The People's Perspective on Medicine

Why Are Pharmacists Silent about Generic Drug Quality?

Some writers have raised serious questions about generic drug quality, but most pharmacists don't seem very interested in the topic. Why not?
Close up of a pharmacist hands selling medicines to a customer on a pharmacy desk

10 Reasons Why Pharmacists Are Silent about Generic Drug Quality:

Two recently published books (Katherine Eban’s Bottle of Lies and Rosemary Gibson’s China Rx) spell out in graphic detail the shortcomings of the FDA and the generic drug industry abroad. One might think that there would be an outcry from the world of pharmacy. After all, pharmacists are ultimately responsible for the products we sell. Why have we heard nary a peep from pharmacists about generic drug quality? 

In my opinion, if you were to ask a pharmacist at a chain drug store whether he feels generic drugs are always as good as brand name, he/she is most likely to say yes. Whenever customers asked me that question, rather than open a huge can of worms, I would typically say that the FDA approves generic drugs. I said this knowing full well that the FDA is quite lax in checking generic drug quality. Instead, the agency naively relies on generic manufacturers to submit truthful data.

I have never worked in a hospital pharmacy so I am not very familiar with the attitudes of hospital pharmacists. I worked my entire career for chain drug stores. So my opinions may be more applicable to pharmacists who work at chain drug stores and independent pharmacies in comparison to those who work in hospital pharmacies.

What Do Pharmacists Think about Generic Drugs?

If I were to discuss generic drug quality privately with other pharmacists, their first reaction would probably be that customers who complain about the effectiveness of generic drugs are kooks, or those customers are simply imagining a difference between generics and brand name drugs. Their second reaction would be that I am a troublemaker for raising this question.

I agree that some fraction of pharmacy customers who complain about the quality of generic drugs are imagining a difference. But I don’t know what that fraction is. I believe that all pharmacists have been confronted with some number of customers who question the effectiveness of generic drugs. Are all of these customers imagining such a difference in effectiveness? Or could some of them be correct in their criticism?

[1] Ninety percent of prescriptions are filled with generic drugs.

You need to realize that the utilization of generic drugs is the primary strategy employed by state and federal governments and private insurance companies to hold down drug expenditures. Because pharmacists fill 90 percent of prescriptions with generic drugs, pharmacists fear that the financial viability of the pharmacy would be in jeopardy if serious questions were raised about the equivalence of generics to brand name drugs. When you’re talking about 90 percent of the business of a pharmacy, this is an extremely important subject.

[2] Most pharmacists trust the FDA to assure generic drug quality.

The biggest reason that pharmacists do not criticize generic drugs is because pharmacists believe the assurances from the FDA that generics are as good as brand name. I believe that most pharmacists and pharmacy educators assume that the FDA is very thorough in examining the quality of generic drugs that are manufactured abroad. I do not believe that most pharmacists and pharmacy educators know that the FDA largely depends on the honor system. The FDA largely depends on foreign manufacturers to submit truthful data to the FDA. As Katherine Eban points out in Bottle of Lies, that is clearly not happening in a shocking number of instances.

[3] Federal and state drug expenditures would skyrocket if fewer generic drugs were dispensed.

If the quality of generic drugs were acknowledged to be frequently inferior, the federal government and state governments’ budgets would explode because they would have to pay for many more brand name drugs. It seems evident that many brand name manufacturers are engaged in a game of price gouging to see how much they can increase their profits. Thus, the expenditures for drugs for people on Medicare or Medicaid or the Veterans’ Administration would skyrocket.

Some pharmacists have a negative attitude toward customers on Medicaid, which is medical assistance for the poor. Many pharmacists feel that state Medicaid expenditures for drugs are quite generous and that many of these Medicaid customers don’t seem to appreciate the generosity of taxpayers while hard-working people often have difficulty paying for the same drugs. And, to make matters worse, sometimes people on Medicaid are rude or impatient pharmacy customers. Thus many pharmacists dislike many Medicaid customers and don’t want to see their own taxes increase to pay for people who are sometimes seen as rude, impatient and unemployed slackers. That definitely does not apply to all Medicaid customers. Many Medicaid customers are very fine people living under difficult circumstances.

[4] Generic drugs save taxpayers and insurance policyholders lots of money.

Many or most pharmacists believe that customers who complain about generic drugs simply don’t like the fact that Medicare or Medicaid or private insurance seem to be coercing people to use generics. If state governments are struggling to pay for drugs for Medicaid patients, those costs would increase tremendously if many generic drugs were removed from the market. In addition, if the FDA were to be stricter with foreign manufacturers, drug shortages in this country would become even more acute and widespread.

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[5] The cost of the pharmacy inventory would explode with more brand name drugs.

The average drug store has something like 2,000 or 3,000 drugs in the pharmacy department. Reducing the number of generic drugs for quality reasons would mean that the cost of the pharmacy inventory would skyrocket, potentially causing many independent pharmacies to go out of business.

[6] Generic drugs increase patient adherence and compliance.

Pharmacists know that the cost of prescription drugs is a big factor in determining whether patients will have their prescriptions filled. The two most common questions that customers ask pharmacists are “How long will it take?” and “How much will it cost?” Thus, pharmacists know that a customer is more likely to decide against having a prescription filled if it is very expensive. The customer then goes back to the doctor who prescribed the drug and says he/she didn’t have the prescription filled because it was so expensive. Consequently, generic drugs increase what’s commonly known in the profession as “compliance” or “adherence” (i.e., faithfully taking the drugs one’s doctor has prescribed).

[7] Pharmacists have no way of knowing whether customers who complain about generic drug quality are telling the truth.

There is no way for pharmacists to definitively tell whether our customers are telling the truth when they say that the generic did not work as well as the brand name. It’s not like having a mechanic fix our car air conditioner. Anyone can sit in a car and easily determine whether the air conditioner is working well. In contrast, pharmacists have no way of verifying that a generic blood pressure pill is adequately lowering the patient’s blood pressure. We don’t have time to physically take the blood pressure of all of our customers who take drugs for that condition, nor would customers or physicians stand for pharmacists acting like policemen to see whether our customers are truthful about generic drugs. Likewise, pharmacists have no way of objectively determining whether a patient’s anti-depressant is relieving the patient’s depression, whether a diuretic is adequately getting rid of fluid, whether the generic version of Ritalin works as well in controlling children’s behavior, and so on. We have to accept the patient’s word.

[8] Understaffing means there’s not enough time for thoughtful conversations with customers about generic drug quality.

Pharmacists who work for chain drug stores simply don’t have enough staffing that would allow them to have thoughtful and detailed conversations about the controversies surrounding the quality of generic drugs. These conversations simply take too much time and cause other customers to have to wait longer. This results in negative comments submitted by customers to corporate or regional headquarters. With the growth of production metrics which rely heavily on how much time it takes to fill prescriptions, pharmacists simply want to get customers out of the store as quickly as possible. Asking your pharmacist “Are generic drugs as good as brand name?” is a short question but it requires an answer that is often quite time-consuming.

Pharmacists working for the big chains are certainly less likely to question quality control with generic drugs if the district supervisor is standing nearby. Supervisors want pharmacists’ conversations with customers to be as positive as possible. I am now retired, but there is no way that I would have had a detailed conversation with a customer about quality control with generic drugs if my district supervisor were standing nearby.

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Many pharmacists feel it is their job to be deferential to physicians. The profession of pharmacy is in many ways subservient to the medical profession. We depend on physicians to write prescriptions. Thus many pharmacists have decided to keep their heads down and be team players rather than troublemakers. Unfortunately, this conformity may keep many pharmacists from being independent thinkers.

[9] Many pharmacists feel that criticizing generic drugs is bad for business.

Pharmacists downplay criticism of generic drugs for the same reason that pharmacists and doctors downplay side effects. Pharmacists who are employed in “retail pharmacy” work in a business. Businesses don’t survive unless they are profitable. Criticizing drugs is simply bad business for pharmacists and doctors. Doctors write prescriptions and pharmacists fill those prescriptions. It is bad for the financial well-being of both pharmacists and doctors when the public has a negative view of pharmaceuticals. Therefore pharmacists and doctors tend to downplay the potential adverse effects of pharmaceuticals. Perhaps physicians are more open to discussions about generic drug quality because physicians have little economic benefit in defending generic drugs, but pharmacists clearly do.

Dispensing generic drugs causes the public to feel that pharmacists are concerned about drug prices. If pharmacists were to question the quality of generic drugs made abroad, our customers would probably assume that is because we want to dispense brand name drugs to make more money. But, in fact, the profit margin on generic drugs is usually better than on brand name drugs.

[10] Many retail pharmacists feel they must be positive about pharmaceuticals.

Pharmacy is largely a conservative profession. Pharmacists who question the safety or effectiveness of drugs are seen as troublemakers and disloyal to the profession. Working for chain drug stores for my entire career, I have seen a very definite emphasis from corporate management to be positive in our interactions with customers. As pharmacists are increasingly monitored by production metrics, it is easier to be positive when answering customers’ questions about drugs. When pharmacists say anything negative, the customer typically wants (and deserves) a detailed explanation from the pharmacist for our negative comment.

The subject of generic drug quality is one that pharmacists don’t really want to discuss. Likewise, pharmacists were not interested in discussing the cardiovascular and cancer risks associated with the once widely popular hormone replacement therapy. Pharmacists are not eager to discuss the muscle pain and weakness associated with statin therapy. They would rather not discuss the tendon damage associated with fluoroquinolone antibiotics such as Cipro and Levaquin. Similarly, pharmacists are not eager to discuss the growing number of side effects associated with very popular proton pump inhibitors (PPIs) such as Prilosec, Prevacid, Protonix, Nexium and Aciphex. In my opinion, the subject of adverse effects of pharmaceuticals is the Achilles Heel of pharmacy. It makes pharmacists uncomfortable.

Are Pharmacists Scientists or Business People?

I do not view most retail pharmacists as unbiased scientists whose primary loyalty is to scientific truth. I view most retail pharmacists as very protective of pharmaceuticals. Those who are critical of the pills we dispense are seen as troublemakers and disloyal to the profession. Consumer activists like Sidney Wolfe, M.D., formerly head of the Public Citizen Health Research Group, are not, in my experience, admired by the majority of retail pharmacists. Such consumer activists are typically viewed as troublemakers by pharmacists.

The absence of discussion of important books about the quality of generic drugs (Bottle of Lies and China Rx) is similar to the absence of discussion of books that are critical of Big Pharma:

  • Marcia Angell MD, The Truth About the Drug Companies
  • Jerry Avorn, MD, Powerful Medicines
  • Thomas J. Moore, Prescription for Disaster
  • Melody Petersen, Our Daily Meds
  • John Abramson, MD, Overdosed America
  • Armon Neel, PharmD, Are Your Prescriptions Killing You? 
  • Jennifer Jacobs, MD, MPH, Do You Really Need That Pill?

In my opinion, the pharmacists I know are not particularly attracted to or interested in books that critically examine the world of pills. Pharmacists are busy raising families, paying school loans, making car payments and house payments, and saving for their kids’ education, etc. They don’t seem to want to be bothered with big questions that complicate their lives and cause our customers to have less confidence in pharmaceuticals. Pharmacists seem to want reality to be simpler than it is. They seem to want to believe that all pharmaceuticals are wonderfully safe and effective. This makes us feel better about our job.

How Do We Know Generic Drugs Are as Good as Brand Name Drugs?

The equivalence of generic drugs to brand name drugs is simply the narrative that pharmacy staff recites robotically in drug stores today. It resembles the long-standing narrative that margarine is safer than butter, even though that claim has recently been seriously challenged.

Many pharmacists proudly wear their white coats in the pharmacy and nothing seems to shake their rock-solid belief in the pill-for-every-ill approach of modern medicine. Many pharmacists don’t seem to know or care how corrupt the pharmaceuticals industry is. Many pharmacists do not seem to know or care that the FDA functions as an enabler rather than a regulator.

In my opinion, most pharmacists are much more concerned about their income than the safety and effectiveness of the drugs they dispense. I haven’t seen that the safety and effectiveness of drugs is at the top of the list of things that pharmacists worry about. In my opinion, the primary reason that students go to pharmacy school is because they know that pharmacists make a nice income. That was the primary reason I became a pharmacist.

The process of filling prescriptions is extremely monotonous and tedious, in many ways resembling the filling of hamburger orders at McDonald’s. The main difference is that a mistake in the pharmacy can be infinitely more serious than a clerk’s error in filling an order at a fast food outlet. A nice salary is all that keeps many pharmacists in the profession and silent about many things that trouble us every day. Many pharmacists say they would leave the profession today if they were able to do anything else that pays as well as filling prescriptions.

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    My pharmacy switched suppliers for losartan sometime before I got my most recent refill. The day after I took the first of the new tablets, I began to hear my pulse in my ears again. That had been a problem before they got my blood pressure under control, and sure enough, my BP is running higher than it had been (and higher than it should be).

    When I talked to the pharmacist, he told me all generics are identical, and it must be my health that has changed. He said I should talk to my doctor about a higher dose. I had a similar experience with a different medication some years ago. When the pharmacy switched generic suppliers, the medication became useless to me. I ended up on the brand and paid hundreds of dollars a month in order to have a drug that actually helped me. I’m afraid I’m going to be forced to do the same with losartan. So frustrating.

    Another newbie here. Because I read “Bottle of Lies” I pay cash, about $100 a quarter to buy name brand Synthroid and I would never buy generic. I also take generic methylphenidate and clonidine for ADHD. My take is that we HAVE to talk about generics in the public square and share difficulties we may have with generics. We also have to push pharmacies hard to be open about what generics they are stocking.

    Chain pharmacies are subject to the same pressures of any retail business. Many pharmacists are very ethical but what are they to do when corporate has sent them one supply, and they’ve had 10 people report issues with it. We have to go above our pharmacists to give them the power to speak up.

    This editorial is jaded, sarcastic, and focuses on money and money-related matters, Mr. Miller uses this focus to influence readers to think that most pharmacists won’t exercise ethical responsibilities to do anything about the problems with generic drug efficacy. Or lack thereof. He maligns the profession with his argument.

    There is also more than a touch of condescension here: stating that most consumers trust the FDA, and that the more you pay, the more it’s worth (better compliance with more expensive drugs?).

    And an outright attack on consumers, echoing Dr. House (remember him?) – “Everybody lies”.

    Mr. Miller’s point #8 is absolutely true – no time for meaningful conversation – but even pharmacists parrot the useless, canned advice to “consult your doctor or pharmacist”. Again, the lack of time gets back to the almighty emphasis on the bottom line, again – money. Lack of time is pervasive throughout the healthcare industry. However, each practitioner prioritizes available time and resources, depending on what each sees as most important.

    So – scientists or business people? I vote “none of the above”.

    I was given a generic drug that did not work the same as the non-generic that I had been taking. I complained to the pharmacist. I then went back to my doctor and was told that it was all in my head. Finally I insisted that I be given my original name brand drug or I would not take any.

    This article is outstanding, and well worth the read.

    I have taken many prescriptions through my life for many serious health problems. Generic drugs have the same drug in them as brand name drugs. The problem comes in when the potency can vary with a generic. For instance, thyroid medicine is given in microgram doses and when a generic is, for instance, 10-20% +/- in potency from the brand that can cause a problem for the patient.

    Also when someone complains the pharmacists should be able to tell the patient that there are different fillers in generics that may affect how well it is absorbed in their body.

    I have wonderful pharmacists who have always been honest and help me to figure out why something may not be working well so that them, my doctor and I can all be happy.

    Even if generic drugs were of good quality coming out of their labs, would they still be of good quality after sitting in a Fed X or UPS or US Postal truck in 90+ degree trucks for 6 hours before they arrive at your door or local pharmacy?

    This is so true. Especially among those who are taking benzodiazepines. The differences in quality among generics is startling and those trying to wean of these poisonous drugs are having more severe effects trying to go off with certain generics compared to others. We are given many excuses by pharmacist but it comes down to them thinking we are imagining it and we are NOT.

    Freshly honest about the business of dispensing drugs

    This article is right on the money. To my dismay I have watched Pharmacy change like all the health professions.
    As you point out, Dr. Graedon, the politicians have no reason to solve these problems. Greed has taken over the politicians, PBMs, Pharm companies, and Practitioners. My own opinion is that we have to start with the companies. No more payment support of the FDA is number one. Then like Europe, HHS tells the companies what they can make for profit.

    My pharmacist listens to me. He also conducts a meeting often with older people to go over their meds with them and talk about possible interactions, etc. I cannot take the generic Norvasc ( amlodipine) because it has absolutely no effect.
    When I could get the authorized generic version, it appeared to work very well, but it is no longer available as far as we can find out.

    Some generics are fine, others are not. I was on a generic paroxetine antidepressant for several years when my pharmacy switched to a different manufacturer. I could tell right away that it was not as effective. Every time I got the prescription filled, I had to specify that they not give me “manufacturer X” but “manufacturer Y.” I filled out a report on the FDA website but never got any reply from them.

    I find it distressing that the ENTIRE discussion revolves around cost and quality. Am I the ONLY person who isn’t convinced that every person in the country NEEDS all these drugs. It doesn’t seem reasonable to me that a person on 10-15 drugs is “healthier”. Everyone I’ve known who let themselves be talked into one of them (particularly as a “preventative”) ends up on multiple drugs in no time. I assume most of them are to deal with the side effects of prior prescriptions. I simply do not believe all these new drugs are particularly effective or necessary and the chemical cocktail many people ingest daily is beneficial and enhancing or lengthening their lives.

    Liked the old website better!!

    Dennis, your article interesting, disturbing, full of truth in most points raised. I went into pharmacy because of the science, because I wanted to make people’s lives better, and I view them as patients, not “customers.” You are right about many retail pharmacists viewing their patients as customers, but do not paint all of us with the same brush, please. There are different levels of competency in every profession. I tell my patients to shop for a pharmacist that they can trust & talk to. A professional that will provide them accurate information about their medication and will intervene and not fill prescriptions that may compromise patient safety. And yes, the salary is very nice, but that cannot be the only reason that someone goes to pharmacy school. It is too difficult to get into, even more difficult to matriculate. There needs to be an internal commitment to doing the right thing, safety & quality patient care.

    I am a clinical pharmacist who has both a BS and PharmD. My career was in the pharmaceutical and biotech industries. I retired as scientific medical liaison after teaching nurses, pharmacists, and physician fellows. My “retirement job” is in the retail/primary care sector. I have NEVER lost my scientific roots nor clinical focus. I use these skills multiple times daily and am patient focused. I have always had mixed feelings about generics, but believed that the FDA was protecting us.

    After reading Bottle of Lies, I have been on a mission: writing letters to government officials, calling my state Board of Pharmacy, telling all my colleagues that they need to read this book. I have priced out what it will cost for my husband to take branded drugs – somewhere in the neighborhood of $4000/month (this is for 2 drugs only + insulin). This is an untenable position for most people. We may do it anyway because I have lost faith in the FDA & the ability to protect the public.

    I am disturbed and angry that the integrity of our drug supply has been compromised so severely & it seems that nothing is being done about it. Where a drug is manufactured and where the raw materials came from should be on every vial dispensed. In order to do that state Board of Pharmacy rules need to be changed. Or it could be changed at the federal level. Either way, it needs to be done.

    My husband takes Effient anti-platelet to prevent blood clots since he had a serious heart attack and bypass surgery. On 6/18 he had a catherization and a stent placed in his cardiac artery. The shortness of breath went away, and he started feeling much better. On 7/5 his generic was changed to a different manufacturer. He started feeling ultra-tired and On 8/8 he had another heart cauterization, and the cardiologist found a blood clot nearly obstructing this new stent. The doctor was shocked; however, nothing was mentioned about the drug. Just that he needed to be more vigilant in diet, and another cholesterol-lowering drug was added.

    We insisted he be changed to the brand name to remove one variable. After his internist argued with the insurance company it was approved but just to the end of the year. His copay is $200, almost exactly the cost without insurance when he first started taking the drug 9 years ago. Now that cost is $600. He will be getting the prescription filled in Canada for $95 without insurance and manufactured in Canada by the original patent holder Eli Lilly. Thanks for providing the names of reputable Canadian pharmacies!

    This is a truly outstanding article. It takes someone on the inside to understand the motivations of typical pharmacists. And it’s in accord with my own experience in attempting to broach any of this with my own pharmacist. He didn’t want to know about it.

    The link to the author’s bio does not work!

    When my daughter was in high school, her Concerta authorized generic (same as brand) was replaced with a new “true” generic. We were bound by our insurance to use a particular pharmacy, where the pharmacist assured us the “true” was therapeutically equal to the “authorized” one. Unfortunately, my daughter suffered terribly, as the time- release mechanism dumped at times and seemingly ran out way before the 12 hours were up. It’s not the med the pharmacists assured us. Her psychiatrist said the problem was definitely the med. Still, our pharmacy flatly refused to fill with the authorized generic.

    Then the FDA changed the rating on the garbage pills from AB to BX. Amazingly, our pharmacy continued to dispense it because they didn’t carry the authorized one. I eventually went to work for a non-profit hospital system, used the outpatient pharmacy, and they dispensed the authorized (same as brand) generic. My daughter said it was so much better, like night and day. I don’t think all pharmacies are so ruthless. Some have an exemplary reputation for accommodating people needing the authorized generic. Our pharmacy was, in my experience greedy, ruthless, and straight up dishonest. I wouldn’t buy a stick of gum from that store.

    My husband takes Flecainide as his pill in a pocket for A Fib. He had been using a generic brand that worked well for him and always converted him to sinus rhythm within 3 hours. The pharmacy changed the generic brand, and it did not work at all on his next attack, so he had to go to the ER. The doctor said there were differences between generic brands, and that we needed to shop around to find a pharmacy that carried the brand that was effective for him.
    Although the pharmacy that carries the “good” brand is not a preferred pharmacy on our drug plan, we use that one. The extra cost of the prescription is nothing compared to the expense of going to the ER.

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