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A lot of people want the brand name because they think it might be better. They don't do the research and they don't want to take any risk with their health, so they just pay for the brand name. Sometimes this is a reasonable choice (as you say, not all generics are exactly equivalent) and sometimes it's not. People who won't do the research won't know which case they're in.

As for insurance companies, they're probably paying far less than the listed price, and have either negotiated it down to be the same as the generic (why not, it costs the same to make) or got close enough and are willing to absorb some extra cost in order to attract people who think it matters.

Also because the epipen's "blue to the sky" media push makes people think that strangers will better use a branded epipen. Schoolkids are taught epipen use, to recognize and deploy them, whereas othe auto-injectors might go disregarded in an emergency. People need to be taught to recognize all such products. If nothing else, it is time for a standard label.

> brand name because they think it might be better

There's also the "death problem". No customer likes to cut corners on something to save their life.

Yeah, that's what I meant, but the way you put it better emphasizes why people act this way.

Not an epipen, but my wife has to get one of her medications from a specific manufacturer due to side effects from the filler present in the most common version.

More generally, this is why so-called "me too" drugs aren't as bad as they are made out to be.

Welcome to medicine. I grew up the child of a doctor, and she always, ALWAYS, bought the generic. They're required BY LAW to have the same "active" ingredients; you just might be paying for a slightly different pill shape, packaging, or taste.

As the second link I've referenced above points out, there's a possibility that two drugs have the same active ingredients but but they absorb differently. Or one company can have a pill and the other a tablet that dissolves in your mouth. But I imagine that the clinical difference is negligible or nonexistent in most cases. I almost always get generic when possible.

But actually, one advantage of brand name drugs is that it could be easier to remember what they do. For example, sometimes I find old prescriptions in my medicine box (yeah, I don't have a good cabinet) and I don't remember what they are for. For example, I might see Zolpidem and and forget what is, but I'd be less likely to forget what Ambien is. But in general, this difference is worth very little to me and I usually get generics on principle.

Another potential difference is that the inactive ingredients can be different. Normally this doesn't matter, but there are rare occasions where people might have an allergy or other bad reaction to those. Of course, it's about as likely for the generic to be the better choice, so that's no reason to prefer the name brands, just a reason someone might want to switch.

This is something I've experienced often, not recognizing a generic drug replacement. My doctor, or at least the pharmacy I use currently, hast started putting the brand name my generic is replacing directly on the label. I've found it to be immensely helpful, especially, in cases where I've been working with my doctor to find the appropriate medication/combination.

I too have noticed this effect with one medicine in particular. I've had several different generics/brands and all worked fine, except this one make. I don't know what it was, but it just didn't work. Quite a strange experience.

This is true, BUT there's no reason to assume that the brand name absorbs better than the generic -- it's specifically NOT been tested.

> hey're required BY LAW to have the same "active" ingredients; you just might be paying for a slightly different pill shape, packaging, or taste.

Yes, but the margin of error of the amount of the active ingredient can be significant (up to 20% in either direction!).

The inactive ingredients can be relevant. Some people have allergies[0], and sometimes the inactive compound can affect the absorption of the drug (which can vary from person to person).

Generics are fine, but it's important to remember that they're not exactly the same as the brand-name drugs, and that can matter.

[0] For example, a lot of drugs contain lactose-based compounds as inactive ingredients, which is one of the reasons that a lot of drugs can cause diarrhea as a side-effect.

What's the mechanism of action for lactose causing stomach irritation? Lactase isn't found in the stomach so it can't be lactose intolerance (as in the common meaning of the phrase, ie. lactase non-persistence).

Microflora in your gut. That's what lactose intolerance basically means--it doesn't directly harm you, but when it's not taken up by the intestines because you lack the lactase enzyme it's consumed by microflora, which create gas and other issues. Kinda like beans which haven't been properly prepared and contain too much non-digestible starch.

It's also why some people who are genetically completely lactose intolerant can actually consume quite alot of lactose, and conversely why people who are genetically lactose tolerant can suffer from gastrointestinal issues pretty easily from dairy products, especially if they haven't consumed them in awhile. The tolerance or intolerance boils down to how the microflora react, not specifically to whether the person produces lactase.

That happens after the stomach.

Did the previous poster edit his comment? I realized after the fact that you appeared to be responding to something different from what the post currently states.

Not as far as I know. My response was to "tolerance or intolerance boils down to how the microflora react", which does happen after the stomach, so it seems unlikely that it could influence stomach irritation.

The word "stomach" doesn't appear anywhere in chimeracoder's post. It only mentions "absorption" and "diarrhea", both of which imply the intestinal tract.

Chimeracoder appears to have edited it. It originally said "stomach irritation".

Totally fair; thanks for the extra info!!

There are examples of generics that were different than the branded versions. Wellbutrin is a great example. A few generic versions were pulled since they dissolved at a different rate and delivered much higher doses of drug and causes side effects. Same thing with a few version of valprolic acid for epilepsy.

The law states the generic should be within 80% to 125% bio-equivalent of the branded version. Normally that's good enough, but for some drugs it causes problems.

Two words, price segmentation, only in that case you don't get anything for the premium except the illusion of better quality.

On a related note, in Quebec, Canada, 9 months ago, a new law passed forcing doctors to prescribe generic version of drugs if they exist (edit: and of equivalent quality). If you still want the brand name, you have to pay the difference.

Now we are flooded with ads from big pharmas telling us to chose the brand name because they are now miraculously the same price as the generic!

Adrenaclick has existed for a long time.

Adrenaclick is the same drug as EpiPen, but a different injection mechanism, so it's a different prescription (if your doctor chooses to prescribive a specific injection mechanism)

The news here is that CVS has a marketing and distribution campaign for a generic alternative to Adrenaclick.

Perhaps we should, as a society, consider the possibility that we might not need branding in medicine.

Also, I suspect there's a lot of doctor<-rep pay4play going on.

There may be quality-control binning involved. Lots that pass the brand-quality standards tests get sold as EpiPen, and those that pass only the minimum standards tests get sold as the generic. There is probably also a "ship overseas" bin. Those tested as dangerous or defective are destroyed.

Of course, that's how I would do it. It is also likely that there is no binning involved at all, and that quality is exactly the same for a branded EpiPen at $600, a generic at $300, and one smuggled through customs from Canada at $150.

> Unless I'm missing something, that means that until now, the company that makes the brand name drug and artificially inflates the price (and blames it on insurance companies) also made the only generic version of the product.

That's actually quite common. For a lot of drugs, the place that manufactures brand-name drugs will also manufacture (some of) the generic versions available. (This may or may not be operated directly by the pharmaceutical company itself).

For really common medication, there will be multiple plants that manufacture the drug. But for less-common drugs[0], it's possible that there is only one place that manufactures them.

> So it's hard to claim that there's even a minor difference, unless the company specifically manufactured them differently

Quality control, for one. Generics are allowed to have a rather wide margin of error on the amount of the active ingredient they contain, for example. Brand-name drugs tend to keep their range much tighter, because they want to protect their brand.

EDIT: To clarify the statement "wide range of error", there are a couple of different ways of looking at it. Think of mean and variance: a drug is allowed to have varying amounts of drug from pill to pill, and the distributions of the active ingredient can have different first (mean), second (variance), and third (skewness) moments in the generic and brand-name versions[1].

But on top of that, there's the question of measuring the active ingredient by mass in the pill, vs. measuring the bioavailability of the drug (ie, how much actually is available to the body to use). The latter is the thing we actually care about. The problem is that defining that is a tough problem, because it differs from person to person, and some inactive compounds affect absorption in some people but not others. Short of literally manufacturing the generic and brand versions simultaneously and randomly assigning them as they come off the belt[2], there is no way to guarantee that bioavailability will be identical between the two drugs for a specific patient. If they have different inactive compounds, or if any part of the manufacturing process differs in any way, they will be different for some subset of patients, and there's no amount of testing that can change that basic fact.

After a drug is approved and becomes generic, the brand name and generic versions are subject to the same rules[3]. The generic drugs aren't "different" from the brand name in this respect; it's just that the brand name is a known entity, whereas it's hard to request a specific version of a generic compound. So if you know that a brand-name version works, it can be preferable to stick with that, because you can always request a prescription to be filled by the brand-name ("dispense as written").

[0] and this is a very long tail, so it's quite likely that a drug you take or have taken falls into this category

[1] To be pedantic, we know from continuity theory that they have to be different, so the question is how different do we allow those to be?

[2] Which, to be fair, is not too far from how some generic drugs are made, but this is completely opaque to the end-consumer and subject to change without notice.

[3] http://www.fda.gov/downloads/AboutFDA/Transparency/Basics/UC...

Generics are allowed to have a rather wide margin of error on the amount of the active ingredient they contain, for example.

What's the range?

This FDA brochure says that generics are held to "rigorous" standards "with respect to identity, strength, quality, purity, and potency."

http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsi...

Should I worry that the FDA is blowing smoke?

I've read and heard that FDA rules allow generic to get 80% - 125% of the active ingredient into the bloodstream as the original drug. Of course the manufacturing tolerances are much better than that, so makers often put just enough to make the 80%.

My links says The generic drug manufacturer must prove its drug is the same as (bioequivalent) the brand name drug. For example, after the patient takes the generic drug, the amount of drug in the bloodstream is measured. If the levels of the drug in the bloodstream are the same as the levels found when the brand name product is used, the generic drug will work the same.

So there should be some specific FDA regulation someone can find that explains what they mean by the same there. I can certainly believe that the regulation would specify a range, but I'd like to see it.

My link also contains a suspiciously pertinent paragraph when you consider that 125-80=45:

FACT: FDA does not allow a 45 percent difference in the effectiveness of the generic drug product.

It's not clear that they would actually be referring to the same meaning of 45% but it is at least an amusing coincidence and there is some chance the FDA is frustrated with whatever it is you read.

Yes. If you have doubts, check out the quality of data collected by the FDA's adverse event reporting system.

- https://open.fda.gov/

- https://github.com/rOpenHealth/openfda

- https://github.com/statwonk/openfda-dashboard

Do you have details on the wide margin of error for the active ingredient?