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Truth about DAW-1

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I really get angry when I see a DAW-1 on a prescription.  To me, a DAW-1 without a good reason is like saying “Hey pharmacist bitch, do what I say right now because I’m the doctor and I know whats best in drug-land”.  Bzzt, welcome to AngryPharmacyLand.

For those who don’t work in medicine, a DAW-1 means “Dispense as Written code 1” (There are a bunch of DAW codes to signify different things like “Generic not available”, “Brand dispensed as generic”, etc).  However a DAW-1 is doctor speak for “I want this Rx to be exactly how I want it, I don’t want any changes/substitutions made”.

Now some doctors are confused.  Lets indulge ourselves into what a DAW-1 means from a pharmacist standpoint.  You see, DAW-1 (to us) is meant to be used when a doctor wishes a BRAND NAME medication used instead of a FDA approved generic.  Most (if not all) states allow the pharmacist to auto-substitute a generic when the Dr writes the brand name on the pad.  This is great because I’d rather have doctors write Maxide instead of  triamterene/HCTZ.  Brand names are shorter and (especially with birth control) a whole lot easier to deal with. 

If a Doctor gets a wild hair up his/her ass and wants trade name Maxide (HAHAH!), they would write Maxide (DAW-1) while checking and initialing the little box by where they sign their name (which NO doctor can seem to get right) to prove that they indeed want the brand name dispensed instead of the generic substitution.  This also can be noted by putting “DNS” for “Do Not Substitute”.  Again, the checking & initialing the little “Do Not Substitute” is beyond an MD education.  If you cannot get this right, then obviously there should be some question as if the DAW-1 is education driven, or some big-titted drug-rep driven.

Whats funny, is when doctors (but mostly PA/NP’s) put DAW-1 on EVERYTHING thinking that it means something.  Diovan (DAW-1), Lipitor (DAW-1), Zyvox (DAW-1).  Now you (and only you) may feel like you are doing the world a favor by putting DAW-1 on a bunch of Rx’s for brand-name-only products, but you’re just looking like an idiot to us pharmacists.  You may think you are actually doing something via the DAW-1 code, but I hate to tell you, most states do not allow us to substitute completely different drugs, only a brand name drug to its FDA-approved generic.  So you are telling us DO NOT SUBSTITUTE a generic for a drug you wrote that has no generic out.  Way to go! You’re a winner!

Wait, you think that the patients insurance company will give 2 fucks about your DAW-1? Hate to tell you, but for all they care you can take that DAW-1, roll up really right and shove it straight up your ass.  99% of the insurance companies laugh at your DAW-1 and make your ass fill out prior-auth paperwork in lieu of putting DAW-1 on the Rx.  Even if they do take the DAW-1 code, they just make the patient pay full price (or just flat out refuse to cover the medication).  Now the patient gets no medication because you are too hooked on the pharma-pot-pie to “settle” for a generic (and the patient cant afford the brand name).  A winner is you! Thats patient care right there!  Remember, patient care does not start with you, it doesn’t start with me, it starts with whoever is footing the bill.  Who pays for the drug makes the rules for the drug (unless your patient wishes to pay for it, but we all know the F in Pharmacy stands for “Free”).

All kidding aside, I’ve seen loads of doctors do DAW-1’s for really stupid shit (like psycho endocrinologists for Glucophage, Glucovance, Amaryl, Glyburide, etc) only to have the patient be SO noncompliant that I could fill the vial up with cow-shit and get more therapeutic response than your DAW-1’d drugs.  Is it my job to make sure they take their medications? Sure, I blow them shit when they are 2 weeks late getting it filled, but I’m not their fucking nanny.  Teachers are also notorious for wanting trade-name stuff because they “deserve it” (and know SO MUCH MORE THAN WE DO).

Really, if you prescribers in the audience really want to get your point across with this DAW-1 bullshit, you are better off telling us WHY the generics cant be used or WHY the formulary cannot be used (brittle blood levels with warfarin/tegretol).  It’ll make it seem less bossy than DAW-1 (bitch!), but maybe (just maybe) we can save you a ton of time by faxing you the proper forms to sign or point you where to get that prior auth.  Give us more “here is why I want this” vs “I just want this because I can”.

So what do we do when a patient brings in a DAW-1 Rx that the patient cannot afford, and the doctor refuses to change it to something else?  The patient is now put into a position where he/she feels they need this super-expensive medicine that their “Obviously” intelligent doctor wants for them.  Never mind the fact that the pharmacist has about 3 alternatives up his sleeves that might not work quite as well as what the reps spout, however its affordable and wont take food off of the patients table.

Here is something else to consider.  Patient brings in a prescription for Drug-X that is DAW-1 for some reason.  Patient cannot afford the $200 cost and the doctor (being an ass) refuses to change it to something else that costs less.  Now the patient either forgoes treatment because the doctor wants THIS and ONLY THIS (even though a $12 generic might not work as well, but its better than nothing) or forgoes buying Xmas presents for their children or some other Quality of Life lowering factor due to the $200 they dropped for this drug.  Or worst case they just go without and get nothing.  Pisses me off when I call the doctor asking to change, and him/her (or one of their front end ‘staff’) says “Nope, we’re not going to change”.  My response is “Good idea, the patient can’t afford this, so now they will take nothing.” Asshats.

There is /always/ some sort of drug alternative in medicine. Sure it may not work as well or be exactly what you are looking for, but having the patient not take/cant afford the medication due to some drug-rep telling you that “this is new and better” when you had been using drug x for the last 20 years before it went generic last week is (to me) bad medicine.

Comments #

Comment by Senior Pharmacist on 2008-12-12 11:01:01 -0800 #

Another very enjoyable column. One of the things I appreciated about my years in hospital practice was when an MD (usually a stupid intern or resident) wrote for DAW, we just laughed our butts off and dispensed what we had. It took an attending, cosigned by the section head, then annoited by God (aka Chair of the P&T committee) to get a brand name drug when a generic was available.
btw…I can count on one hand the number of drugs for which I think there is believable evidence that a brand name drug is “better” than its AB-rated generic equivalent. So in reality, 99% of the time the MD isn’t settling for anything. They’re just being a pain in the butt.
Keep up the good work.

Comment by TheAngriestPharmacist on 2008-12-12 11:42:18 -0800 #

“I’ve got countless studies that say that brands are better than generic at patient and disease oriented outcomes.”
“Really, dick? I’ll send you one study. You send me one study. We’ll compare then talk tomorrow. Mine was just published in JAMA.”

Comment by RXDawg on 2008-12-12 11:43:15 -0800 #

This is one of the greatest things about working in hospital with a formulary. We don’t have this problem AT ALL. All ACEIs are converted to lisinopril and there are many other meds we can interchange. Now if we get out of a drug class then we start talking with the physician but the ones I work with are almost always very understanding about it. The versatility I have as a pharmacist in hospital vs what I could do in retail is astounding to me. I’ve never understood why retail law wont budge to allow things of this nature. To hell with MTM, if I was a retail pharmacist I’d be pushing for laws to back us up and make changes for the better of everyone involved if necessary.

Comment by Mike on 2008-12-12 12:03:33 -0800 #

Hey TAP, hopefully I’m reading incorrectly or you just mistyped, but you are not saying that generic drugs might not work as well as their brand name counterparts are you, because that’s what it sounds like. If so, then I wouldn’t blame MD for writing DAW1. As you know, for a generic drug to be approved it must prove to the FDA that it is bioequivalent to the brand name.
In PA and WV, the physicians must write “brand medically necessary” on the rx for no generic substitution to be made. This doesn’t really happen much around here except by your friends the dermatologists or in cases where the patients demand the brand name from the doctor and they are too spineless to refuse. Also in PA and WV, the law actually states that the pharmacist is “required” to subsitute a generic unless the physician directs otherwise.

Comment by Google Account on 2008-12-12 12:17:14 -0800 #

Hey, AP:
I’m a pathetic MD who lives in mortal terror of pharmacists thanks to your site. I dutifully do anything you tell me to do. I have a question, though, for you. I hear from endos that I should never Rx generic Synthroid. I do anyway because patient’s would kill if they had to pay for branded every month vs. the $4 generic. Same with Glucophage. I hear from heme’s never to do generic Coumadin, nevertheless I do it because often for the patient it’s not branded vs. generic it’s branded vs. no medication. What’s your spin? Is there anything I should be careful about, aside from the obvious like ARBs in diabetics with cough on ACE, etc.?

Comment by on 2008-12-12 13:14:03 -0800 #

This is interesting. The criteria the FDA sets for generic bioequivalency is the same criteria the FDA requires when the Brand Name makes a change to the product (formulation, manufacturing procedure etc). So, different batches of a brand are allowed to fluctuate as much as a generic. Even with narrow TI drugs, the horror!

Comment by Cathy Lane RPh on 2008-12-12 14:28:02 -0800 #

How the tide has turned in the past 20 years! Truth be told, this has been the issue ever since generics came out in the 80’s, just now, we pharmacists have more footing in freely suggesting to prescribers that DAW should be a very small minority in the bulk of commonly prescribed drugs.
Drug Topics sent out a survey the other day about differences between generic houses. There are some generic brands associated with tablets that crumble, or break, or packaged funny, but I don’t have any issue with the stated drug quantity. I am irritated with how some companies make the lettering hard to read, or expiration dates too small or if in unit-dose, the plastic requires iron fingernails, but unless I start seeing a company trend of recalls (and, it is alarming that there even the number of recalls we see notices for!) I’m not too concerned about generic manufacturers. It is irritating though that Baxter and its heparin mix-ups refused to redesign vial labeling until babies died, and then when they finally came out with something acceptable, they advertised themselves as being a leader of industry. I mean, shouldn’t leaders be pro-active, before deaths occur?
However, I have to chuckle every single time there’s reference made to ‘teachers’, because I cannot help but feel that a third grade teacher out there whacked a wrist with a ruler and there has never been chance for a decent revenge or something. All my folks were teachers and yes they seem to know how to get the most information out of other people, but they may not be aware of stuff I’m learning every day, so I treat all retired teachers the same as other patients, with respect as their pharmacist. I consider many of them as some of the more informed of my patients, but realize they’re like any other person that wants to know what’s new.

Comment by Hallawe MacLean on 2008-12-12 15:46:23 -0800 #

So true, so true. There is a doctor here in my town who combines two of your pet peeves. Improper use of DAWs and inability to use eScripts. Several months ago he made one DAW-1 prescription and apparently has not figured out how to turn off the DAW code in his computer so everything he prescribes comes with a DAW-1 now.

Comment by Steph on 2008-12-12 21:21:14 -0800 #

My favorite line–your new trademark?
“the F in Pharmacy stands for ‘Free’”
What? There’s no F in pharmacy?
I tell everyone about you–you’re the best!

Comment by Emma on 2008-12-12 21:23:29 -0800 #

My personal favorite argument with an MD for this one was a few months ago when Fosamax went authorized generic. The script said brand medically necessary and was going to cost the patient the same for 1 month as the generic did for 3. I called, no switch. I further try to explain that in this case especially, they really were THE SAME DAMN PILL, minus the cute little bone imprint on one side. Still no switch.
Apparently the patient was listening to me though because she brought in a new generic authorized script for the next month.

Comment by Steve on 2008-12-13 05:08:00 -0800 #

I had a doctor write DAW Atarax yesterday that was a half hour of my life I’m never getting back because the 90 year old man didn’t understand the number of ways I tried to explain that Pfizer doesn’t make the brand anymore

Comment by KDUBZ on 2008-12-13 06:45:53 -0800 #

Pathetic MD (sorry I wish you had left something nicer to reference!)
No need to fear, you obviously are willing to ask questions and have respectful dialogue, rather than thumb your nose. I am even going to go out on a limb and guess you are a friendly guy to deal with, which is IMO something this world needs more of. In my experience, even in cases where I would steer you towards the brand, generics the pt can afford always trump brand that is filled inconsistently. That being said, with regards to synthroid (sorry fellow RPh’s who disagree) I tend more towards the brand. If the pt starts with generic and stays with it, then ok. The problem comes in when pharmacies keep getting levothyroxine from different manufacturers. In other words I tend toward the brand so that the product is consistent for the patient over time. With Coumadin, I worked for a brief while in a clinic. We had a patient that went from brand to generic and in the same time went from stable, consistent INR’s to unpredictable swings in INR levels. Take home point here, don’t screw with whats working. As long as the patient is stable on either brand or generic then I would not switch.
But that’s just my opinion and I could be wrong!

Comment by on 2008-12-13 07:52:37 -0800 #

DAW 1.
On Minocin.
And what’s worse, they come with manufacturer coupons. So when the coupon finally expires the patient is left with a hefty copay or percentage and they’re irate, demanding to know why, and NO the doctor wants BRAND because the generic doesn’t work! Then we give them the price for minocycline and suddenly, it’s aokay, works juuust fiiiine.
TAP, most Rphs I’ve seen in the blogosphere don’t blink over Synthroid/Coumadin, but what about the anti-seizure medications, like Dilantin and Trileptal? I was always taught that you start one of those be it brand or generic, you stick with that and don’t switch.

Comment by drh on 2008-12-13 08:07:19 -0800 #

I don’t write anything DAW and, if I do, you can be sure I argued with the patient about it first. There must be some internet sites out there convincing some people that generic drugs are bad, because some of them can be so hardheaded. I tell them straight out that their insurance won’t cover it, and I won’t try to prior auth because it’s not warranted. 9/10 call back because they’ll take the generic once they find out the price.
Now, it would be great if you can keep giving my patients the SAME generic brand warfarin and levothyroxine consistently, but I don’t live in some fantasy world where I think insurance and patients will actually pay for the “brand” name.
Sorry so many of us docs are such a-holes. I think some of them think it makes them seem smarter and wiser if they insist on generics and then cite some kind of study to back it up.

Comment by Google Account on 2008-12-13 09:24:27 -0800 #

I have done a lot of research on the whole generic/brand issue and to the doc who was asking, it can be a concern with warfarin, levothyroxine, and several others but the KEY is to maintain the patient on ONE kind or, rather, one particular brand of the drug. Therefore, if there isn’t a good patient/pharmacist relationship, the patient could have different generics every month, and that could cause unstable blood levels. This is why the patient/pharmacist/doctor relationship is SO important! We must work together not against each other to take care of the patient and doctors need to realize that 99.9% of patient care happens in the pharmacy (thanks to HMOs and P{PPOs and PBMs and other useless initial agencies) and pharmacists do most of the legwork in getting patients their medicine! AND I DEFINITELY AGREE that a $5 drug that may not work the BEST is better than nothing, so take your ego out of it and get the patient some medicine.

Comment by random retail pharmacist on 2008-12-13 16:49:43 -0800 #

I’m not usually one to comment on blogs but some topics just get me… Don’t you just love it when a patient insists on the brand JUST because the doctor writes it so, and then when you tell them that it’s been discontinued by the manufacturer and they STILL believe there’s a way you can get it… because of course, the BRILLIANT DOCTOR (who doesn’t even realize that brand has been discontinued, so how smart could s/he REALLY even be?) said so…
What’s even MORE annoying is when the generic is ALSO made by the BRAND drug company… IE: Omnicef made by Abbott also manufactures the Dava generic cefdinir and the capsules WERE EXACTLY the same… (it said OMNICEF on the generic caps)… It’s like… the same damn thing… Of course, doctors who claim they know everything, won’t believe you. It’s all some myth that pharmacists make up to make money.
In response to NTI drugs, like phenytoin, levothyroxine, warfarin, etc… I inform patients that there is a generic equivalent (at a much cheaper alternative – some are even on those 90 day plans available at almost any pharmacy nowadays) but that they should always first consult with their doctor and that they may need additional bloodwork to ensure therapeutic levels. Luckily, the company I work for tends NOT to switch generic manufacturers every other day with these drugs – so they won’t receive a generic by one manufacturer one month and another the next… should be true for most other pharmacies.

Comment by Craig Terry on 2008-12-13 17:01:00 -0800 #

How about a Dr. writing for Aldactazide and Calan SR brand necessary. The patient informed me that the Dr. wanted brand because other generic blood pressure medications gave her really bad headaches. The best part is she only had me fill a 2 day supply for her because she wanted to make sure the meds worked and did not give her a headache. Thank god that I was able to transfer the meds to another store in my district. Or I would have been stuck with the Calan SR and Aldactazide until they expired.
I had some tell me that the pantoprazole,made by Wyeth, did not work the same as the brand Protonix. I tried to explain that it is the same medication,just packaged differently. She gave me a look like a calf looking at a new gate.

Comment by WAGslave on 2008-12-13 21:13:55 -0800 #

The way some prescribers write DAW-1, I swear that they must hold shares in Pfizer, Merck, etc. That’s the only reason I can think of that accounts for their resistance to comprehension when it comes to the interchangability of brands versus generics.

Comment by on 2008-12-13 21:20:10 -0800 #

My favorite was when a patient brought in a script for Altace (this was before the generic) and the insurance wouldn’t cover it and specifically said they would only cover a generic ACE. So I call the MD and leave a message with the nurse and she said she’ll get back to me. Ten minutes later she calls and tells me the doc is going to change it to Diovan. Um, what? He must have gotten a lot of lap dances from those reps to completely blow off the fact that I specifically said the only thing insurance will pay for is a generic ACE. Unbelievable! So glad he gives a shit about his patients.

Comment by Robert Stone on 2008-12-14 05:41:52 -0800 #

My problem is not brand vs generic, it is generic vs generic. I take oxycodone 30mg for chronic pain. Let’s just say it is a carcinoma and leave it at that. I used to get a nice blue pill that I could slap in my pill cutter and easily divide. Nowadays I get a hard little white pill that crumbles into about twelve pieces when I try to half them. WTF. I just can’t make this happen. I can’t afford double the number of 15 my pills nor can I afford brand (if there is one) and my oncologist and pain management docs don’t seem to give a shit. Is it my fault that a bunch of tucked up goth kids have decided to crush this stuff up and turn themselves into walking zombies. Do I sound pissed? Fuckin A bubba.

Comment by nodrugs4u on 2008-12-14 10:20:42 -0800 #

I believe that a big part of this brand/generic debate has to do with the word “generic.” Generic does not mean knock-off.
Quite a few of DAW=1 I’ve seen is so that the insurance company will cover the med. Sure, the copay is $50, but it beats the retail price of $399.99. Most insurance companies will cover brand under DAW=1, but not DAW=2. The patients know this and ask/convince/coerce/force their MDs to make it DAW=1.
Most MDs I interacted with do not care about brand/generic. “Whatever the patient want” is the most common reply to inquiries. Word of advice to the MDs. Make sure DAW=1, or excess of it, will not affect your bottom line. Depend on the contract, it can.
Now, if the drug chains do not change their generic manufacturers like a hooker goes through her Johns, the patient might have more faith in the generic. How would you like it the the same medication you’re taking looks different almost every month?
Allow me to side tract, if constantly changing manufacturers creates customer dissatisfaction, why do chains never change the manufacture on generic Vicodin? Come on, I’ve been using Watson 349 for years now. What’s up with that?

Comment by rxman95 on 2008-12-14 11:10:06 -0800 #

Ok this is only 1 of a few thousand pet peeves of mine with a local Dr. in our clinic. FYI in the state of MO the pharmacy has to call the Dr. to change a DAW to substitution permitted. We fill 90% medicaid and guess what medicaid or any 3rd party won’t cover? Yep you guessed it “BRAND NAME DRUGS” when a generic is out there. Well the Dr. I’m referring to always writes DAW on all of her Rx’s because she thinks that if she writes substitution permitted that a pharmacist can substitute any drug they want, not just the generic. I have tried to explain this to her, but in her infinite Dr bullshit wisdom she disagrees and said she will alway write daw. We had to purchase a stamp that says “dr. approved generic” so that we can stamp every one of these mother f*#*R*s. You would think that the Mo board of pharmacy would change the law so that they can’t hang our asses out to dry if we forget to stamp one of these bullshit daw scripts!!

Comment by Danielle on 2008-12-15 04:52:09 -0800 #

I have a question about Lamictal/Lamotrigine. When the generic first came about, I was thrilled to save a few hundred bucks a month (before we had health insurance). When I requested the generic; the doc told me the generic could be 20% less effective than the brand name because of the different suppliers. Is this true?

Comment by DaveK on 2008-12-15 16:29:50 -0800 #

OMG…great topic. You forgot about my personal favorite. The md checks the label box and expects brand. On several occasions, I asked the pt if they did it after the fact and they said no, but who knows…
Another fav…the diltiazem er’s. OK which one? Did you ever call an mdo on that one for a new pt? They have no idea. It doesn’t really matter, but if you’re prescribing the drug, know it. Verapamil is another issue altogether. You really should call if you get verapamil sr 120 1 qd. Granted the tabs s/b bid and the caps qd, but there are exceptions. And again…you can see the blank stare over the phone.
I completely agree on Synthroid and Coumadin…doesn’t really matter, but whatever brand you start on, stay on it. The problem is that you can’t be sure unless you DAW the rx. To make things simple, DAW Levoxyl – it’s cheap anyway but Levoxyl’s a generic and usually cheaper than Synthroid as a rule. DAW Coumadin and I’d add Dilantin too in the list of frequently prescribed drugs.
As far as the 99.9% of the other drugs, there are RARE cases where a pt has a rxn to an excipient, but far away the exception rather than the rule. This rash of new authorized generics (for those of you who don’t know, often when the patent is lost, the brand company sells the brand product as a generic – EXACTLY the same thing) has proven that beyond a shadow of any doubt. We were dispensing the auth generic for Protonix – EXACT same tab, even said Protonix on it. I even called the mfg and they confirmed that it came off the same presses – NOTHING different and yet we had patients who SWORE it didn’t work but the brand Protonix did. Fine…you might as well throw dollar bills out the window, but that’s your choice! I’m just glad I’m not on your ins plan b/c I don’t want my premiums jumping up b/c of your stupidity!

Comment by Crusty RPh on 2008-12-15 19:11:56 -0800 #

I have a patient whose endocrinologist is unwavering in his demand for DAW-1 on Syntroid and Gulcophage, but doesn’t seem concerned at all about the 30 days supply lasting 40 days between fillings. It is hard to take his DAW-1 seriously.

Comment by Google Account on 2008-12-16 08:52:15 -0800 #

I don’t know if other states have similar ‘rules’, but in Washington, if prescribers register with the state to be an authorizing prescriber (meaning they authorize substitution by the pharmacy of a formulary drug for all state insurance plans – Medicaid, L&I, and state employees) then they can sign DAW-1 to override the formulary restrictions. Example – patient has script for Diovan HCT. Dr is registered, but signs substitution permitted. The pharmacy substitutes lisinopril and HCTZ (of course, they review the patient’s history and make sure it’s appropriate) which are covered. If Dr is registered and signs DAW-1, then the Diovan HCT is covered. If the Dr isn’t registered, then the pharmacy has to go through the calls to change the script or to get prior auth.
In some cases, this system works well. In others, it’s just encouraged the Drs to sign DAW-1 for everything.

Comment by on 2008-12-16 17:50:51 -0800 #

you know, not to sound all pro DAW-1…but the way things are going with reimbursements on generics (almost literary giving it away for free with people on some insurances) there is probably a better profit margin on dispensing brands ..albieit a very low profit margin…
thats how bad things are getting

Comment by tech_girl_in_red on 2008-12-17 15:45:59 -0800 #

what about lamictal? is that one that shouldn’t be switched? we have and there were no problems but i was just wonderin what you all thought. what i hate is when guests want a generic that DOESNT exist yet. and they argue that they have seen it online so it MUST be commercially available and then dont believe me so i have to get the rph to explain to them what i just blathered on to them about

Comment by HRGPharm.D. on 2008-12-17 22:24:24 -0800 #

Today I got a script for a DAW-1 Aerochamber. It provided us with a good laugh. 🙂

Comment by FillMaster-5000 on 2008-12-18 04:42:58 -0800 #

Have the people who created Prozac (or at least, bought the rights to the name “Prozac”) come out with some new study they’re blowing up the asses of gullible MD’s everywhere that says brand name Prozac releases better than the generics, Because in the past few weeks I’ve gotten two new scripts from two different doctors for Prozac 40 mg DO NOT SUBSTITUTE. I haven’t dispensed brand name Prozac in over two years and then that was to some yuppie who wanted brand name everything.
Doctors shouldn’t feel compelled to write DAW-1 on a prescription just because their patient wants them to. If the patient wants us to fill with the brand name, all they have to do is say at the drop off window is “I don’t want a generic, I want the brand name” and we will fill the brand name (even if the Rx is written for “Doxycycline 100 mg”.)
Sure it may cost a lot more and they may have to wait a couple of days while we order it, but thats just tough cookies for them.

Comment by Google Account on 2008-12-18 04:56:02 -0800 #

I am really struggling internally with not allowing myself to print this and fax it to every fucking doctor in my town who DAW’s everything, which by my count, is about 8 of them.
Great column, thanks.

Comment by Mike on 2008-12-19 09:01:08 -0800 #

No it is not 20% less effective. See the following explanation:
Article; Pharmacist’s Letter; July 2008; Vol: 24
There is a big misconception that generics vary by as much as 20% from brand-name drugs.
Some take this to mean that the amount of drug in the PRODUCT can vary by 20%. Others think it refers to the amount of drug ABSORBED…or the average BLOOD levels.
These assumptions are wrong.
The difference between most bioequivalent products is usually less than 4%.
The “20% rumor” originates from a lack of understanding of the statistical tests required to show bioequivalence.
A generic drug must show that the 90% CONFIDENCE INTERVAL of the mean rate and extent of absorption is within 20% of the brand.
The confidence interval is just a statistical test…to indicate how much results vary from the mean.
The important point is that these results can’t vary much for the confidence interval to fit within the 20% range.
Reassure patients that generic equivalents produce the same therapeutic results in the vast majority of cases.
Keep in mind that generics are tested against the brand…NOT to each other. In rare cases this could mean slightly more variation amongst different generics.
For some very delicately controlled patients on narrow therapeutic index drugs, such as antiepileptics and warfarin, try to stick with the same generic manufacturer for each refill. View Detail-Document
My only other comment is about the NTI drugs mentioned. There was a study a couple of years ago that was conducted by the makers of Synthroid that attempted to prove that Synthroid was better than the generics. The results that the difference in bioavailability between Synthroid and the tested generics was equal to the difference between different lots of brand Synthroid. Of course they tried to keep these results as quiet as possible. Also, remember that either Maxzide or Dyazide was created because one was supposed to be the generic of the other (I can’t remember which one came out first), but had statistically significant better bioavailability than the current brand and couldn’t make less bioavailable to match the other so they decided to market their own brand. Just food for thought.

Comment by miraidebbie on 2008-12-19 21:37:36 -0800 #

Danielle: Like someone else said above, generics can be slightly different than the brand name but the margin of difference is the same for different lot numbers of the brand name product. In general I think seizure drugs are iffy and one class of meds you’d be more willing to stick with brand name (if you’re using it for seizures, I know it can be used for multiple things). I think of it like this. If when you were getting your dose figured out if at 200mg you still had seizures, 250mg you got bad side effects, and you putz around with 25mg tablets or splitting pills to get right to 225mg because that’s what works, I’d be less inclined to switch.
If it were me and it was costing me hundreds of dollars, I’d take generic in a heartbeat. The doctor can always adjust your dose to get the same response as before. But if it was the difference between paying a $5 generic copay and say $12 for brand, I’d be less likely to want to make any changes whatsoever in a drug for seizures, a blood thinner, etc.
We have a dentist that always checks DAW-1 for toothpaste. Okay, at least it’s not $200 when it’s not covered, which it never is, but still. And for the life of me I don’t know why endocrinologists start people out on brand name synthoid anymore, I feel bad for the people who are just pissing away $15 every month instead of $5 when they could have just been started on the generic in the first place. And if our pharmacy switches generics for levothyroxine 99.9% of the people see no difference and don’t care, and if someone throws a fit we can special order the old brand.

Comment by Talley on 2008-12-21 05:03:35 -0800 #

Hey Pharmacist Bit,
Give my patient the Metoprolol XL. And do not substitute with generic Metoprolol.
You think you can swallow the XL part and save the patient some money for the “Xtra Large” in XL? You could have become a doctor and saved the world. Still its never too late to change professions. You might think the “professional switch” is as easy as switching Metoprolol for Metoprolol XL for my patient with heart failure?
Next time you wanna swallow something, come over and suck my dick for a while so I will dispense ya something to swallow.

Comment by Shalom (R.Ph.) on 2008-12-21 07:36:27 -0800 #

HRG: you dispense brand-name Aerochambers?
It’s only Optichambers here, and an occasional Vortex. None of the state plans pay for Aerochambers.

Comment by THI on 2008-12-23 22:40:12 -0800 #

I got into a semi-heated debate with a patient about how her Watson-branded generic Hydrocodone 10/325 didn’t work so she needed name brand Norco, also made by Watson. I explained to her they were the exact same, down to pill shape, size, color, and manufacturer. She still managed to find a doctor who wrote a DAW script for the Norco.
About once a week I’ll get a script written for a generic with NDPS all over it. Makes me scratch my head and wonder what kind of doctor would write for Lisinopril, DAW.
It could be ‘Talley’, who fails to realize that Metoprolol XL (or more appropriately Metoprolol Succinate ER) is a generic in the first place. And that Metoprolol Succ. ER (Toprol) is not the same as Metoprolol (Lopressor).

Comment by Student of the Game on 2008-12-24 22:07:16 -0800 #

Tracking Some Friendlies

I’m tracking some friendlies out on the internet. The Angry Pharmacist, whom I have been a fan of for over a year now is just one of the types I look up to. Pharmacy Mike I have also been following, he is a good guy… though he used to sadde…

Comment by PharmacyChuck on 2008-12-27 19:47:42 -0800 #

In Florida, a “Medically Necessary” hand-written on the Rx is necessary for the DAW-1 to be valid. So generally when I get a “No Substitutions” of “DAW” box that’s just checked, or even “Med. Nec.” printed on the Rx rather than hand-written, I give the pt the prices and they quickly tell me to fill the generic. I don’t bother calling the prescriber, since intent is not really an issue if they don’t follow the letter of the law in this case. I had one pt starting Pegasys/Copegus with a “Medically Necessary” on the Copegus Rx that was going to run him $1000/month… the doctor never called back… never called back… meanwhile this poor guy is going without his meds and terrified that he wasn’t getting treatment for his HCV. Patient care, way to go. Anyone else have trouble not getting to talk to anyone with an education higher than 11th grade at a doc’s office?

Comment by on 2008-12-29 12:59:06 -0800 #

I wasn’t particular about generics vs branded drugs until it became apparent that the Procardia capsules I take for throat spasms contain an accidental additional active ingredient: the peppermint oil. The generics typically skip adding the peppermint flavoring and the saccharine…. It was several years before I realized that peppermint oil by itself has been demonstrated to help with my kind of throat spasms….
So I typically medicate with Altoids, and save the Procardia for situations where the peppermint oil intervention isn’t enough. {And yes, if I had an actual heart condition, I know that the 10mg capsules are _not_ the drug of choice}.
The only other time when I want to get a particular version of a drug [and if it’s generic, that’s fine too], is if I’m being prescribed an antibiotic — some of the versions of generic Amoxicillin come in large tablets that I can’t swallow… so I do make a request for the smallest version of the prescribed dosage [or I ask if I can grind the pill and wash it down with liquid…I used to work at a pharmacy school that got rid of its compounding laboratory and the faculty made off with impressive collections of glassware, including the mortars and pestles..].

Comment by Canpharm on 2009-01-09 14:36:13 -0800 #

Bottom line is that drug reps blow docs in order for their pet docs to write their expensive brand products. In Canada as in every other country, the government is looking at cutting their health care expenses. The first place they look to cut dollars is the pharmacy. Doc’s here in AB just received another 9% wage increase over the next 3 years by the gov to compliment their 15% increase 3 years ago. Did I mention the nursing wage increases that occur every time a bargaining session comes up with the government? Pharmacy dispensing fees haven’t changed in over 15 years and supplements paid to pharmacies from generic companies will soon end crippling an already struggling retail pharmacy environment. Smaller pharmacies will be forced to close their doors while bigger chains will absorb the business taxing already time strapped pharmacists in these bigger chains. More prescriptions mean more errors and lower customer/patient care. If the government really wanted to save everyone some cash they would remove drug reps from doctor offices. There is nothing wrong with generics that cost 50% less than brands. It would also help if doc’s would had courage to rely on their years of medical training instead of writing expensive brands that the drug rep told them to write. It’s sad but providing the best most cost effective patient care has lost it’s place in todays billion dollar drug manufacturing business. Drug companys spend billions of dollars each year to stick their greedy noses in doctor offices all over the world. They pay pharmacy software companies to view and monitor specific doctor prescribing habits. They use this info to design marketing strategies to pressure individual docs in order to have their products prescribed. Free lunches and golf passes from drug reps seem to work as well. The general public and even most health professionals have no idea what is happening. It’s dissappointing to see this part of the medical field.

Comment by Elly Glam on 2009-01-20 20:28:23 -0800 #

And don’t you just love it when the patient themself walk/stumble in with this CIII script for their 120 count of Percocet DEMANDING brand. I hate DAW 2, personally. So you type in the script as a “Waiter” promising them the script in 15 minutes or less because it is “urgent!!”. And not only is it the brand they want…they want the “green ones” and ONLY the “green ones”, because they don’t know the brands, they only want and know what fucks them up the best..oh excuse me, “works the best and takes away all the pain & agony they are in”. That’s the part they tell you AFTER you rush to feed their need. So now you have to check the safe, look through all the bottles and you don’t have any. You have their filled script ready to go and now you have to confront the patient, that’s the fun part. You go “I’m sorry, we only have the “yellow ones” in stock.” and then comes that look…the one where you’re the person that killed their dog, their grandmother, or just entirely ruined their life at that very moment. Fury overwhelms them and they demand their script back causing you to waste 20 minutes of your life over the fucking color of a pill. Daw-2 is the devil in disguise.

Comment by girl rx on 2009-10-12 20:02:17 -0700 #

Just thought I’d comment (pharmacist here too)… My brother has seizures and everytime they switch generic manufacturers without telling him he goes sub-tx and starts having nocturnal seizures. His MD wrote DAW and the pharmacist refused to fill Brand Lamictal — they claimed they don’t have to in the state of NV (not true I checked the law). Anyhow, when he switches from one generic to another…This has happened 3x times and when he goes back onto the old generic seizures stop… it’s clear they are not equivalent. Even, the American Neurology Assoc (??) has issued a position statement for seizure meds against generic substitution….

Comment by JC on 2010-01-14 06:46:55 -0800 #

I have been a pharmaceutical representative for 11 years and wanted to make a few observations. There is a wide price range from one pharmacy to another pharmacy for the same product, even when a pharmaceutical company has priced the product reasonably at the whole seller. I have seen products I promote range from ridiculous high mark up. I believe in the free market but the pharmaceutical companies are not the only cause for outrages drug prices. The pharmacies need to take some of the blame. I know from a friend who is a pharmacist that pharmacist bonuses are based on generic conversion (even when a generic is not available, thus the DAW1), which cost pennies on the dollar, but then the generic price is increased to just below the branded product’s price. This allows for a huge profit margin. I guess this is how pharmacy chains can afford the high dollar/high visibility real estate I see popping up all over the place.

Comment by Dream Mom on 2010-04-01 13:12:10 -0700 #

I have a son with a progressive neurological disease and I am a single mother and the lone caregiver. Recently, our mail order pharmacy decided to swap out a brand name seizure drug for a generic, despite the fact that the neuro checked the box and signed his name on the brand name only side. When I called the pharmacy, they claimed they could do this unless the doc wrote DAW1 on the prescription.

Here’s my issue. The generic does not work for him and he has intractable seizures. He’s on around a dozen different meds for different issues, some of the meds are for seizures. It’s a pain for me to make sure the doc has checked the box, signed the prescription for a brand name and now writes DAW 1 on it. In this instance, I called the mail order pharmacy to correct the order and tell them to dispense the brand name drug and not the generic. It took me a few more minutes to discuss this with them. What a waste of my time. I don’t intend to have to watch over the physician to make sure all prescriptions are written a certain way because the pharmacist chooses to do something different. The doc already signed and checked the box for brand name only.

I am well aware of generic drugs and the price difference however they don’t always work well for my son so I stick with the brand names. I have enough to do without having to oversee all of this. I think it’s easier for me to skip the mail order pharmacy and go to a local pharmacy where they will dispense the prescription as written. Of course, then I can make multiple trips to the pharmacy since they never have the entire amount available, even though I reorder some supplies every month.

I don’r have any nursing care and can’t afford a wheelchair van. I can’t lift my 180 pound son into the car and yet, I can choose to jump through the mail order pharmacy hoops or go to the local pharmacy and pay more. And the whole reason I choose to stick with the brand names is because the generics have proven to be a disaster for him time and time again.

For myself, I have no issue with generic drugs. On the rare occasion I need a prescription filled, I have no issue with it.

Before you attack the physician or even the patient, maybe you need to reconsider and look at a different perspective. As a mother and caregiver I have a few priorities of my own: 1) Don’t change what’s working. (If a brand name works, don’t change to geneeric.) 2) I need things to be easy. Anytime I have to make calls to resolve issues, it’s not easy. 3) I automate everything wherever possible. The pharmacist choosing to fill things differently, is a lot more work for me.

Perhaps in the future, it should be the patient’s responsibility to ask the doctor for a generic when they have limited resources.

Comment by TXJEN on 2010-04-05 09:31:31 -0700 #

I came across this blog while researching DAW-1s. I had been taking Name Brand Topamax (for Migraines) for 3 years but when the generic came out I switched to that (save a bit of money). I noticed almost right away that it was getting more migrianes that before but I chalked it up to being streesed out because I had just been laid off. After a year of being on the gerneric and switching everything else about my life and still getting migrianes and feeling like crap all the time I finally realzied that it was the generic Topamax that was the root of my problems. I went to my pcp and requested that she do the appropriate paperwork for me to recieve the name brand. After 3 weeks of waiting I went to go pick up the Rx and it was going to be over $400.00 because the insurance company is penalizing me for getting the name brand- even though the generic did not work as well and made me feel horrid all the time. I am not making sure that the rx was filled with a DAW-1 code.

Before you get upset at pts and drs about writing DAW1 on everything maybe there is a good reason behind it. Yes the drs that write it on everything and the pts who demand it are annoying but its quite possible that alot of the people tried the generic and it did not work as well. The whole point of these drugs is to make it where you can function There is nothing wrong with asking for name brand when the generic doesnot work and your dr knows that.

Comment by Mark on 2010-09-18 23:10:32 -0700 #

I’m a tech and I’ve also seen stupid MDs DAW-1 Atarax and Artane, then bitch at my pharmacist when they founu out we’d ‘substituted’ another drug! I’m in Texas, so I like the way the law says a Dr has to WRITE ‘brand medically necessary’ and that ANYTHING else can be ignored; no check boxes, no DNS, only that phrase. BTW, is there an ‘Angry Tech’ blog??

Comment by Mark on 2010-09-19 21:57:10 -0700 #

The other ones I love are the DAW-2s, patient wants brand. I run it through and it comes back as ‘brand copay + cost difference.’ If you want the brand, the ins makes YOU pay the difference! I tell the pt and I get this confused/angry ‘My copay’s only supposed to be $xx” I have to restrain myself from finding the biggest, hardest thing I can throw at them!!!
I’ve also heard from auditors that since Texas requires ‘brand medically necessary’ on a DAW1, that if the Dr doesn’t have documented proof of failed therapy with the generic, HE will have to pay the charge back out of his reimbursement. Don’t know if it’s true, but it should be.
A personal story about DAW1…A long time ago, my mother was taking verapamil and doing just fine. Dad’s job moved us to a new city and her new Dr insisted on Calan SR, wouldn’t allow generic. It cost he $57 more at the pharmacy. When she got the bill from the Dr’s office, she deducted that $57 from her payment and LOUDLY told them why! She got the generic the next month.
This is now my favorite blog to read!!!

Comment by KidT on 2010-11-09 15:25:11 -0800 #

I just read your post. Funny. I think it was a very nice, well written article, with very good points to be made.

I think from now on, I’ll actually write DAW-1 and put the word *BITCH!* next to it so that the next time you come across my words you will know your place in this little world called health care. And I’ll fill out the necessary paperwork/prior auth with glee.

Eat a hot bowl of dicks (DAW-1). No dick substitutes. Now THAT’S funny!

Comment by generics suck on 2011-10-28 21:21:57 -0700 #

this is the reason patients end up dead, because pharmacists like you think everyone should be on generic…”they all practically do the same thing anyway right?”…wrong, how many cases do we have to hear about epilipsy, heart failure, antipsychotic meds getting switched just because the ab generic equivalent is in PARENTHESIS and thus legally ok and then oops patient decides to commit suicide because come to find out LEXAPRO AND CELEXA ARE NOT THE SAME THING…who knew?!. Perhaps these doctors starting writing DAW all the damn time because they couldnt figure out why for the life of them all their patients were coming back on generic meds and not the brand name they wrote. Just because it pops up in yalls little system that their happens to exist something very similar does NOT mean it has the exact same chemical make-up…that would be A-A rated, last I check A and B are 2 different letters although they do fall very similar to the front of the alphabet…hmmmm.
Doctors try writing everything under the sun…DAW, BRAND NEC., ETC just to find out that technically if they dont use the code DAW1 or hand write BRAND NAME ONLY legally you pompous pharms can just switch it anyway. Let me ask you this, do you ever get a perscription that is written for the generic i.e. metoprolol? Well it seems to me then that the dr does in fact know the difference so why not just fill what they write…hint hint it’s the first name you see, not that other one you guys get paid off of in parenthesis 😉
I love this whole crap about “saving the patient money” get real, you make money off those switches and how in god’s name that is legal the world may never know, excellent lobbyists i suppose. I have insurance, why you people switch my meds without asking or telling ME THE PATIENT ME THE CUSTOMER is beyond me. Do you think I pay money out of my paycheck everymonth for insurance just to get the same $4 piece of crap generic that a cash paying patient gets, think again buddy.
and dont get me wrong i get it, some people cant afford their meds, this is true and it should be their choice to decide which they’d rather have, but it does make me wonder that a patient who is on 4 different antihypertensive generic meds paying anywhere from $4-$20 generic cost per med….maybe couldnt simply be on 2 branded agents that have a guarenteed chemical makeup everytime (no switching from this manufacture to that one) and thus be more compliant, feel better (less side effects), and pay around the same price. makes you think.
But the problem is we live in 2 different worlds, 1 is where you make the money pretending like you care about the patients health and then there’s the world of the patient where we actually care about our health and somehow manage to pay you to mess it all up for us.

Comment by pharmacist that trusts doctors and patients on 2012-01-02 00:07:17 -0800 #

I was once one of you all blabbing about the data concerning generics vs brand, well let me give you a word of advice. i am a pharmD and have worked in retaial and now am in the hospital clinical setting. I have witness first hand how some of those generics out there are not truly equivalent compared to the brand name counter parts (has anyone even noticed when some patients request a certain manufacturer or the doc does as well or daw 1 is written. well be cause i have seen increasing numbers of complaints that the some of the generic manufacturers are not keeping within the guidelines as specified by the FDA. People i have seen have numerous negative reactions to certain generics. Pharmacists need know that there is Indeed a reason, and that reason is very simple and not stupid. doctors need to be respected as such, the FDA and all the insurance companies alike should be quite frankly ashamed by this. and it all comes down to money. i’m sorry but if a seizure patient is stable on a brand (keppra) for example, then it went generic. The patient had developed seizures again. upon switching back to the “angry pharmacists” daw 1, the patients seizures stopped.the doctor is in charge. listen to the doctors. let them fill out the forms and stop brushing aside these scripts as nonsense as one day you too may find yourself as a patient in the very same conundrum. pharmacists are the right hand of the doctor, if laziness is your business, then let me assure you, you are doing more disservice to patient care. if you notice that there are certain manufacturers that you seem to be getting pt complaints about, then keep a record and report it to the FDA, as there is clearly a quality control issue going on. So keep you oath that you took to to your best for patient care seriously and do no forget the doctors who also took this same oath. stop being lazy, be a patient advocate!

Comment by Bobby on 2012-03-12 08:34:52 -0700 #

U sound like a real winner. Are u pissed off because u couldn’t get in medical school or just a asshole or both. My wife has to take a drug that requires DAW1 or it cost her $600. With DAW1 it cost $58. The reason is the generic does not work. Now this has been determined by the Dr and the patient. If u want to make these deci sions them go to medical school. You must work for CVS which have the biggest asshole pharmacists on earth. Otherwise do your job and fill prescriptions and try not to make a mistake.

Comment by aaron crouse on 2012-03-14 17:59:30 -0700 #

your a a idiot are you are doctor of medicine no you dispense drugs. a daw -1 is designed because not all drugs that are brand to low cheap crape made out in say no fda rules in poor countrys so how do i know i aint getting poison were we have laws and most fda . and by refusing what my doctor ordered the prescribing physican and a insurance company deceding what to cover and what not to based on price have violated ethics violations, violated my right to medicine etc. how do you know this daw-1 wasnt intended for someone who allergic to a crap produced wholesale medicine the reason wwhy brand names are more expensive is yes name but two they actually work. do you know fda gets paid off on medical drugs. so again i am all for cheap drugs but when your a company whos making a 1000 fold or more and too cheap to buy realiable drugs thats says soemthing and if your gonna pay for cheap drugs and not expensive that also says something their in it for business not your wellness. you realize this would get your lisencse taken away to dispense drugs, by the way i could sue the state or federally dumbass to get my script paid for by insurance company and claim these people are doing fraud. so your making yourself look like a idiot yourself by posting nosense. you havent a clue and these insurance companies get screwed up doctors they have money and they scream communism dumbass if regulation actually came in. i have problems with certain psych meds so i would have my doctor do a daw-1 and if the state refused i sue over torture its in crediable and in constitution. and again if you refuse on grounds of religous i am gonna say since i am transsexual to feel my order i just use the idea they tried that for nonwhites and so we would find that under law if they didnt prescribe, they also violated their liscense. doctors today violate their moral conscense but if saves a life then gonna do it or get sued. i dont give damn about religion if you have say relgious beleifs that would contradict saving a life why you become a doctor this jsut legal harassment. sorry medicine considered under secular you cant you use the bullshit law.and then when you do lets say aboration sorry according to archeology and the bible god delights in aboration so again i gonna make you look like a hypocrit and slanderize your bunish legally its called legal slander.

Comment by veritas on 2012-05-26 16:15:55 -0700 #

Every patient is an individual and it is documented that 15% of the time generics do not work. When a Pharm substitutes his opinion for a doctor’s bad things can happen. I was denied my heart medication. The pharmacy refused to fill for the brand name and used a generic that all of my cardiologists agreed was not the appropriate medication for my particular heart defect. One pharmacy failed to notify me regarding the change in my drug plan’s formulary so that I could ask for an exception for this medication. My drug plan refused to accept my doctor’s statement that I required the brand name medication. Then I discovered that for over two years, while my doctors were accusing me of not taking my medication, the pharmacy not only was not giving me the brand name, but also the wrong generic medication. During that period of time, not only was I hospitalized five times and underwent surgery to implant a defibrillator, the blockage in my heart progressed from 40% to 60%. Could this have been prevented with the correct medication? Yes! My recent defibrillator printout shows improved heart function. In this case the Pharm did not know more than my cardiologists. I will be pursuing this. My experience with Pharms regarding my pain medication is so horrendous that it rises to the level of malpractice. Yes, I do believe my race has played a part in the negative treatment I received from these Pharms. Rules should be in place to prevent any prejudice religious or otherwise from being inflicted on innocent patients.

Comment by veritas on 2012-05-26 16:33:03 -0700 #

Just wanted to add to my previous comment. Many patients are becoming knowledgeable about their medical care. Here is the data about generic drugs and whether they are truly equivalent.

“Most (but not all) pharmacists routinely tell patients that generic drugs are identical to brand name medications. That is hardly surprising. This is what pharmacy students are told during their education process. It is also what the FDA states on its website:
“A generic drug is identical–or bioequivalent–to a brand name drug in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use. Although generic drugs are chemically identical to their branded counterparts, they are typically sold at substantial discounts from the branded price.”

Now we don’t know about you, but when we see the word identical we assume that means exactly the same as. Here is how defines the word identical:

“1. Similar or alike in every way
2. being the very same
3. agreeing exactly

Related Words for: identical
Indistinguishable, one and the same, selfsame

Medical Dictionary

  1. Exactly equal and alike
  2. Of or relating to a twin or twins developed from the same fertilized ovum and having the same genetic makeup and closely similar appearance; monozygotic.”

In our opinion, the FDA’s use of the word identical, when describing generic drugs, is misleading. First, the inactive ingredients (colors, binders, fillers, etc) do not have to be “alike in every way” to the brand name product. In fact, they are often quite different. These so-called inactive ingredients or “excipients” may influence how the product affects patients. For example, a patient who is allergic to a particular color may develop a rash when switched to a generic product.

The formulation may also differ dramatically from the brand name. Many pharmacists may be unaware that the physical characteristics or release properties of a brand name drug often stay under patent even after the active ingredient becomes available generically. This is especially problematic for slow-release or long-acting medications. Generic manufacturers may have to come up with different technologies to deliver the active ingredients. This means that the products are not always “indistinguishable or one and the same.”
To see this for yourself, visit the FDA’s website and report on the antidepressant bupropion XL.

If you look at the graph the FDA provides you will discover that the mean plasma concentration of the two drugs is certainly NOT identical! The generic formulation (which uses a matrix technology to release the active ingredients) produced peak blood levels in 1.5 to 2.5 hours, whereas the brand name product (using a membrane technology) produced peak blood levels around 5 hours. This kind of information for other generic formulations is not always easy to access.

Here is something else a pharmacist might not realize. According to the FDA, 80 percent of the active and inactive ingredients in our pharmaceuticals come from abroad. It is estimated that 40 percent of the finished pills come from abroad including countries such as India, China, Brazil and Mexico. It is also very clear that the FDA does not have the resources to inspect all or even many of the manufacturing plants producing either the raw materials or finished products millions of Americans take every day. That means that there is no verification system that the pills are exactly what they say they are.

We have seen manufacturing problems with some of the most prestigious drug companies in the U.S. (Johnson & Johnson and GSK). These problems occurred at plants where the FDA visits on a regular basis. Do we really believe that chemical companies in China that are not inspected are producing perfectly identical generic drugs at cutthroat prices?

Perhaps it is time for pharmacists to acknowledge that there are no guarantees when it comes to generic drugs. Pharmacists must be the patients’ allies and advocates. When patients experience problems with certain generic formulations, pharmacists should offer a sympathetic ear and report the problems directly to the FDA’s website (MedWatch). Perhaps if pharmacists insisted that the FDA do a better job both approving and monitoring generic drugs, patients would have more confidence in these money-saving pills.

Comment by Gila on 2012-06-07 23:41:09 -0700 #

Working in pharmacy for many years, I was lead to believe all generics were the equivailent to the brand. Not True. And not every generic is the same!! I have witnessed this myself. Never really needing any medications until the last few years I have fell victim to a long illness which is incurable. Most pharmacists are empathetic and treat people who need pain meds as if they are addicts. Because of people abusing narcotics. It used to be only people who were sick and dying got pain meds. Now they are prescribed widely. I never had hydrocodone prescription for a simple dental procedure until I moved to the 48 states. I have documentation proving certain generic medications are not effective and/or equal to the brand name med. I agree with your statement Veritas however, I do not believe you were discriminated against or an error was made because of your race. Most errors are made because a pharmacist has been in a hurry, not checked prescription and not counseled properly or the patient refused counseling.
I can understand the angry pharmacist to a point. I mean come on . . . the doctor is not rolling over names of medications every 30 seconds nor are they handling the stock bottles like a pharmacist. Yes some doctors can be jack asses but most aren’t. And I come from a Pharmacy World.

Comment by Gila on 2012-06-07 23:49:11 -0700 #

Well said – Thank YOU

Comment by Gila on 2012-06-08 00:02:34 -0700 #

pharmacists are not supposed to be switching out brands and different generic brands back and forth just for this very reason. They are not all equal and people who are prone to seizures is documented with more seixures.

Anti-seizure medications are not to be flip flopped from one manufacturer to another.

Comment by Gila on 2012-06-08 00:06:24 -0700 #

Honestly – I think your fear is that you will be stuck with the remainder of the brand name instead of making the patient purchase etc. It has nothing to do with how the drug metabolizes in a patient. But with your cost that sometimes you are left with a balance of an expensive medication.

Comment by MM on 2012-10-11 19:42:12 -0700 #

Very well said Veritas (truth)! You have pointed out the most valid and pertinent points regarding generic vs brand. I couldn’t have said it better; and, I agree wholehearedly. People should be aware of the actual differences and then make an educated decision as to which they would prefer to have. Unfortunatley, in most cases, price is the only factor that people tend to consider. They choose to take on the risks and play those odds. Thank you for putting the “real” facts out there.

Comment by Edward on 2013-07-26 14:17:58 -0700 #

Idiot alert !
The Good Doctor is writing (DAW-1) so he does’nt have to spell out “Do not Substitute” period.
What’s wrong with that ! I suggest you make an Appt. with Psych, and have them adjust your medication.
maybe them geneics your taking are’nt working ? there’s a reason other than what you describe why he does’nt want a substitute ! Feel free to call the Doctor for his/her reasoning.
You sound Butt-hurt to me……….
Ha-ha !

Comment by Edward on 2013-07-26 16:48:31 -0700 #

Why are Pharmacist’s Angry and powertripping anyways ?
I never knew there was such animosity between Doctors and pharmacists.
How sad………
Pharmacist Suck !,
No, Pharmacists can Suck my Balls ( DAW-1)

Comment by Ghent on 2013-10-12 14:50:13 -0700 #

“Perhaps it is time for pharmacists to acknowledge that there are no guarantees when it comes to generic drugs.”

– Perhaps it’s time for you to acknowledge there is NO GUARANTEE for anything, especially your health. Medicine is all one giant experiment. No one is identical. You are a number on a bell curve. Statistically, drugs are more identical than people. They must fall within 10% +/- of the brand-name drug concentration, per pill, per lot#, to gain FDA approval. SAME RULES WITH THE BRAND NAME DRUG! Statistically and scientifically, that IS identical. Plus… When you take a medication, you are not taking a perfect, safe, cure-all. You are taking a TOXIN with a therapeutic side-effect! You are not a pharmacist, you have no education in this area.

“Pharmacists must be the patients’ allies and advocates.”

– We are. Like TAP says, ‘you dick’! Try getting empathy from your “Dr Complex” doctor. We advocate for you all … the… fricking… time! Every second we’re at work we keep you from dying, we keep you from spending too much money on a drug, we try to remind you to take it correctly and on-time, we even tell you when you really don’t even NEED to take a drug and should modify your sick, sad obese, grease-eating couch potato life and stop gnawing away at our sanity as we smile at you from behind the counter, secretly wishing we had a frying pan and a brick wall to beat both sides of our head at the same time!!!!

Why don’t you actually listen to people who do this for a living and devote their lives to it. Stop being arrogant and stubborn and let the people who know & care, actually help teach you something.

The “Race Card”? Why is it the most racist people always play the Race Card somewhere in their complaint. Get over it. You may have a complaint, but it has nothing to do with your race. You’re the one who is racist (and arrogant and self-consious), not other people. No one else cares about the color of your skin or religion – just you.

Buproprion XL and SR are different drugs. They are not FDA-substitutable. You are not a pharmacist, so you need to listen to those that are.

Comment by Pamela on 2013-10-25 05:03:51 -0700 #

I am a person who suffers from chronic back pain and most generics have not worked. The best pain medicine they had was the old Vicodin ES but I guess most people who think when you ask for your pain medication you just want to get high, I just want to be able to go to the grocery store twice a week, to church on Sunday, and a family event once a month.

Not only are generic pain medications different so are other. I am sitting here typing with my feet proped up and my feet so swollen they will hardly bend at the ankle. Why, because I was told to get the generic for maxide (furosemide) like I usually do. So another trip to doctor for another a script for the brand name.

Give patients a chance, usually they do know what works with their bodies.

Comment by Johnny on 2014-04-25 14:10:19 -0700 #

I guarantee that most DAW 1’s are written at the patients request. You’re an idiot. How about you just fill the fucking prescription.

Comment by Paul on 2014-06-25 12:33:35 -0700 #

Dear Angry,

Me thinks some pharmacists get angry when brands are requested (for whatever reason) and the product is generic and offers the pharmacist a “Huge” amount of profit. This isn’t new. When I was running a generic company in the mid 90’s a patient called me to complain about prices (yes, prices of a generic!). It was the generic to slobid. The patient complained that a bottle of 100 caps was $60…I told him, a cash paying customer to shop around. Funny thing is he did…only to be told by many pharmacies that it was $60 bucks. He said he would complain to his Senator (Kennedy at the time) and I started to get irritated. I told him to sit down while I give him “old pricing” from my factory to the pharmacy and to the wholesaler (one pharmacy bought direct at the time). The price per bottle was $2…Yup, $2 whole dollars. So who is really the villian…PHARMA who invests 800 to $1Billion in a new compound? The generic companies who are always asked to drop prices more and more or all the pharmacy chains, retailers and wholesalers that make a fortune.

Oh, and when you try to extract a $15 co-pay from me for Tetracycline when I know you get it for less than a buck…that is truely crimminal. I was charged $4.99 when I decided to pay out of pocket. But how nice that information would be to folks like my Mom who lives ona fixed income.

Spare us your DAW 1 tears Angry Pharmacist….there are a lot of angry other people in the world and with good reason.

Comment by Deb on 2014-07-01 13:01:50 -0700 #

I would like to comment on the Name brand Norcos verses the generic Hydrocodone. I have been on pain meds for over 15 years due to a motorcycle accident that left me in chronic pain from 5 compressed discs, left hip displacement, left arm with adhesive capsulitis (frozen shoulder) and siatic nerve damage. People are all different in their body chemistry…But I have found that all 4 “norcos” being the Watson yellow and white 853, qualitest yellow V 36 01, & Mallinckro M367, all work equally well for me. When they dont its time to go in for a couple of Dilaudid injections and then back to the “Norcos” for “maintenance”.

To be honest with you I really believe that with this type of med most all generics are going to work pretty equal to the name brand. And those that complain because it is not NAME BRAND I hate to say it but believe that on their part it is Psychological. Now when it came to my Levothyroxine that is a different story between the synthroids, levothroid, levothyroxine, etc…My blood work &physical body changes, were proof of the differences I was going thru when these drugs were changed. They are NOT all the same.

I hope that this info can be somewhat helpful to all.

Comment by Chris on 2014-08-07 00:00:21 -0700 #

Not only do I agree with this comment, but wow with this article. How can there be people agreeing with you? “Trained” professionals no less?

Angry, either you know you are WRONG to write this or you don’t actually BELIEVE what you are saying. Otherwise, I invite you to voice your concerns by putting your name and pharmacy on it, and submitting it to your district manager. And then to the local doctors.

You won’t because you know you will be fired, sued or both. I certainly don’t want you near my prescriptions or anyone else’s as your disregard for medical training and the law border on sociopathic.

If you wanted to be an MD instead of a PhD you should’ve worked harder. But you didn’t, so do what the professionals say and count to 30. Or 60. Or 90. And stop trying to diagnose anything other than a cash register.

Comment by MJ Toles on 2017-11-15 06:03:04 -0800 #

I am in disagreement with this angry Pharmacist.

I take brand name Lasix 40mg/3x daily for congenital bilateral lower limb lymphedema. As a child the doctors knew nothing about the lymphatic system as it was not a part of their education. Only with a focus on the effects of cancer – and particularly male testicular cancer did this move to the forefront for treatment.

As a youth I was in and out of the hospital being tested and prodded and filmed as a case study in the extreme effects of a largely compromised system.

After the advent of generic drugs for years I was able to have the doctor
still put through the prescription DAW. Of late that is no longer possible and in fact only one pharmacy in my area will arrange to order this on my behalf.

If I were to choose between the price of generic and brand name, hands down – no question – as often there is a $90 difference monthly that I pay.
However, trying numerous times with varying distributors, furosemide does not work at all for me and produces adverse side effects (acne and all sorts of skin related issues AND it does not relieve the swelling at all.
So it’s like throwing the $12 in the trash and left me praying for a genetic stem cell solution.

That 15% of cases where generic doesn’t work is very underestimated.

The other issue I observe is in the college students I teach suffering from depression. They finally get diagnosed and put on medication, only to have the pharmacist placed at the whim of the drug stores to get the lowest bid – changing prescription distributors without notice to the patient. Each time this variable is introduced it can lead to essentially experiencing having gone cold turkey off one medication for its generic substitute and the student sinks into depression without understanding what has taken place. Not the prescribing physician’s problem, and I would go so far as to give leeway to the pharmacist – but the company policies are deeply flawed and lend to inflicting unnecessary harm to unwitting individuals in need of medical care.

So, I beg you to consider to step down from your high horse and do a bit more research. Money or cost of care is not the measure to pursue….you should keep in mind too that there needs to be health assistance for all individuals without paying the deep price of ill health.

If you know your trade sufficiently, you should agree that this is in fact the way generic can go astray, despite “cheaper” intentions.

Comment by JOE on 2018-01-18 12:48:15 -0800 #

daw-1 sometimes is necessary when commercial drugs are the only drugs covered by insurance.

i.e. some insurers only have commercial meds on formulary, esp when the patent just now expired and they wont cover it early on.

in those cases, yes, DAW-1 is in fact cheaper than GEQ.

Comment by Pharmacists are not Docotrs on 2018-05-11 05:51:37 -0700 #

If Pharmacists want to be a DO or MD then go to med school you have no right to think you know better than a Doctor but you do think you are LOL

Comment by jd10033 on 2018-06-19 08:59:04 -0700 #

Scenario: Doctor has not initialed DAW – but the brand name, through the patient’s prescription provider, is actually cheaper than the generic equivalent. Can the pharmacist / pharmacy fill the prescription with the brand name (cheaper) even through the DAW box wasn’t initialed – and what’s electronically sent to the pharmacy is the brand name… ? ? ?

Comment by vertuc2 on 2018-11-15 06:36:46 -0800 #

The author of this article actually sounds very unintelligent, using the word “ass” numerous times in a perseverative fashion as though of limited vocabulary.
What this pharmacist (or pharmacy tech) author (clearly male because no evolved female speaks this way) fails to realize is that your customers are legally NOT allowed to return your products to you for a refund. Therefore, you as pharmacist are not privy to the patient’s actual complaints about your product. Meanwhile, the customer to whom you sell your wares but whose medical condition is my personal responsibility will provide me feedback that you don’t receive. Feedback such as — the filler since switching to generic is causing GI distress or an allergic reaction. Glucophage (also Wellbultrin) generic is actually more poorly tolerated than brand name. Think about it: A pharmaceutical company of a brand name product makes MUCH more money the better tolerated their product, including fillers that have no side effects. In contrast, the generic manufacturers are more likely to get the large deals with the likes of CVS if they can make their product (which includes fillers) as cheaply as possible in order to pass on the savings to the pharmacy and allow the pharmacy to make more money. Furthermore, generics are allowed to vary their dose from what is listed by up to 10-20%, and THEY ARE ALLOWED TO SCREW UP THE CONTROLLED RELEASE MECHANISM provided that the total dose excreted over 24 hrs (whether in a delayed fashion or all within the course of minutes) equals the dose claimed on the package (with up to 10-20% variance).
I suggest this author open up a dictionary to increase his (author is clearly a “he”) vocabulary.
Lastly, medical residents & interns should *NOT* be penalized for an education that they did not receive. It is very easy for a specialist within any field to consider specialists outside of their field as “stupid” (even within Medicine this happens).

Comment by Sultrylady on 2019-01-02 08:23:42 -0800 #

Tough, you bitches! I can’t take the generic of Ativan – Lorazepam, it just doesn’t work for me! I’ve been taking the brand name for over 10 years now for an anxiety disorder. If I need the brand, I’m getting the brand.

Comment by Dee on 2019-05-04 07:33:22 -0700 #

Looks like several people beat me to it but how long has this person been a pharmacist and has no idea generics are not all created equal? In most cases they are less effective than brand name as well. I’d venture to say in the majority of situations the DR writes DAW because the CHEAPEST generic isn’t working for the patient. Why are they receiving the cheapest generic? Because it’s more profitable for the pharmacist to fill the cheapest generics for customers. This is honestly disgusting because the pharmacist knows generics are not all created equal yet is more worried about the bottom dollar. This pharmacist and similar pharmacists belong in prison. You’re not even a DR….def not God! GTFOH

Comment by Dee on 2019-05-04 07:41:22 -0700 #

Angriest Jackass, you’re a pos! You should be in prison! Obvious fact that generics vary which means the implications of your bs are substantial. Clearly you have no compassion only concerned about the profit margin on some placebo garbage generic.

Comment by wpeckham on 2019-05-04 18:47:01 -0700 #

My wife takes about a dozen medications (long story). There are about three that she needs the brand name, because for some reason we have never been able to nail the generic makes her sick as a dog. That would be less of a trial but the pharmacy keeps ignoring the DAW on the script and dispensing the generic, which they will not (cannot) take back and she cannot use. Sorry, but I have NO sympathy for that pharmacist or pharmacy. (And DARN little for the insurance company!)

Comment by Julia Nielson on 2019-05-30 20:01:46 -0700 #

My pharmacist said to tell my doc to write “dispense as written” as I was getting a costlier generic than the other for some reason. Then they were sold out one time and it was a pain to get a new script for the other which had by then become the same price…oh dear!

Comment by Russ C. on 2019-08-31 10:22:28 -0700 #

I am in complete agreeable with you on this, only that my situation is epilepsy related, and that Phenytoin will not do the proper therapy and control my neurological system and eliminate constant and repetitive seizures.

Three times in the past 27 years I have had the same thing happen as you (not informed by pharmacy) while having family members pick up my prescriptions while I was working and couldn’t make the pick up myself.

In the meantime, Dilantin has gone bat-sh/t crazy in pricing (thanks to a fraudulent presidency and their “behind closed doors” passage of a so called affordable care “Act”… yes, it’s an ACT, nothing else) and is costing me an arm and both legs to afford to continue to be seizure free.

For a generic to only require as little as 80% efficiency in matching performance of a brand name drug is totally INSANE!! There should be higher standards required.

Sincerely, Russ C.