You’re at the pharmacy with a splitting headache. Should you reach for brand-name Aspirin, or save a few bucks and go for the generic version of the drug sitting right next to it on the shelf?
That’s a question Canadians are increasingly likely to face when it comes to prescription drugs, too. As pressure mounts on public and private insurers to keep a lid on soaring drug costs, you may have no choice but to pay out of pocket if you want to stick to the branded stuff.
The debate on generic vs. brand-name drugs has become a political hot potato in Canada, the U.S. and many other countries. People — including politicians — usually have an opinion about it.
Ask a doctor, however, and you’ll likely hear that the answer is complicated.
Generics are similar, not identical, to brand-name drugs
A generic drug contains the the same active ingredients as its branded cousin. But it can differ from the reference pharmaceutical in two ways.
First, when it comes to the active ingredients, generic drug makers are required to show that their products behave in similar — but not necessarily identical — ways in the body. Second, the non-active ingredients in a generic drug can be different than what you’d find in the better marketed stuff.
“You give a tablet orally, but what you want to reach is a certain level in the blood that is considered to be sufficient in order for the drug to achieve its goal in terms of efficacy but not necessarily to exceed it, because very often if you go over a certain level of exposure, you might have undesirable side effects,” said Brian White-Guay, a practising physician, who recently retired as professor in the Faculty of Pharmacy at the Université de Montréal.
Health Canada, like other public health regulators, has strict rules around what it means for the active drug to have similar efficacy and for what drug makers can use as non-active ingredients.
But is ‘similar’ always good enough?
“Family physicians in Canada would say that generics are generally identical to the proprietary drugs,” said David Price, professor and chairperson of the Department of Family Medicine at McMaster University.
However, he added, “we do know that there are specific examples where if you’ve been on a proprietary drug, sometimes it’s better not to switch to a generic.”
One area where doctors have flagged possible adverse effects from moving patients to generic drugs is psychotropic drugs, such as antidepressants and anti-psychotics.
“The assumption has been that if [a generic drug’s] pharmacological structure is similar, then [its] safety, efficacy and tolerability is also similar,” said Roger McIntyre, professor of psychiatry and pharmacology at the University of Toronto.
And that, he added, “is a very dangerous assumption.”
The scientific community needs significantly more data than it currently has to properly compare generic and brand-name psychotropic drugs, he added.
McIntyre told Global News he’s seen at least 10 cases of patients who had been stable for years on anti-depressants but suddenly relapsed after their pharmacy switched their prescription to generic drugs.
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Even switching between generic drugs can be tricky
Switching drugs isn’t just a potential problem when going from a pricey bran-name product to the cheaper, generic version of it.
Generic versions of the same drug may also be similar, but not identical, to one other. Even a difference in non-active ingredients might have undesirable effects in some instances, by causing side effects in certain patients or affecting the way the active drug behaves in the body, said White-Guay.
In fact, that’s becoming a growing concern, as more and more of the drugs used to fill prescriptions are generic.
The use of generic drugs has been soaring across many advanced economies in recent years, in part because the patents on a number of blockbuster drugs have expired, allowing generic manufacturers to produce and market their own, cheaper versions of the medicines.
But public and private health insurers are also increasingly pushing generic drugs. That’s because spending on pharmaceuticals has ballooned, due to aging populations, people of any age using more prescription drugs, and the sky-high price tag of a few new breakthrough drugs, said Rosalie Wyonch, a health policy analyst at the C.D. Howe Institute.
Between 2015 and 2016, for example, spending on prescription drugs went up 12 per cent for public health plans in Canada. And a full eight percentage points of that increase was due to one specific class of new patented drugs for hepatitis C, which can cost more than $10,000 a year per patient, Wyonch said.
Substitution to generic drugs is one of the ways in which insurers are offsetting these cost pressures, she added.
In 2017, generic drugs accounted for 70 per cent of retail prescriptions, but only around 20 per cent of Canada’s spending on prescription drugs, according to the Canadian Generic Pharmaceutical Association.
Still, Canada has been grappling with drug shortages, 77 per cent of which involve generics, according to a recent C.D. Howe study co-authored by White-Guay.
In other words, drug-swapping may happen not just because a brand-name drug isn’t covered by insurance, but because, say, there’s a shortage of generic drug A and only generic drug B is available.
Doctors can write “do not substitute” on a drug prescription, if necessary, White-Guay said. However, patients often have no idea whether they’ve gone from a brand-name to a generic or from one generic to another, he added. And that makes it harder for doctors to spot and report adverse reactions from swapping drugs.
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Still, cases where switching between versions of the same drug present problems are usually the exception, not the rule, Price said.
“Most of us would say, in general, they are very equivalent,” he said.
That, though, isn’t necessarily true of mail-order drugs, which don’t necessarily meet Health Canada’s standards.
Trying to cut costs by buying medications online is risky, said Price.
“Often, you pay for what you’re getting.”
So, brand-name Aspirin or no-name aspirin?
It depends, said Price. If you’re dealing with a mundane headache, you may find that a generic doesn’t work as well for you as the brand-name variety. Or it might work better. Either way, the health stakes are low.
However, if you are, say, taking aspirin as a blood thinner because they found a clot in your lung, you’ll want to have a chat with your physician before changing anything.
“Most times, your family doctor won’t know the answer right away and will have to do some research into it,” Price said.
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