Linda Wasmer Andrews

Minding the Body

Psychopharmacology

Generic Drugs Live Down to Expectations

Generic drugs have an image problem, and it could be affecting your health.

Posted Oct 20, 2015

morgueFile
Source: morgueFile

Generic drugs are the omega dogs of the pharmaceutical world. They don’t get much respect, and that could lead to reduced effectiveness and increased side effects.

Generic medicines are designed to be bioequivalent to their brand-name counterparts — identical in all ways that matter therapeutically. Plus, they often cost substantially less than the brand-name version of the same drug, making them an appealing option for many people.

Yet in doctors’ offices and across the internet, tales abound of patients who took a turn for the worse after switching from a brand-name drug to a generic. Scientists have proposed several potential explanations. Most focus on biochemical properties of the medications in question; for example, differences in additives or small variations in bioavailability. The possible role played by these factors — seemingly minor, but perhaps clinically consequential for certain patients and medications — is now being investigated and debated.

Less discussed is the psychological side of the story: Regardless of drug chemistry, another reason why generics may work less well or cause more problems is because that’s exactly what patients expect.

Not-So-Great Expectations

Kate Faasse, Ph.D., a postdoc research fellow in psychological medicine at the University of Auckland, studies consumer perceptions of generic and brand-name drugs. Her latest study, just published in Health Psychology, included nearly 90 college students with frequent headaches. The students were given four doses of ibuprofen, an over-the-counter pain reliever, to treat their next four headaches:

  • One pill labeled Nurofen (a brand sold in New Zealand, where the study was conducted), which contained active ibuprofen.
  • One pill labeled Nurofen, which was actually a placebo.
  • One pill labeled generic ibuprofen, which  contained active ibuprofen (in reality, the same product used in the Nurofen condition).
  • One pill labeled generic ibuprofen, which was actually a placebo.

Below, Dr. Faasse explains what her research revealed about the placebo effect — symptom relief caused by expectations of feeling better after treatment rather than by the pharmaceutical action of the drug.

In your study, how did the presence of a brand name on a common pain reliever skew people’s perceptions of its effectiveness and side effects?

Dr. Faasse: We found that if the tablets had an active ingredient or a brand name label, they worked equally well. In other words, placebo tablets with brand-name labeling worked just as well, statistically speaking, as tablets that contained active ibuprofen. In contrast, if the tablets had no active ingredient and generic labeling, they were much less effective at reducing pain than any of the other treatment conditions.

When we looked at the side effects that participants reported after taking the tablets, we found that they had more side effects after taking the generic placebo compared to the branded placebo.

Were you surprised that the placebo labeled with a brand name was as effective as the active ibuprofen?

Dr. Faasse: No. Our research over the years has consistently shown that expectations are very powerful in medical treatment outcomes. There’s a large body of research showing that expectations can influence the effects of placebos. Positive expectations can enhance the effectiveness of active treatments, too, likely because they increase the placebo component of the response to active drugs.

In one particularly striking study by another research group, positive expectations about the effectiveness of an opioid pain reliever doubled the effectiveness of the drug. Negative expectations completely obliterated the analgesic response.

In your new study, do you think the findings were due to positive attitudes toward brand-name medications, negative attitudes toward generic medications or both?

Dr. Faasse: I suspect it’s a combination of both, although we still have a lot more work to do to tease out the effects. We know that people tend to have more positive attitudes toward brand-name medications (as well as a whole lot of other brand-name products!) Branding a medication with a well-known pharmaceutical company or product name carries the implicit promise that it is authentic, is backed by scientific research and will be effective.

Branded medications also typically cost more than generics. Recent evidence indicates that placebos labeled as more expensive pain relievers work better than the same placebo at a lower price point. For example, one study found that an expensive placebo improved motor function in Parkinson’s patients more effectively than a cheaper treatment.

Along with having positive perceptions of branded medications, people also tend to distrust generic drugs. Generic drugs are often seen as being less safe and effective and causing more side effects compared to their brand-name equivalents. Additionally, a systematic review found a commonly held belief among patients that lower cost indicates lower quality.

How much of the positive attitude toward brand-name medication do you attribute to attractive packaging or eye-catching ads?

Dr. Faasse: In our study, the “brand-name” tablets had labels similar to the original packaging, and the “generic” tablets had plain-looking labels. I suspect that the more aesthetically pleasing packaging of many branded drugs contributes to positive expectations of the treatment.

It’s likely that the familiarity of brand names due to snappy advertisements plays a role in this process, too. In an earlier study, we found that when participants took a familiar drug (actually a placebo they had taken in a prior study session), they had larger placebo effects compared to participants who were switched to what they believed was an unfamiliar drug (also a placebo). Participants also experienced more side effects on the unfamiliar treatment, particularly when it was labeled as a generic.

It sounds like many people may have a bias against generics, whether they’re consciously aware of it or not. What are the implications?

Dr. Faasse: We’re starting to see evidence that negative views of generics can affect treatment outcomes by reducing the placebo component of treatment effects and enhancing the nocebo component — side effects caused by expectations about the treatment rather than by the pharmaceutical action of the drug. These side effects can be distressing and add to the burden of illness. People may stop taking their prescribed treatment, or their physician may prescribe additional medications to help manage the nocebo symptoms.

Generic drugs have the potential to increase access to affordable medical care and improve health outcomes, particularly where money for health resources is limited. The catch is that, in order to get optimal outcomes from generic drugs, we first need to raise our expectations.

Linda Wasmer Andrews writes about the intersection of mind and body. Connect with her on Twitter and Facebook. Read more from her blog:
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