From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: re kickback on   prescriptions
Date: Fri, 04 Jul 1997
Newsgroups: misc.health.alternative,sci.med.pharmacy

In <33BB7A73.71B7@videotron.ca> Ibrahim Abdelatiff
<crescent@videotron.ca> writes:

>why is it then  some doctors persist on brand name  products and
>a (no substitute) mark on the prescription ?
>on a tv program last year there was report  that claimed that doctors
>with the highest  sales  record in some areas will get  a free trip
>to atend a conference in florida on a weekend .


   Generally doctors put a "no substitute mark" or prescriptions only
when there appears to be some nonequivalence in products.  Case in
point was the old Dyazide, which was only half as potent as the
equivalent generic, or Maxide.  And there was the big Synthroid vs
generic bruhaha, in which doctors were victims of suppressed
equivalence studies (in punishment of that, I've vowed never again to
write a Synthroid prescription in my life, except under extreme patient
duress).

   In some cases, it's really hard for the doctor to tell whether or
not a drug is equivalent.  For instance, I have patients who swear the
Geneva generic alprazolam is not as potent as the Upjohn brandname
("Xanax") stuff.  Do they just get the placebo effect of the name, sort
of like buying Delmonte peaches, instead of the identical product with
a generic label?  Maybe, but strange to say, I get no complaints with
the Greenlaw generic alprazolam.  That company is Upjohn's generic arm.
They get supplied with the identical Xanax/alprazolam base powder, and
merely tablet it under the generic name.  I wouldn't expect there to be
a difference, and there doesn't seem to be.  Geneva, however, makes
their own alprazolam someplace, and it doesn't seem to be as good.  I
have no studies to prove this, however.

                                     Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: re kickback on   prescriptions
Date: Sun, 06 Jul 1997
Newsgroups: misc.health.alternative,sci.med.pharmacy

In <5pmbbc$khq$1@news.duke.edu> SRenick <*ser3@acpub.duke.edu> writes:

>sbharris@ix.netcom.com(Steven B. Harris) wrote:
>>   In some cases, it's really hard for the doctor to tell whether or
>>not a drug is equivalent.
>
>The "Orange Book" (Approved Drug Products with Terapeutic Equivalence
>Evaluations) lists bioequivalence information for pharmaceutically
>equivalent products (ie same active ingredients in identical strength and
>dosage form). This reference is available at medical libraries and most
>pharmacies.


   Yes, and it's worthless.  It tells you what drugs are supposed to be
therapeutically equivalent, but not which ones have been proven to be
by testing them in real patients to see if they are as effective in the
condition treated.  Indeed, the entire point of the abbreviated
approval process is that you DON'T have to do this.  And I notice that
you ignored my comment about the unexpected (and now well-known)
inequivalence of brandname Dyazide and generic "equivalent dose"
triampterine/HCTZ preparations.  What did the Orange book say about
THOSE **when they first came out**?  Hmmm?  Or is that "wups"?

                                  Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: re kickback on   prescriptions
Date: Wed, 09 Jul 1997
Newsgroups: misc.health.alternative,sci.med.pharmacy

In <xapapp-0907970218090001@user63.infohouse.com>
xapapp@broadway.gc.cuny.edux (A. Papp) writes:
>
>In article <5pn9fo$4ob@dfw-ixnews10.ix.netcom.com>,
>sbharris@ix.netcom.com(Steven B. Harris) wrote:
>
>snips
>> inequivalence of brandname Dyazide and generic "equivalent dose"
>> triampterine/HCTZ preparations.  What did the Orange book say about
>> THOSE **when they first came out**?  Hmmm?  Or is that "wups"?
>>
>>                                   Steve Harris, M.D.
>
>Dr Harris, it is triamterene, not triampterine. Although triamterene does
>contain a pteridine (not a pterine) group, it does not show up in its
>name, which than would be triampteridine anyway.



   Son of a gun, you are right.  And I did assume the "p", knowing
about the pteridine rings.   I've just been trying to get some of the
blasted yellow stuff to disolve up for an experimental IV preparation
for animal research.  No luck, not even in acid.  What the world needs
is a good water soluble, quick acting, potassium sparing high volume
diuretic.  Or, at least, it's what I need for the project right now.

                                         Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: Premarin, Soy and Estrogen Replacement
Date: Fri, 01 Aug 1997
Newsgroups: sci.med.nutrition,sci.med,misc.health.alternative,sci.med.pharmacy,
	alt.support.menopause

In <19970801162901.MAA21006@ladder02.news.aol.com> pmlassoff@aol.com
(PMLassoff) writes:

>In article <33E1E182.40E@netcom.ca>, Tom Matthews <tmatth@netcom.ca>
>writes:
>
>>Again, I really hope that alternative medicine helps break the
>>stranglehold chemical houses have on healthcare.  The whole estrogen
>>thing is a good example why.
>>
>>Terri Mitchell
>
>Although you mentioned that you won't be posting again, I think you
>should continue to remonstrate using facts and logical arguments. Harris
>is an arrogant fraud who knows very little of which he writes, but tries
>the "I'm a doctor, so I know" arguments. Although personally I have to
>see published controlled trials of alternative medicine before believing
>in its efficacy, your discussion about Premarin was exact and factual.
>The generic argument goes a bit further, involving bioanalytical studies
>(mainly blood levels using different forms) that the FDA would allow
>generics for any other product. There's a huge amount of discussion on
>FDA's rationale for disallowing generics, as the originator product is so
>variable, both interbatch and intrabatch.
>
>Pete Lassoff, Pharm.D.
>London


Dear Pete:

   Her discussion of Premarin was "exact and factual"?  I suppose you
like the part where she claims that estrone sulfate and the various USP
hormones are different molecules depending on where they come from,
since they have different "hydrogens and gee gaws?"   Er, you say you
have a Pharm. D.?   From which correspondance school?

   There seems to be a giant mythology here (probably based on the
Wallstreet article, which got this point entirely wrong) that somebody
wanted to make generic Premarin only to give women a low cost estrogen,
which they didn't have previously.  That's hardly the issue.  There
have long been cheap MEDICAL equivalents of Premarin (i.e., other
estrogens in various formulations), but there has been no GENERIC
equivalent.  The last is an important LEGAL rather than medical idea,
for a formal (legal) "generic equivalent" allows a pharmacist in most
states to dispense (at patient request) a generic drug *where a
brandname is writen for,* unless the physician has specifically
forbidden it.  The number of prescriptions for "Premarin" without the
magic words "no substitutes" makes this a fat (1 billion dollar)
financial target for a generic knockoff.

   It is emphatically NOT the case, dispite Ms. Mitchell's bad
information, that somebody tried to get their own horse pee estrogen
mix approved as as generic Premarin.  Such an attempt would probably
have succeeded, and may yet succeed in the future.  The formula the FDA
actually turned down was a mix of the two major estrogens in Premarin,
which had been made sythetically. The FDA ruled (quite rightly, I
think) that this wasn't quite the same thing, for legal purposes. This
has nothing to do with horses or politics, BTW, for the FDA has
previously ruled that no combination of sythetic T4 and T3 hormones can
serve as a generic for Armour (animal) Thyroid extract.  A synthetic
with totally defined chemistry is just not the same thing as a natural
product extract with a lot of other minor ingredients, no matter if
medically we all suspect it really doesn't make much difference which
you use.   There is still a USP Foxglove leaf preparation, for
instance, but if you write that scrip, the FDA won't let the pharmacist
substitute digitoxin for it as a "generic equivalent."  Same principle.
If you write for "thyroid extract," the pharmacist cannot dispense some
synthetic T4 brand, even if it's cheaper.  That can happen if you write
for Synthroid.

  To recap, the great Premarin generic debate is about money, and the
drive of pharmaceutical companies to make a generic which will allow
them to profit on the 1 billion dollar Premarin *tradename.*  The same
thing would be happening with thyroid extract or foxglove leaf if they
had the market-share that Premarin does.  But they don't.  All the FDA
has done is rule that there can be no such thing as a generic for a
brandname natural product extract, which isn't itself a natural product
extract.  I'm sure you will be able to understand the principle if you
think about it.

                                            Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: Premarin, Soy and Estrogen Replacement
Date: Fri, 01 Aug 1997
Newsgroups: sci.med.nutrition,sci.med,misc.health.alternative,sci.med.pharmacy,
	alt.support.menopause

In <slworkEE95GE.6nE@netcom.com> slwork@netcom.com (Steve Work) writes:

>Steven B. Harris (sbharris@ix.netcom.com) wrote:
>
>>   To recap, the great Premarin generic debate is about money, and the
>>   drive of pharmaceutical companies to make a generic which will allow
>>   them to profit on the 1 billion dollar Premarin *tradename.* The same
>>   thing would be happening with thyroid extract or foxglove leaf if
>>   they had the market-share that Premarin does.
>
>Remember that drug companies carefully choose their brand names to be
>easy to pronounce and write out on the Rx pad. Because they know that
>MD's want to write their scrips as quickly as possible. The motivation
>for this was much bigger in the days before substitution laws became as
>common as they are today. For example, I'll bet many pharmacists have
>never seen a scrip for "acetaminophen 325mg with codeine phosphate 30mg"
>in their lives (if they did, they'd probably call the doctor to see if it
>was legit). But they've seen plenty which start with a T followed by an
>unreadable squiggly line followed by a 3. With older outdated
>substitution laws, the pharmacist might have had to fill the Rx with the
>more costly brand-name drug with the easy seven-letter name. With today's
>policies of generic substitution and the 3rd-party payors requiring
>generics, the benefits of the short easy name aren't what they used to
>be, but the case of Premarin is one where the name -is- still valuable.


   Darn right.  Premarin has been around since 1941, and by now EVERY
doctor knows the name and the dose, even if they couldn't write "mixed
conjugated equine estrogens" to save their lives.

                                      Steve