Of drugs, fake drugs and druggists
May 25, 2004
It was one hot summer day I remember, when an elderly lady hobbled into my little rural clinic several years ago. She was not feeling well, as I can tell, by the harried look in her face and the sweat that trickled down her brow. “Doc, la-in bala pamatyag ko” she muttered. “Daw naga sakit pirme akon batok labi na gid kung naga duko ako mag panglaba.” (Doc, I am not feeling well. My nape constantly hurts, especially when doing the laundry.) After a few comforting words and basic H & P questions, I proceeded to measure her blood pressure. It was 200/105. I told her that she had high blood pressure, and that she should probably be hospitalized to avoid a stroke but she refused, pleading that she can’t afford it. Eventually, after fanning herself, the blood pressure dropped to 140/90. I gave her a prescription for an antihypertensive with along with a smile, feeling good about what help I have offered expecting a grateful response. But instead she snapped and said: “Anhon ko ini ang papel? Indi man ako makasarang magbakal sang bulong”. (What will I do with this piece of paper? I can't afford to buy medicine.) And she went away, only to suffer a stroke a few months later. From the grapevine, it was said that she did fill her script at Mercury Drug, but she took it only for a week as a month’s worth of medicine is worth more than her pay as a labandera.
All of us have been faced by this problem all the time. Day in and day out, we hand out prescriptions but patients don’t fill them or take the medicines as prescribed because they simply can’t afford to. The high cost of medicines makes the cost of life so cheap.
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"In a way, all of us at one time or another were pharisaical hypocrites, because by enjoying these freebies, the poor consumer will eat up the costs. They charge it all to the account of the indigent patient who must pay much more for the medicines they sell."
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The problem is not just expensive drugs, but expensive healthcare costs across the board. In order for a hospital to survive, it has to live by a prepaid system and through a “get your own supplies” method. Thus, in most instances patients need to place a deposit before the operation, before being admitted, or even before emergency service can be administered. Sadly, patients often have to deposit their lives because they have nothing else to pay with.
What exactly am I talking about? Just go to the average University or Provincial Hospital: when a patient is short of breath, an intern hands out a script for a nasal cannula before oxygen can be placed. When a patient is exsanguinating, a nurse gives a script for Red Cross blood, so transfusion can be given; and even if there is already shock, a family member has to run to a pharmacy to buy LR or dextrose and an Abbocath so fluids can be administered. Before a CBC can be run, someone has to find the cashier so the dirt cheap simple blood test can be done. If the patient manages to survive the ER, his family would now have to telegraph back home to sell the carabao so they can place a deposit for an explore lap, while another relative in the hallway helps push in the disemboweled intestines back until surgery can be preformed. If the patient is still lucky enough to survive the ordeal, daily scripts are handed out for antibiotics so that the poor man will not die of sepsis. Of course, the rest of the relatives will have to fend for themselves and bring their own banig, orinola, soap, water and food to wait it out. Later, after all land titles were sold as collateral, the patient dies and the family gets the huge bill while trying to get a cheap coffin to bury their beloved.
Medicines are not cheap. According to the Department of Health’s own admission, to date the cost of medicines in the Philippines remains high and is even higher by 40% to 70% compared to other ASEAN countries. Despite this, our government also admits “our budget for drugs and medicines is too small to procure sufficient quantities of low-cost, essential drugs for the population in need”. President Gloria Macapagal-Arroyo tried to alleviate this by launching her “GMA-50%” in 23 July 2001, “a commitment to lower the prices of drugs and medicines frequently bought by the poor by 50%”. This is reminiscent of the generics law, which tried to lower drug costs to the consumer by allowing cheaper non-branded drugs to flood the market. It was well for the poor patients, but bad for the big drug companies who then further stretched their ad and “bribe” campaigns to keep the profits flowing. Further, there were issues on the reliability of the generic drugs especially their manufacturing and ingredients.
Not all drugs of the same name are the same. Of course, if the active ingredient is present at the declared dose the pill can be labeled as such. But there are also other components that differ such as the coating, base, buffer, preservatives and formulations (such as extended release tablets and strawberry flavoring) that may make one brand more desirable than another for a particular person. There are also manufacturing differences: some factories may not be as stringent in quality control as others and so the doses may vary and there may be contamination or mislabeling. Then there is the issue of storage and handling which impact hugely if the medicines need to be kept at a certain temperature (such as vaccines, parenteral solutions and suspensions) to preserve drug viability. In these aspects, the bigger companies with experience and expertise seem to be more reliable and therefore may claim some sort of superiority over the cheaper products. But barring all these other factors, it’s the same candy in a different wrapper with a steeper price tag.
There is another huge issue: the cheaper drug may not be a drug after all. It might be baking soda or a more toxic chemical. Fake or counterfeit medical products abound in pharmacies everywhere, especially in obscure “pharmacies”, rural areas and most especially in the World Wide Web. According to the US Food and Drug Administration (FDA), “in South-East Asian countries approximately 10% of drugs on the market are believed to be counterfeit. In China, authorities believe that for some drugs, counterfeits account for 50% of the product on the market. It is reported that in underdeveloped countries such as Argentina, Colombia, and Mexico, up to 40% of manufactured pharmaceuticals may be counterfeit.” Sometimes, you get what you pay for. Often it is the poor ignorant patient that might be paying with their lives.
The Bureau of Food and Drugs (BFAD) lists the most commonly counterfeited drugs in the Philippines to be the following: Appetens Tablet, Postan Capsule, Mosegor Vita Tablet, Augmentin Injection, Decilone-Forte Tablet, Fortum Injection, Propan with Iron Capsule, Voltaren SR Tablet, Inoflox Capsule, Verorab Injection. Take note of this and print this list if you have to.
Do not readily trust the unbelievably low discounted prices of medicines that can be bought via the Internet without a prescription! The most popular of these is Viagra and other erectile dysfunction drugs, weight loss medicines and drugs that “enlarge” whatever part of your anatomy. They are indeed too good to be true and both you and your partner will notice it. The FDA also lists other Internet sold medicines that are dangerous and may be fake: Accutane (isotretinoin), Actiq (fentanyl citrate), Clozaril (clozapine), Humatrope (somatropin [rDNA orgin] ), Lotronex (alosetron hydrochloride), Mifeprex (mifepristone or RU-486), Plenaxis (abarelix), Thalomid (thalidomide), Tikosyn (dofetilide), Tracleer (bosentan), Trovan (trovafloxacin mesylate or alatrofloxacin mesylate injection), Xyrem (sodium oxybate). If you are in the United States and want to verify the authenticity of certain pharmaceuticals, you can access the National Association of Boards of Pharmacy (www.nabp.net, (847) 698-6227) to determine whether a Website is a licensed pharmacy in good standing or not.
Lately there has been a lot of talk about buying drugs in Mexico or Canada due to higher drug costs in the US. However, the FDA reports that “In an investigation that ended in the indictment of seven people and five companies in the spring of 2002, undercover agents in the Manhattan District Attorney's Office in New York bought more than 25,000 counterfeit Viagra pills. They pretended to sell the impotence pills and uncovered four supply streams from China and India. Drugs coming to the United States from Canada may be coming from some other country and simply passing through Canada. The drugs could also be counterfeit, contaminated, or subpotent, among other things”. Think twice therefore.
This entire bad rap about cheaper drugs seems to push drug companies to promote their products even more. Not just for general good but more for personal gain. It’s big business of course. And doctors are into it hook, line and sinker. Why would you say “no” to a free car, a free trip, a free hotel, or free registration to a conference you barely half attend while sightseeing? Why would a doctor deny himself of well-earned goodies like nice pens or bags or an expensive lunch or karaoke while flirting with a skimpily clad “rep”? In a way, all of us at one time or another were pharisaical hypocrites, because by enjoying these freebies, the poor consumer will eat up the costs. They charge it all to the account of the indigent patient who must pay much more for the medicines they sell.
That’s why in the US they enacted the Stark Regulations (Phase I and II). These limit questionable financial relations between doctors or medical institutions and drug companies and certain illegal practices (such as self-referrals and affiliations with businesses that have relations to the practitioner). These include: clinical laboratories, physical therapy, occupational therapy and speech-language pathology services, radiology, radiation therapy and medical equipment and supplies, parenteral and enteral nutrients, prosthetics, orthotics, home health services, outpatient prescription drugs and inpatient and outpatient hospitalization services.
In more simple examples, health care providers should not be accepting gifts and gratuities from drug companies, (except education and research grants) not sell their own drugs or promote products in which they have an investment in, and they should declare their affiliations and supports from drug companies whenever they lecture or publish. There should also be no self-referrals: sending patients to a lab/physical therapy center/radiology/pharmacy which they own/co-own or have an agreement with the owner wherein there is a commission for the referrals. Even in the Philippines, laws to this effect are in existence, but enforcement is another story. Too many times have we heard of physicians receiving a nice gift such as a trip or a car if he writes enough prescriptions of a drug to reach a certain quota. These shameless practices should be stopped. Damo gid diri and igo. Bato bato sa langit...
So let’s be sure we get the right drug the right way, and also try to practice medicine the right way.
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