In the research literature drugs are not referred to by brand
names. In the context of rigorous attention to scientific data, as
opposed to the world of sales and marketing, using trade names would
suggest influence by commercial pressures, which would call into
question the investigator's independence and objectivity. Shouldn't
independence from commercial pressures be just as important in the
clinical world? But, surprisingly, in day-to-day practice nobody seems
to be at all concerned about this. Everyone — physicians, pharmacists,
patients, insurance companies — seems to use brand names to refer to
medications. I see this as directly related to the pervasiveness of
pharmaceutical company marketing and I believe it is a serious problem.
Part of the problem is that no one recognizes it as a problem.
Look at how fundamentally our thinking is affected. The alternative to
using the brand name is to use the "generic" name, right? But this term
in itself is misleading: what we call the "generic" name of the drug is
actually the name of the
drug! "Zoloft" was in fact a brand of the drug
sertraline from the beginning, but everyone acts as though "sertraline"
came into existence only after the patent on "Zoloft" expired. (Many
people refer to sertraline as "generic Zoloft.") With older drugs our
thinking is clearer — we don't think of aspirin as "generic Bayer,"
it's aspirin, and "Bayer" is one brand. It is remarkable that even
doctors and pharmacists are often confused about this, and that it
needs clarifying. Try ordering a new drug still on patent by its actual
name and you're likely to get "I didn't think that had gone generic
Actually, it's worse than that. I recently tried to order simvastatin
from a mail order pharmacy and was told they didn't carry it — one of
the dozen most prescribed drugs in the country! It took three people 10
minutes of searching around before I was told that they had "Zocor,"
however! A national mail-order pharmacy, and they didn't list the drug
under its actual name — nor did anyone even seem to know the actual
name of the drug!
"Tissues, tissues... let's see.... Hmmm, I guess we don't carry
tissues.... Oh, wait — we have Kleenex, is that what you want?"
Brand name drug marketing is by far the biggest product promotion
success in the whole world of commercial enterprise, because the
primary brand names have not just become synonymous with the actual
names of the drugs, they have replaced
the actual names of the drugs.
Adofen, Affectine, Alzac, Ansilan, Deproxin, Erocap, Fluctin, Fluctine,
Fludac, Flufran, Flunil, and 27 other trade names besides the one
everybody knows — all are brands of fluoxetine, but even pharmacists
still call the stuff "Prozac." Imagine how the marketing folks at GM
would be rubbing their hands with glee if everyone referred to their
Toyotas and Hondas and Fords and Subarus as "Chevys!"
These habits are very deeply ingrained. For instance, remember that
each nation handles its own trademarks and patents, so brand names are
local to a specific country. On the psychopharmacology mailing list — a
listserv that has over 1000 subscribers from all over the world —
American psychopharmacologists routinely refer to "Celexa" and
"Trileptal" and "Remeron" despite constant reminders that these names
are unknown to prescribers in England, Indonesia, Turkey, Australia,
Brazil, South Africa, etc. I have seen the periodic notice about not
using brand names go out from the list moderator (as it has regularly
for years) and the very next day someone from the US posts a comment
mentioning "Luvox," prompting a follow-up question from a member in
Japan politely asking what Luvox is. It is remarkable that even in a
group of medical professionals, in a context in which it has a direct
and personal impact on successful communication, and in the face of
constant reminders, people still can't wake up to what they are doing.
Judging by the psychopharm mailing list, this seems to be especially
problematic in the US.
Note that Luvox is a particularly illuminating example, since the
original manufacturer of fluvoxamine no longer makes this drug. Thus,
there is actually no "Luvox" on the market any more. But try referring
to it as fluvoxamine and see how many blank stares you get until you
say, "You know... Luvox."
What is so insidious is that everyone seems completely unaware that
there is a problem here. The health care system and the public have
been hypnotized by the drug companies. I use the word deliberately: the
methods used are classic hypnotic techniques. With doctors, the drug
reps first establish a context of support and nurturance — gifts of
"Cymbalta" pens and notepads, sandwiches — and then they set up a
discussion that embodies a further distraction: they show us data on
Cymbalta. We say, but what's the difference between Cymbalta and
Effexor, they respond with more data about noradrenergic effects at low
doses, we're partially convinced but a bit skeptical, etc. We think
that we are being objective, that we're sophisticated enough to
critically evaluate the data on Cymbalta and thus are immune to bias —
and all the while the real marketing agenda succeeds brilliantly: we're
talking about "Cymbalta," not about duloxetine. Cymbalta, Cymbalta,
Cymbalta, Cymbalta. A lot of us end up a little fuzzy about what
duloxetine is. ("Oh, you mean Cymbalta!")
I am convinced that this is one of the big reasons the drug companies
find it worth their while to spend collectively over $11,000 per doctor
per year on detailing: in between bites of "complimentary" chicken
pesto panini they train us in a language and a habit of thinking. And
we doctors remain completely unaware of what we have bought into and
then talk to our patients and each other using exclusively brand names
— the language that we learn from the drug reps — thereby teaching our
patients how to think and talk about meds. All this is now reinforced
by direct consumer marketing: "Ask your doctor if Paxil is right for
you!" Patients begin requesting "Paxil," and after the original patent
expires some will say, "I don't want that generic stuff, I want Paxil."
And we write prescriptions for "Paxil." And the shareholders are happy.
I think that a doctor should be somewhat embarrassed to use brand names
in talking about medications. It suggests that her/his primary source
of information about meds is the drug rep rather than the medical
literature. It shows that s/he is not involved first and foremost in
assessing the research data. When I use the actual names of the drugs
instead of brand names, my viewpoint changes — the language reminds me
that my position is that of an applied scientist, that my job is to
weigh all the information available and make judgments about what is
best for my patient based exclusively on the evidence, not on the pitch
of a salesperson.
It has occurred to me more than once when talking with a drug company
representative that I could say, "OK, I'll refer to olanzapine as
'Zyprexa' if you pay me for advertising your product each time I do
it." But that would be grossly unethical, wouldn't it? Well, is it less
unethical for me to do it for free? (Or for "free" lunches and pens and
notepads and clocks and letter-openers and mugs?)
So I'm stubborn in fighting this. I'll endure the puzzled pause of a
pharmacist when I phone in a refill for escitalopram — though, sadly,
to be certain that they get the prescription right I usually have to
add, "You know... Lexapro." I try to teach my patients the names, not
just the brands, of the meds I prescribe them. I refuse to be a
marketing tool. The drug companies may be taking over the world, but
they're not going to take over my mind.