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Generics-First Policy For Anti-Psychotics Draws Controversy

Audrey Quinn

There's controversy over Washington state's effort to save money on drugs for mentally ill Medicaid patients. Doctors are advised to choose cheaper generic drugs over name brand ones for patients on the state health plan.


King County Sheriff Sue Rahr has a personal connection to the issue. She's seen a family member struggle to get the right anti–psychotic drug.

Rahr: "Once I saw the difference that the appropriate medication can make, it's life changing for a person"

Rahr says doctors, not legislators, should determine the right medication for mental health patients. KUOW's Audrey Quinn has more.

King County Sheriff Sue Rahr has seen a close family member battle with mental illness.

Rahr: "Oh, it's awful to watch. It's just so very hard to go with somebody through that process of accepting that you have a problem, accepting that you can treat it with medicine, that there's not something wrong with taking medicine, and thinking, all I have to do is swallow this pill and I'm going to be better. It isn't that simple, it's not like taking an antibiotic. The symptoms are so much more complicated and the side effects are a very big issue."

Rahr says finding the right medicine was so hard her relative almost gave up on treatment.

Quinn: "How many different drugs did you see your family member try?"

Rahr: "Oh gosh, at least a half a dozen. And each time, you get your hopes built up, your expectations built up, and then, oooh, it's not gonna work, or, this side effect is too difficult."

Quinn: "What kind of side effects did you see?"

Rahr: "Not being able to sleep, being anxious, those kinds of things."

Her experience made Rahr skeptical of the state's new "generics first" policy for anti–psychotic medications. It's an extension of a law passed by the Legislature in 2009 that aims to reduce Medicaid spending.

Jeffrey Thompson heads Washington State Medicaid.

Thompson: "What we're asking for is for the physician to stop and take a big deep breath and really ask, is there good science, and a really good clinical rationale of why they would start a more expensive drug when there is a less expensive drug that is equally effective. And if they can come up with a reason why they want to start a more expensive drug, then we will make sure that that expensive drug, if there's good rationale, gets dispensed."

Thompson says if someone really has a problem with a generic drug, their doctor can switch them to the name brand. But mental illness advocates stress the importance of putting patients on the right medication the first time they get a prescription.

Stephanie Lane is with the Washington state chapter of the National Alliance on Mental Illness.

Lane: "My concern is that this is a fail first, not a recovery first."

Quinn: "And what does that mean, fail first?"

Lane: "Fail first means the state of Washington wants you to try a drug, even though it might not work for you, because it's a generic and it's cheaper"

Sheriff Rahr also opposes the state policy, as a law enforcement officer.

Rahr: "You're going to try and save money on the front end by using a less expensive medication, but the consequence of failure is you're going to send somebody cycling through the criminal justice system. Which is way more expensive than purchasing the correct medication at the front end. You don't monkey around with this stuff."

By law, the active ingredient in generic drugs has to be chemically identical to that in the original medication. So are generics really inferior to name brand drugs? University of Washington pharmacy professor Donald Downing doesn't think so.

Downing: "In terms of their differences pharmacologically, most of the time there is little if any difference. In fact, there are brand name manufacturers who make the generic of their own product."

There can be a variability in just how much of the active generic drug gets into a person's system. But Downing says name brand drugs have just as much variability in their potency. However, he says, there could be a placebo effect. Patients who know they're getting the cheaper generic drug could have a slower recovery.

Downing: "Of course we're going to battle with that, a perception maybe by a patient that they're getting a second class drug. And that's nothing to throw away. I mean that's an important conversation to have. Because in fact if the placebo effect is strong and somebody doesn't have trust in their provider to give them the best drug, then their outcomes may be very poor, they have more side effects. And so we do have to take that into consideration."

A number of private health insurance companies require patients to try generic drugs first when starting a new medication. Federal lawmakers also tried to enact a generics–first policy for Medicare patients in 2007. That bill never made it out of committee.

For KUOW news, I'm Audrey Quinn.

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