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They were never really properly investigated.

Eban's "Bottle of Lies" book is shocking: https://www.katherineeban.com/bottleoflies

Peter Attia on Youtube also did an investigation on this.

If you're lucky your drugs have the right amount of the active ingredient. If you're unlucky they have chalk dust in them. If you're even more unlucky, they have carcinogens in them.

the term carcinogen is very broad, I think you just mean the bad ones can cause harm (sorry, former CA resident here)

> the term carcinogen is very broad

No, it is very much not. https://www.merriam-webster.com/dictionary/carcinogen

> I think you just mean the bad ones can cause harm

There are no "good" carcinogens. They're all bad. They all cause harm and cancer because that's the one and only meaning of that term.

Carcinogens cause cancer. Not just random harm.

Cause with some probability, right? What's the increase in relative and absolute risk? (+ dose?)

Yes, I would avoid them too. Compounded with corruption and other issues, pharmaceutical plants are regulated at a state level and the regulations vary widely. In some states, like Gujarat, the minimum level for the active ingredient to be be present in a drug is 0%. You can be getting a placebo and not be able to do anything against them because it is fully legal. From people I know in the business, it is quite common to have very large variations in active ingredients in a compound and blatant disregard for safety norms. Largely though, the poorer quality drugs are sent to African countries and higher quality end up in Western markets.

If a war happens that cuts off Europe from the factories in Asia I wonder how long the supplies last?

I'm actually not at all an isolationist. I love trade. But there are certain things a sovereign nation should not outsource. We had a warning with COVID about this but apparently saving money is more important.

> For the last decade, I've requested my pharmacies to not give me any drugs manufactured in India if possible.

> The problem now is almost every generic drug is made in India and I'm having a near impossible time avoiding them.

How often do you find pharmacies are able to meet your request? How can you even tell? When I receive a prescription I have no idea where it was manufactured.

Packages (be them bulk for use in pharmacies or set packages) generally have their country of origin on them, often with some level of detail of where specifically.

Yea and you can look up the manufacturer on openfda api

https://open.fda.gov/

The company that manufactured it is on the label. Oftentimes a Google search will show they’re partnering with Indian manufacturers.

When working with a new psychiatrist, I like to perform a test and establish ground truth that will serve as the basis of our work.

I mention as soon as possible that I'll be requesting name brand prescriptions. If they get it and clearly understand why I'd request name brand, then, great, they've passed the test and we can continue. If they balk, I explain:

1. That the teva-brand generic budeprion XL that I received in place of name-brand Wellbutrin XL in 2010 caused a catastrophic relapse of my symptoms -- and was shortly afterwards withdrawn and banned from the US market.

2. That after I was switched to generic amphetamine salts from the name-brand Adderall formulations I'd been taking, blood tests revealed -- repeatedly -- that there were no detectable amphetamine metabolites in my body, and I was incapable of functioning. As soon as I switched back to a name-brand formulation, the metabolites suddenly reappeared at the expected concentration in my bloodwork, my symptoms abated, and I was able to resume the parts of my life that had derailed in the intervening months.

3. That if the doctor has any problem with or doubts about my requests for name-brand-only, dispense-as-written prescriptions, I will find a different psychiatrist.

This reminds me of the Rizatriptan I take (a migraine medication). I'm supposed to dissolve the tablet in my mouth. Most batches wont dissolve, they form like a clump dough under my tongue until I eventually swallow the clump with some water. But occasionally I get a good batch and I'll put it under my tongue and a few minutes later I'll be ready to swallow the clump of dough but find that the tablet has completely dissolved into nothing. I couldn't believe it the first time it totally dissolved, it was like magic.

I suppose I should ask the pharmacist, because the quality control is all over the place on this medicine.

If you remember what the pill that dissolved properly looked like you can usually search drugs.com to find out the probable generic manufacturer based on color, shape, imprints.

My pharmacy seems to alternate randomly between the dissolving and non dissolving kind, which is a fun additional detail to figure out while trying to get the damn package open.

The problem I've encountered is that for so many drugs, especially generics, it's impossible to find a middle ground on cost that allows me to pay a reasonable amount for the higher quality without going broke. So often my choices are either the generic from India (how many times I've seen Dr. Reddys Labs on the packaging...) for a fairly low price, paying effectively full price for either a 'brand name' generic or the actual brand name.

When it's something simple like Bactrim the price difference is large percentage-wise, but still palatable. But for so many other drugs the price difference is 1000's of percent between the two, even if I use stuff like GoodRx.

The prices on the drugs from india have so undercut generic manufacturers elsewhere that they have to resort to either harder-to-manufacture/more-expensive generics, or just go out of business.

So much of the blame for this, at least in the US, lies at the feet of the health insurance and pharma industries.

> I've requested my pharmacies to not give me any drugs manufactured in India if possible.

Are the brand-names manufactured to a higher spec?

Even though you are right - everyone should demand safe generics, because there is no healthcare in any country without them - your words will get lost in the mire of the mind of the libertarian Hacker News 22 year old, who takes no non-stimulant medicines, telling you nobody is forcing you to do this or that, that you should just die.

Supposedly no, but in reality what happens is that when a drug is approved, lots of documentation about that drug + formulation is already published as a result of the R&D processes along with agency oversight in various countries.

When a brand name drug goes off patent, everybody (including competitors and generics manufacturers) already has a pretty good idea of both 1) the commercial market for generics, and 2) the components of the drug.

What isn't shared are trade secrets disclosing manufacturing processes, as well as the inactive ingredients+formulation of the drug. Competitors & generics OEMs are left to guess and use best judgment when they create competitors to the original, and sometimes they make bad decisions.

Actual manufacturing quality should be equally high, but the resulting drug may not end up being exactly the same as the branded version, even if the differences have nothing to do with the active ingredient.

There's also a certain amount of tolerated variance in generic drug manufacture. Sometimes this isn't a big deal, but other times it can be a problem. For example, if my generic tizanidine (muscle relaxant) is 10-20% less or more effective, it's not really a big deal: I get a little sleepy or need to take an extra pill. When I was on duloxetine for nerve pain, though, I could feel the swings/differences in generics and it was a major problem.

yes. i’ve seen the sausage being made. the quality of the factories making the drugs varies wildly. and the factories where the brand names make them are generally much higher quality in all respects.

edit not to mention the processes can be wildly different too as those are not part of the initial disclosure to get patent protections.

I've seen the sausage being made and actually made it myself.

In every example I've come across, branded medicines (at least for the big companies) are made in the manufacturers own factories.

Pfizer, Novartis, Merck, etc all have their own factories in Europe and North America.

I suspect most libertarians think the biggest problem here (and in many other areas) is that the government is providing a guarantee of safety, but not actually taking the steps which are required to ensure safety (because it'd be extremely difficult).