
The Cold-Medicine Racket - Thevet
http://www.theatlantic.com/health/archive/2014/12/dayquil-screed/383768/?single_page=true
======
rayiner
This is such a great example to highlight how information asymmetry and choice
overload act to undermine markets.

> The difference in price between brand names and generics accounts for tens
> of billions of dollars "wasted" every year by Americans in pharmacies,
> according to the economics researchers.

> Consumer confusion, or misplaced trust, is compounded by the fact that a
> drug store is likely to have upwards of 300 cold-and-flu products

> One myth is that "brand-name drugs are made in modern manufacturing
> facilities, and generics are often made in substandard facilities." But, the
> FDA counters with the reminder that it "won't permit drugs to be made in
> substandard facilities."

Imagine how much consumers would overspend on branded medications if they
couldn't count on the FDA as a backstop.

EDIT: By "backstop" I mean the FDA's role in ensuring that generics are
bioequivalent and meet manufacturing standards. Imagine how much more
effective brand advertising would be if some of the choices on the shelf
really were manufactured in a dirty factory in Mexico.

~~~
PhantomGremlin
The FDA does try, but it's ineffective and totally overwhelmed. Here's a
recent story[1]:

    
    
       In January, FDA inspectors paid a surprise
       visit to the facility in Toansa, in a rural
       area north of New Delhi, and found broken
       equipment, windows stuck open and flies
       “too numerous to count,”
       ...
       Workers ran quality tests over and over
       until they got the results they wanted
    

Just google around and you will find many many many stories like this. It's
been an ongoing problem with generics (mostly from India) for quite some time.

I don't know if brand-name drugs are any better, probably many of the same
ingredients are sourced from the same suppliers. But at least the brand-name
drug has a reputation, i.e. a "brand name" to protect.

Edit: Just wanted to add: RTFA I linked to. My one quote doesn't do the
situation justice. The culture at some companies is IMO really really bad.

[1] [http://www.bloomberg.com/news/2014-03-06/flies-found-by-
fda-...](http://www.bloomberg.com/news/2014-03-06/flies-found-by-fda-threaten-
indian-town-built-on-generics.html)

~~~
datasage
Stores like CVS and Walgreen's do have their store brand to be concerned
about. So if brands do provide some guarantee of quality, buying from those
stores is likely not worse than the branded products.

------
PaulHoule
The most pernicious recent development is the widespread use of phenylephrine
to replace pseudoephedrine. Neither personal nor clinical evidence support the
effectiveness of phenylephrine, but it is very clear that phenylephrine causes
a dramatic increase in blood pressure in many people.

There are some pseudoephedrine products on the market which are supposed to be
diversion-resistant for methamphetamine production but it seems if you stop
people from making meth they will just order up some other sympathicomimetic
amine from China.

~~~
debacle
Just get yourself an ephedra plant and steep your own tea. Pseudoephedrine
itself does bad things to some people.

~~~
iQuercus
Surely you jest. Let me skip the well regulated, well-tested, reliable,
precisely dosed, quality controlled and impurities-removed, time-released (if
you so desire), mass-market product in favor of a plant that I have to take
care of, and cross my fingers when the time comes that it delivers what I
need, without potentially dangerous impurities, in the proper dosage and
assume that it will be safer?

It would be like ripping out the perfectly functional seatbelt in my car and
replacing it with a home-made duct-tape based mechanism for reduced side
effects.

~~~
debacle
Ephedra is a meager little shrub that doesn't have a lot of needs and has been
drank as a tea for thousands of years. Ephedrine is also much safer than
pseudoephedrine with fewer side effects.

I grow a lot of medicinal herbs and have never had to worry about dangerous
impurities or quality control, except for the occasional spider web. I'm not a
homeopathic nut, but certain things (mint, ephedra, thyme, sage, peppers) are
easy to grow and provide tangible, scientifically confirmed benefits.

~~~
viewer5
I don't know about the others, but mint being "easy to grow" is an
understatement. Left unattended, it can take over a garden like the legions of
Rome.

------
mmohebbi
"The idea is to help everyone find exactly the right cold medication."

[http://www.iodine.com/cold-and-flu](http://www.iodine.com/cold-and-flu)

I work at Iodine (our Cold and Flu tool is featured in this article) and we're
watching this thread. Feel free to ask medication related questions of our
clinical team or technical questions of our engineering team.

~~~
atirip
Please look at your website with iPad for example. And then please get rid if
of that share bar that annoyingly covers the content. Thanks.

~~~
amandalotti
thanks for the tip! we're on it

------
MiguelVieira
But branding does have an impact on the effectiveness of some over-the-counter
medicines (because of the placebo effect):

>The effect of branding--that is, the labelling and marketing--of a well-known
proprietary analgesic used to treat headaches was studied in a sample of women
given a branded or unbranded form with either an inert or an active
formulation....The findings showed that branded tablets were overall
significantly more effective than unbranded tablets in relieving headaches.

[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1505530/](http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1505530/)

------
JoblessWonder
This reminds of of the time I sat the cold/flu aisle looking at cough medicine
for so long... Through the haze of my head-cold I finally figured out that
there were three different products by the same company that had the exact
same dose method, dose size, and active ingredients. The only difference was
the name of the product and the price.

*EDITED:

Front: [http://i.imgur.com/ZkcPiEY.jpg](http://i.imgur.com/ZkcPiEY.jpg)

Back: [http://i.imgur.com/gOj5uYK.jpg](http://i.imgur.com/gOj5uYK.jpg)

~~~
mmohebbi
This is amazing- we hadn't noticed this! It feels like they are A/B testing
different boxes. I particularly like the MLB logo in the corner of one of
those boxes.

~~~
JoblessWonder
Yeah... That is probably be the case. But as someone who hadn't slept more
than a few hours at a time due to my cold I was pretty sure I was losing my
mind. If/when I go to the cold aisle this year I'll check and see if the
packages are still there.

------
smacktoward
I wonder how much of that wasted money could be saved by taking an approach
with brand-name drugs similar to the one taken with cigarette packages:
require them to carry a big-ass label. Something to the effect of "THIS
PRODUCT IS MEDICALLY EQUIVALENT TO [ insert name of generic here ]" in great
big, bold type.

Of course that would cut into pharma's profits, so it would never in a million
years actually happen.

~~~
MichaelGG
Except generics aren't guaranteed to be equivalent. Indian pharma companies
have been incredibly corrupt, outright lying about their products:

[http://fortune.com/2013/05/15/dirty-
medicine/](http://fortune.com/2013/05/15/dirty-medicine/)

I'd be very hesitant about buying medicine from such companies. But I agree
that if the regulators could assure quality, then yes, pointing out
equivalence would help a lot of people.

~~~
pnathan
Incredible.

Is there a data source for companies & drugs that are known bad?

~~~
refurb
The FDA does a pretty good job of forcing the offending companies to recall
the bad product. They even go as far as banning any imports from said
companies until they've proven that they have cleaned up their act.

~~~
pnathan
Well... um. Read the Fortune article, and that pretty much invalidates your
statement. This particular company was in the middle of an investigation and
was _still_ shipping product. Similar situations have occurred in the past (I
can't recall names anymore though).

I would love to pull up an app, tap a few buttons, and ask the pharmacist to
change the meds to brand name when they are selling me products produced by
$sketchy_fraudulent_company.

~~~
refurb
I'm not saying the FDA does a good job of catching this activity early. The
only way they find out is either through inspections (they are horribly
understaffed) or through product complaints.

When do they find out they drop the hammer. Most (all?) Ranbaxy plants are
banned from importing product into the US and many products were recalled.

~~~
MichaelGG
Really? Articles from early 2014 say 4 plants are banned, while Ranbaxy's
website boasts 21 manufacturing locations.

Sun Pharma, which is buying (or bought?) Ranbaxy, recently got a plant ban
_for the same types of issues_. (They delete test info if it isn't in their
favour, and have terrible hygiene at the labs.) It's obviously endemic. And
Sun quickly noted that the ban only affects 1% of their revenue.

It seems unbelievable that this deep level of corruption is exposed, and the
FDA does limited bans and recalls. Instead of, say, completely banning the
company and high-level individuals involved, until a complete end-to-end audit
is completed. It's simply counterfactual to think these limited bans are
accomplishing anything, or that a company is going to utterly and completely
change the way they conduct themselves from individual techs all the way up to
the board.

The Fortune article says none of the FDA inspectors would ever personally buy
drugs from Ranbaxy, ban or not.

~~~
refurb
_Articles from early 2014 say 4 plants are banned, while Ranbaxy 's website
boasts 21 manufacturing locations._

Interesting, I looked it up and yes, the FDA is banning each plant separately.
One could argue that the FDA can only ban the plants they find problems at,
however, I would agree with you that Ranbaxy's behavior is bad enough to stop
_all_ shipments into the US. Not sure why the FDA decided to be more lenient.
Maybe the law governing the FDA limits how far it can go? I don't know.

------
kbutler
Here's another racket: "decongestants" containing phenylephrine as the active
ingredient (most U.S. over the counter decongestant products).

"Phenylephrine was not significantly different from placebo in the primary end
point, mean change in nasal congestion score at more than 6 hours (P = .56),
whereas pseudoephedrine was significantly more effective than both placebo (P
< .01) and phenylephrine (P = .01)"

[http://www.ncbi.nlm.nih.gov/pubmed/19230461](http://www.ncbi.nlm.nih.gov/pubmed/19230461)

~~~
hkarthik
yup, that data was very obviously suppressed to keep the DEA happy and prevent
meth labs from easily obtaining large amounts of pseudo-ephedrine.

Ask any seasonal allergy sufferer, we all look to find out where the 24 hour
pharmacies are so we can get access to the "good stuff" when sinus trouble
inexplicably hits and you need the behind the counter pseudo-ephedrine to get
through it.

------
zaroth
If I actually trusted the FDA to do their job properly maybe I could spend
less time staring at brand names in the cold aisle.

If we all trusted the FDA implicitly, then the next logical step could be to
actually _ban_ the entire concept of applying brand names to off-patent
pharmaceuticals and rework the entire cold aisle into a patient-education +
active ingredient grab bag. In such a world, phenylephrine is phenylephrine,
guaifenesin is guaifenesin, and all shoppers would care about is the form
factor and dosages.

I've read on HN about exactly how many fucks the FDA gives these days when
billion dollar pharma is forging test results while they knowingly pump crap
generic meds with zero quality control out of their dirty factories. See, for
example,
[https://news.ycombinator.com/item?id=8468099](https://news.ycombinator.com/item?id=8468099).
So that leaves us with the flimsy fallback of hoping brands like Mucinex
believe good QC is absolutely essential to maintaining their market position.

TFA claims American consumers waste "tens of billions" on brand name pills.
I'm sure this stat isn't just cold/flu meds, but probably including
blockbusters like Lipitor vs generic as well. That's like a $10 billion tax
because we can't fully trusted the quality and bio-equivalence reviews the FDA
is tasked to enforce?! By comparison, the total FDA budget is $4.5 billion.

~~~
zaroth
To give a specific example of where this works in practice, take buying a good
piece of steak. While some chains try to brand their beef one way or another,
all you really want to look for is "USDA Prime". The USDA... they really,
really know how to grade a cut of beef. I trust them implicitly, when I see
"USDA Prime" I know exactly what I'm going to get.

Now imagine having that same level of trust in the FDA. "Guaifenesin 1200mg 24
Hour - FDA Prime" would be all I need to see, and I'm grabbing that bottle.
Spend a cool $5 billion setting up that program for the Top 100 generics, and
you save Americans, what, maybe about a trillion dollars over the next 30
years?

Just like with beef, this isn't about controlling production, or subsidizing
the factory, but simply establishing public trust in an inspection process.

------
VLM
An interesting analogy of the situation which didn't make the article is a
good analogy of the cold medicine racket would be, imagine if liquor stores
were not able to legally sell components of mixed drinks. So a liquor store
could only sell tens of thousands of different ready to drink products such as
screwdrivers, old fashioneds, rum and cokes, mint juleps, but it was
practically impossible if not illegal to buy plain old vodka in a bottle.

And for marketing and trademark reasons you had to study the fine print to
figure out what is in each bottle. So you can't buy a bottle of ready to drink
screwdriver, you have to look in the fine print for "Slammer Canadian Lite
Extra Dry Extreme" to figure out its a bottle of screwdriver.

I'm not suggesting I want bulk generic powder guafenisien but life would be a
lot simpler if it was more like the produce aisle, OK I got runny nose and
cough so take one of pseudoephedrine and one of dextromethorphan and call it
good, instead of the "confuseopoly" system we currently have, which I'm sure
reduces everyone's quality of life while increasing profits.

~~~
maxerickson
One of the points made in the article is that you _can_ buy single drug
generics and combine them as needed.

So for your analogy, the liquor store would have to have a small shelf of
mixers and giant coolers full of premixed stuff. But flavor is easier to deal
with than medicine, so people won't put up with it, so liquor stores mostly
sell ingredients.

------
ToastyMallows
This reads like a big ad for Iodine.com

~~~
AnodyneComplex
I thought the author actually had a pretty skeptical take on things. The
ending quote is pretty hilarious:

"It's a press release, Mary. The iodine algorithm saved your husband from the
brink of ruin. His newfound sense of consumer empowerment was so invigorating
to his spirit that he no longer needed any Mucinex at all."

------
throw7
I've been waiting for awhile to catch a cold so I can try a neti pot. My usual
goto is zinc lozenges as soon as the cold hits/gargling with hot salt
water/staying well hydrated/and resting.

~~~
cortesoft
Try to do it first thing in the morning before you blow your nose. I have
found that blowing my nose drives the mucus two directions... out my nose and
up into my ears.... this prevents the neti pot from being able to properly
clear out your nose, since it can't reach the mucus that has been driven up
into your nose.

------
Detrus
I think the real racket is that people are taking medications to suppress cold
symptoms in the first place. A healthy adult should be out no more than a week
from a strong cold/flu. That wouldn't be a big deal except people get so
little time off from work they don't want to waste it on a cold.

Wether they spend $10 on symptom suppressors or $50 is besides the point.
Taking medications for what your body should be capable of handling with
proper nutrition and rest cannot be healthy.

~~~
benjohnson
>>Taking medications for what your body should be capable of handling with
proper nutrition and rest cannot be healthy.

Could you explain a bit more as I can think of a case where this seems to be
false: While my child's body can eventually handle colds and flus, if his
temperature goes above a certain level there's a significant chance for brain-
damage, so I counteract the bodies natural fever with medication.

~~~
ceejayoz
It should be noted that a _low_ fever appears to be helpful for the immune
response. [http://www.nbcnews.com/health/health-news/sick-feverish-
suff...](http://www.nbcnews.com/health/health-news/sick-feverish-suffer-
through-it-get-well-faster-docs-say-f1C6436878)

If you're running a 101 degree fever, it may be more effective not to suppress
it.

~~~
amandalotti
yeah i wrote a pretty comprehensive blog post about this - ie when it's better
NOT to treat a fever [http://www.iodine.com/blog/should-you-treat-a-
fever/](http://www.iodine.com/blog/should-you-treat-a-fever/)

------
jopython
I use a netipot with lukewarm water and a pinch of salt to flush my sinus if I
have any cold symptoms. I never had any real cold since 2007. Never took any
cold medication.

------
BorisMelnik
I would love to see this represented in an infographic or some sort of visual
aid. The biggest racket in my opinion is the whole Tylenol / generic or
ibuprofen / generic the prices can be ridiculously different. One thing about
the pain relievers is the quality of the shell or coating you are getting.
Some of the generics come broken up into tiny pieces while you won't see that
with brand name meds.

------
snarfy
I learned all about this stuff from some pill popping raver kids. 300 brands
and about 6 different ingredients. One of the ingredients only purpose is to
make you vomit.

------
gmarx
Agree in general but remember the case of Ranbaxy? FDA oversight is not
uniform and becomes weak outside the US

------
edw519
Good: Brand

Better: Generic

Best: Nothing

"If takes about 1 week to get over a cold if you don't take medicine, but only
7 days to get over a cold if you take medicine."

~~~
relaytheurgency
The medicine isn't supposed to improve your recovery time, it's supposed to
lessen the ill effects of having the cold. Your comment doesn't make sense in
that context at all.

"It takes about 1 week to get over a cold if you don't take medicine. It still
takes 1 week to get over a cold with medicine, but you'll feel much less
hindered by the effects of the cold itself."

