establishing public trust in an inspection process.
An interesting analogy of the situation which didn't make the article is a good analogy of the cold medicine racket would be, imagine if liquor stores were not able to legally sell components of mixed drinks. So a liquor store could only sell tens of thousands of different ready to drink products such as screwdrivers, old fashioneds, rum and cokes, mint juleps, but it was practically impossible if not illegal to buy plain old vodka in a bottle.
And for marketing and trademark reasons you had to study the fine print to figure out what is in each bottle. So you can't buy a bottle of ready to drink screwdriver, you have to look in the fine print for "Slammer Canadian Lite Extra Dry Extreme" to figure out its a bottle of screwdriver.
I'm not suggesting I want bulk generic powder guafenisien but life would be a lot simpler if it was more like the produce aisle, OK I got runny nose and cough so take one of pseudoephedrine and one of dextromethorphan and call it good, instead of the "confuseopoly" system we currently have, which I'm sure reduces everyone's quality of life while increasing profits.
One of the points made in the article is that you can buy single drug generics and combine them as needed.
So for your analogy, the liquor store would have to have a small shelf of mixers and giant coolers full of premixed stuff. But flavor is easier to deal with than medicine, so people won't put up with it, so liquor stores mostly sell ingredients.
This reads like a big ad for Iodine.com
I thought the author actually had a pretty skeptical take on things. The ending quote is pretty hilarious:
"It's a press release, Mary. The iodine algorithm saved your husband from the brink of ruin. His newfound sense of consumer empowerment was so invigorating to his spirit that he no longer needed any Mucinex at all."
Well, we are trying to counter all the pharma ads!
But really, we hear from users all the time that they get confused in the cold and flu section of the pharmacy. We hope to help address this problem.
I've been waiting for awhile to catch a cold so I can try a neti pot. My usual goto is zinc lozenges as soon as the cold hits/gargling with hot salt water/staying well hydrated/and resting.
Try to do it first thing in the morning before you blow your nose. I have found that blowing my nose drives the mucus two directions... out my nose and up into my ears.... this prevents the neti pot from being able to properly clear out your nose, since it can't reach the mucus that has been driven up into your nose.
remember not to use water fresh out the tap.
I think the real racket is that people are taking medications to suppress cold symptoms in the first place. A healthy adult should be out no more than a week from a strong cold/flu. That wouldn't be a big deal except people get so little time off from work they don't want to waste it on a cold.
Wether they spend $10 on symptom suppressors or $50 is besides the point. Taking medications for what your body should be capable of handling with proper nutrition and rest cannot be healthy.
I'm an MD, and I used to avoid treating cold symptoms for these exact reasons, until I came down with a nasty sinus infection that was a complication of my cold virus. Basically, because I left my sinuses all stuffed up, I created a nidus for infection -- ie the perfect environment for bacteria to breed -- so I had a cold for a week, and then I had a bacterial sinusitis for another 2 weeks and finally broke down to take antibiotics. I could have avoided the sinus infection (and the antibiotics to tamp it down) if I'd just taken a decongestant when I had the cold. And the side benefit is my cold would have felt less miserable, too. And it wasn't about not taking time off from work because a lot of this was during a vacation anyway.
Point is, treating cold symptoms can actually prevent complications, so it's not all bad.
>>Taking medications for what your body should be capable of handling with proper nutrition and rest cannot be healthy.
Could you explain a bit more as I can think of a case where this seems to be false: While my child's body can eventually handle colds and flus, if his temperature goes above a certain level there's a significant chance for brain-damage, so I counteract the bodies natural fever with medication.
"what your body should be capable of handling with proper ... rest"
Which sets up a glorious chicken and egg where due to the peculiar anatomy of my sinuses or whatever, I find it nearly impossible to rest without some form of cold medicine. By the end of a simple cold, I'm really looking forward to finally getting a decent nights sleep and not feeling miserable when I'm sitting around.
I don't exactly enjoy the state of being sick.
Cold symptoms are mostly an immune overreaction. The way the body responds is very much suboptimal. Just because we (usually) recover on our own doesn't mean medicine is bad.
Wow, would you really not spend $50 to avoid a week's worth of cold symptoms? Sounds like a bargain to me, even just for the improved enjoyment of the after-working-hours time.
I use a netipot with lukewarm water and a pinch of salt to flush my sinus if I have any cold symptoms. I never had any real cold since 2007. Never took any cold medication.
I would love to see this represented in an infographic or some sort of visual aid. The biggest racket in my opinion is the whole Tylenol / generic or ibuprofen / generic the prices can be ridiculously different. One thing about the pain relievers is the quality of the shell or coating you are getting. Some of the generics come broken up into tiny pieces while you won't see that with brand name meds.
I learned all about this stuff from some pill popping raver kids. 300 brands and about 6 different ingredients. One of the ingredients only purpose is to make you vomit.
Agree in general but remember the case of Ranbaxy? FDA oversight is not uniform and becomes weak outside the US
Good: Brand
Better: Generic
Best: Nothing
"If takes about 1 week to get over a cold if you don't take medicine, but only 7 days to get over a cold if you take medicine."