I love generic brand products. I will fight to the last breath for my Shoppers’ Choice Adhesive Bandages rather than pay an extra $0.49 for Band-Aids. So why, then, have I been paying up to $395 every month for brand-name medication for the last two years instead of getting the generic version for $7.56? After all, aren’t generic drugs the same as their brand-name counterparts?
Let’s go back to November 2019, three months into my first year of medical school. I’m at the pharmacy picking up my monthly supply of Concerta, a task that has been a routine part of my life since I was diagnosed with ADHD at 15. When the clerk hands over the bottle of pills, I notice that the tablets are round instead of the barrel-shaped ones I’m used to. But I don’t think anything of it, because generic drugs are the same as brand-name, right? I just put the meds in my backpack, pay, and head back home.
That’s when the “off days” start. You know, when you wake up more tired than you went to bed, and the world looks a bit grayer, and inertia seems stronger than it used to. I chalk it up to seasonal affective disorder and buy myself a cheap light therapy lamp I can find on Amazon. It doesn’t really help, but my suspicions seem to be confirmed anyways when I return home to California for winter break and feel better almost instantly. I don’t give a second thought to the barrel-shaped tablets I pick up from my home pharmacy.
The new semester starts, and I am just settling back into my life in Chicago when COVID-19 sweeps into town and stops the entire world. I’ve never had trouble summoning the energy to feed myself or get out of bed before, but then again, I’ve never lived in a world where cities have to load their dead into ice rinks because the morgues are full. It seems reasonable to feel a little down, and then a little more. To wish everything would just … stop.
When lockdowns begin, I return to California to shelter in place with my partner and his dog – but I still don’t feel better. I’ve lost more than 10 percent of my body weight, leaving me at 5′ 7″ and 108 pounds. And as summer arrives, restrictions start to lift, and the world starts to come back to life again, I find myself Googling how to tie a noose. The internet reminds me that there is no reliable, considerate way to commit suicide, and I feel even more trapped than I did when lockdown first began.
But then, on one May morning, I’m halfheartedly preparing for Zoom class when I reach for my Concerta and promptly knock it off the bathroom shelf. There are only a couple pills left inside, so it topples and bounces right into my still half-full suitcase. I pause, unsure if I care enough to retrieve it, before remembering this month’s refill, which I’d just picked up yesterday and is still in my purse. When I pull the bottle out, I’m surprised to see the barrel-shaped brand-name pills. But of course, it doesn’t matter – right? Shrugging, I pop a pill and head back to my laptop.
For the first time in a long time, class is fun. I have the energy to stay engaged, and I feel like I have things to contribute. Outside, the sun is shining; the weather has been clear for weeks, but today, I notice. I don’t think about dying at all. And the next day is the same, and the next. After three days, an idea takes root in my brain. I fish out the old bottle from my suitcase and take one of the remaining generic pills. Just as I suspected, I sleepwalk through the entire day, feeling like there’s a ball of lead suspended behind my ribcage. The next day, I switch back to the brand-name pills, and the weight disappears again.
Like any millennial, I take to the internet to investigate further, and that’s where I stumble upon author Gina Pera’s blog ADHD Roller Coaster. Pera, the author of Is It You, Me, or Adult A.D.D?, has been writing about the ADHD community’s concerns surrounding generic formulations of Concerta since 2011. Her reporting sends me down a rabbit hole of pharmacokinetics and legislative red tape that I’d never known existed – even as a medical student.
According to the FDA, the area under the curve of the plasma drug concentration over time, which reflects drug exposure, can range from 80 to 125 percent of the brand-name medication. Generics also don’t need to have the same delivery systems as their branded counterparts either – which is particularly striking in the case of Concerta, which is differentiated from the chemically identical Ritalin XR by a unique osmotic release mechanism.
Unsurprisingly, multiple studies have found that switching from brand-name to generic Concerta caused significant adverse effects. The bioequivalence ratings of at least two generic formulations have been downgraded by the FDA after evidence emerged that they delivered the drug at an inadequate rate, thanks to lobbying by Ms. Pera and other ADHD advocates. Even more alarmingly, this phenomenon is not limited to a tiny subset of patients on this specific medication. Branded formulations of antidepressants and antiepileptics have also been associated with better clinical outcomes when compared to their generic counterparts.
I’ve only taken brand-name Concerta for almost two years now, and I haven’t thought about killing myself ever since. I am still a ride-or-die generics supporter in most ways; I’ll happily take the generic ciprofloxacin prescribed for my infected cartilage piercing, or pop a Daily Value loratadine when my seasonal allergies act up. But I was fortunate enough to be able to figure out what was happening to me. I had doctors who believed me and were willing to work with me to help me get the branded formulation of my Concerta. I’ve had the resources to afford the exorbitant fees my insurance charges for opting for a brand name instead of a generic. I want to share my experiences for the patients out there who aren’t as lucky, and for providers who want to do right by them.
Jolene Won is a medical student.
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