The trend from drugs of value to medications of convenience

Pharmaceuticals are amazing stuff. You can bitch and moan about their costs, side effects, or the number of them you’re taking, but what they’ve done to extend life and improve its quality is truly remarkable.

And for all the bad raps they get, I salute the pharmaceutical industry, and those who work anonymously in labs around the world, to bring us these miracles.

But drug companies also do absolutely weird crap. One thing that’s recently driven me nuts is the trend away from drugs of real value toward what I call “drugs of convenience” (DoC).

What is a DoC? Let’s take “Sukitol.” Sukitol is dosed twice-a-day. Taking a pill twice-a-day is something most of us can remember to do. Sukitol costs, say, $2 a pill. So a month of Sukitol is $120 (these numbers are just for example, obviously).

But, like all drugs, Sukitol’s patent is going to expire. Then it will become a cheap generic (sukazolamide), and the price will drop to $0.20 per pill. So a month will now cost $12.

About 3 months before the generic comes out, the Sukitol rep shows up at my door. He now carries once-daily Sukitol-ER! Yes, now you only need to take Sukitol-ER once-a-day! And they trumpet this like it’s a major freakin’ medical breakthrough.

And they no longer carry plain old Sukitol samples. So if I want to start someone on Sukitol, I need to use Sukitol-ER, and when it goes generic in a few months, the patient ain’t gonna want twice-daily sukazolamide.

Sukitol-ER is priced at $4 a pill, so a month is, again, $120.

When the generic comes out, the patient’s insurance has a choice: pay $12/month for twice-daily sukazolamide, or $120/month for Sukitol-ER. That $108 difference becomes pretty significant if there are, say, 1 million people on the drug.

Now we get into numbers. The patient’s insurance co-pay is $5/month for sukazolamide OR $40/month for Sukitol-ER. The insurance company is hoping that by putting more financial burden on the patient, he’ll decide to go with the cheap generic.

But the drug companies have a counter to this- They’ve introduced coupons, also called “co-pay cards” or “patient loyalty cards” that give the patient $40 a month off the copay. So by using these things the patient gets Sukitol-ER free, while the insurance company is still getting dinged for the rest of the cost.

Now, given my never-ending battles with insurance companies, I don’t often sympathize with them. But here I do: the patient is getting the gold mine, and the insurance is getting the shaft. And, of course, this situation increases health care costs for ALL of us, because the insurance has to raise my premiums to pay for the fact that somebody just can’t bear the thought of having to take their pill twice-a-day instead of once.

My friends who are pharmacists also hate having to deal with the reimbursement issues on the co-pay cards, but that’s another story. If they want to comment on it, they’re welcome to.

But the fun doesn’t end there. Let’s take a real drug: Flexeril (generic name cyclobenzaprine). This muscle relaxant came to market quite a while back, and consequently has been available as a generic for many years. It’s taken as a 10mg pill 3 times a day, and the generic is dirt cheap. Like a few pennies per pill.

So roughly 10 years ago, LONG after generic 10mg cyclobenzaprine was commonly available, some enterprising drug company actually was able to patent it AGAIN as a 5mg pill. They claimed it was less sedating at the lower dose, and therefore constituted a whole new drug.

And so it went to market as expensive Flexeril 5mg, because heaven forbid you should actually suggest a patient buy cheap generic 10mg cyclobenzaprine and break them in half!

Eventually the patent wore off on Flexeril 5mg, too, and it went generic, along with the 10mg. So what happened next? Another drug company actually re-patented it at a 7.5mg dose and renamed it Fexmid. I am not making this up.

Still another company has developed a once daily form of it called Amrix. So from 1 drug we now have 4 freakin’ patents.

Here’s another one: Doxepin is an ancient (by drug standards) antidepressant. It’s been around since the 1960′s. So it’s dirt cheap, and comes in pills of 10mg and up. BUT some pharmaceutical company, after 40 years on the market, has re-patented it as a 3mg or 6mg sleep aid called Silenor. So you can buy 30 days worth of 10mg pills at Target for $4 OR you can pay the same amount per pill for Silenor in a smaller size. Step right up and buy this bridge!

But the fun goes on! One that really chaps me is the bizarre trend of combining 2 old, cheap generics (some of which are even available over-the counter) to create a new, overpriced drug.

Other companies combine an existing generic with a soon-to-be generic as a desperate way of getting a few last bucks out of it. Because heaven knows it’s such a serious burden to have to take 2 pills at the same time instead of 1. This list includes Treximet (Imitrex + Naprosyn), Vimovo (Naprosyn + Nexium), Caduet (Norvasc + Lipitor), Vytorin (Zocor + Zetia), Symbyax (Prozax + Zyprexa), and many more.

No matter how much pharmaceutical companies try to portray these drugs as major medical breakthroughs, they aren’t!

I just can’t help but think that the money spent on creating them would be better spent on more novel drugs with greater long-term potential (and profit, since I admit that’s the key) to help people.

“Doctor Grumpy” is a neurologist who blogs at Doctor Grumpy in the House.

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  • BladeDoc

    Yet another problem that could be solved if people actually had to pay for meds out of their own pockets. You want the convenience, pay for it. The fact that people are willing to take the more convenient drug only if the copay is waived is a perfect example of moral hazard.

  • ninguem

    The next step in Dr. Grumpy’s tale, is the drug companies all stop making generic sukazolamide. Then you have no choice but to prescribe the branded drug.

    Or a single generic manufacturer ends up the only manufacturer of a certain generic, and the generic drug ends up costing more than branded equivalents.

    Mylan got fined for that with certain old benzodiazepines, about ten years ago.

    Or FDA designation for ancient generics. URL and colchicine and quinine, going on right now. They didn’t even have the fig leaf of cutting back the dose and calling it a new drug.

  • Health blog

    Hey- did you forget the miracle of isomers. Amazing that Nexium, Lexapro and others happen to be discovered just in time to be an improvement of the original but not until close to when the original patent expires.

  • Norm

    What if a physician had 10-15 years to earn the money they spent for their education. At the end of say 15 years they are told you are no longer an M.D. and you have to go back to school for another 10 years to be granted your M.D. license. My question is, how do you think that would affect the price of their services if their earning potential was 15 years vs 40 years. It cost about one billion dollars and 12-15 years of research to bring a drug to market, the pharmaceutical companies then have less than 15 years to market, recover the one billion cost and generate enough revenue to fund future research.
    Authors are granted copyrights in excess of 50 years for their works and yet pharmaceutical companies usually have less than 15 years of patent protection. Maybe a deal could be worked out for lower price branded drugs in exchange for a longer patent life.

  • Susan

    Thank you, Dr. Grumpy, for this very great service in spelling out for people the lengths that drug companies are going to in trying to get their money. If all patients asked these five questions of their doctor, they’d have a better chance of avoiding unnecessary spending on prescriptions:

  • soloFP

    I find that most patients are happy with $4 and $10 generics. Often the 90 day price is cheaper than mail ordering the same 90 days supply. Cost savings usually is the key to the patient. Time savings is important to me, as often the latest brand name drugs require staff to prior authorize the drug and forms for me to sign to get the patient the “free copay” version of the drug. By rarely prescribing the latest brand name drugs, I have saved at least 5 hours a week not working for the drug companies to prescribe new drugs that are simply the old drugs repackaged.

  • MIS Prof

    What if pharmaceutical companies spent less on marketing? Then they might make more in profit for their owners or have more to spend on R&D.

    Dr. Grumpy,
    Great post! Amazing games are played. It helps to circulate information about them.

    • Norm

      If only it worked that way. Pharmaceutical companies would not spend millions on marketing if it did not work.
      Developing pharmaceuticals is quite similar to software, virtually all of the cost is in developing the drug or software. After it is developed one can copy it for pennies on the dollar.
      The one point I was trying to make is, perhaps if the patent on the drug was longer the price could be lower, since they would have a longer time to recover their cost.

  • carol

    “… the patient is getting the gold mine, and the insurance is getting the shaft.”
    No, not so at least not for those of us on Medicare D – we get the shaft because the costs of these drugs put us into the “donut hole”. The cost of the drug, not what I pay or do not pay as co-pay, is what determines when I arrive at that crucial juncture.. My donut hole amount is equal to more than 1/3rd of my yearly income. To not get into the hole I do not take an important presciptive med. If, for lack of the drug, I develop the medical issues it is supposed to help prevent, it will cost all of you a heck of a lot more than if I could afford to take the medication.
    ( )

  • Mary

    I am a NP who works for pharma. How about the behavior of the providers and staff? I get calls such as, “we don’t want sandwiches or soup” Happens all the time. “Can you support our meeting?”
    For those of you who don’t know, pharma does not give out pens, trips etc and hasn’t done so for about three years. Meals must be modest and infrequent.
    Providers want to talk about everything else but about disease and current therapies. When you try to have a non biased(yes there are many rules) discussion, they walk out without a thank you.
    After leaving practice for 25 years, it was an eye openener

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