The best drug discount card

The Pediatric Insider

© 2013 Roy Benaroch, MD

I’ve gotten loads of drug discount cards in the mail to give out to patients. They look almost too good to be true—they claim to have no costs, and to provide discounts on prescriptions of up to 75%! Wowza, can’t go wrong with that! Right?

When something looks too good to be true, it usually is.

I’ve gotten these from a few different organizations, but they look similar. One is from “The Healthcare Alliance”, which has a .org web address on their letterhead—that extension is traditionally used by non-profits, but when you look through their website, they don’t claim to be non-profit. And in fact the .org address actually forwards to a .com site.

I found an exposé of their pharmacy discount card from a local TV investigation. The good news is that it does work, at least some. The amount of discount varies widely. On average, their reporter got a 23% discount off retail prices. But the card doesn’t really help people with insurance—it won’t cut your copay, and insurance drug costs are already negotiated downwards. The biggest savings seem to be for people without insurance, and only for some of the most popular generics.

The bad news: companies like this collect your personal information, including your contact info and information about the medicine you purchase. They sell this info to marketers who will use it to try to sell you more stuff. Now, you may not mind this, but you ought to at least think twice before agreeing that all of this personal health info is being sold. Marketers will know if you have diabetes, or hemorrhoids, or if you’re on a birth control pill, or if you’ve taken morning-after contraception, or if you’re on medicine for anxiety or depression or genital warts. To me, that’s kind of creepy.

The good news is: there is a better way! A retired-doctor-friend of mine, Rich Sagall, has set up a real non-profit organization that offers comprehensive, reliable information on saving money on prescriptions—and his site has a downloadable drug discount card too. Best of all, the Needymeds privacy policy is right there for you to see, and they do not, ever, sell or use your private health information for marketing. They promise to keep your health info private, the way it should be.

So: forget about those too-good-to-be-true discount cards from for-profit companies. You can save money by using generics and by taking advantage of the Needymeds non-profit, 100% legit discount card. That one is NOT too good to be true. I guarantee!

Expensive placebos are more effective

The Pediatric Insider

© 2010 Roy Benaroch, MD

A simple study from the March, 2008 issue of the Journal of the American Medical Association illustrates something important about the way we perceive the effectiveness of medication.

82 adult volunteers were recruited. They were told they were taking part in a trial of a new pain medication, testing its effectiveness using a standardized, well-established protocol using low-voltage shocks as a painful stimulus.

All of the pills were placebos.

Nevertheless, most of the study participants were able to tolerate higher intensity electrical shocks after taking the pill. And the ones who were told that the pill cost $2.50 found their placebo more effective than the volunteers who were told that their medication costs 10 cents.

Details: 85% of the participants taking the “expensive” placebo found it effective, versus 60% for the cheapo pill.

The authors conclude that one way for clinicians to help patients enjoy the benefits of their generic medication is to de-emphasize the price. By not dwelling on the inexpensive price of certain drugs, they might seem more effective. Of course, the converse is also true: why not deliberately prescribe the most-expensive, newest medication because it’s somewhat more likely to be perceived as effective, even if it’s no better at all?

The costs of a medication have no bearing whatsoever on how effective it might be. Don’t let Jedi Mind Tricks fool you into wasting money on the fanciest New Kid on the Block without real evidence that it really is better than a well-established, safe generic.

Total recall

The Pediatric Insider

© 2010 Roy Benaroch, MD

Niyazi wants my take on The Big McNeil Recall: “What do you think about the recent recall by McNeil for Tylenol, Motrin, etc.? Is it something that we need to worry about at this time?”

As you’ve heard, dozens of children’s liquid medicines manufactured by McNeil (owner by Johnson & Johnson) have been recalled. Dozens of products have been affected, including both the children’s and infant’s forms of Motrin, Tylenol, and Zyrtec. There’s even a separate website for parents to request refunds.

So what’s the danger? Honestly, I don’t know. The efforts of my crack research team have not turned up any useful details, so it’s impossible to know what really happened. The company is claiming that the products may have been too strong or too weak, or that they may have contained miniscule particles of some kind. There seems to be no implication that the products were actually unsafe, or that anyone has been harmed. Perhaps more details will emerge later.

This has certainly has blown a new hole in J&J’s reputation. It’s the third major recall since August, for a problem unrelated to the prior two issues. For those of you who had felt that name brands are always better or more reliable than generics, you might want to give the less expensive alternatives a try.

In fact, why not take this chance to get rid of most of the worthless items in your medicine cabinet for good? Simplify! Here’s a complete list of medications that ought to be in your home for your children:

• diphenhydramine (Benadryl, or a generic alternative) for hives or other allergic reactions
• ibuprofen, for fever or pain (over 6 months of age)
• acetaminophen, for fever or pain (under 6 months of age). I’ve discussed choosing between ibuprofen and acetaminophen before.
• hydrocortisone ointment for itchy rashes

If your child has seasonal or perennial allergies, you might want to keep some generic cetirizine or loratidine (Zyrtec or Claritin) around, too. Notice: no “cold” medicines– they don’t work anyway– and no weird combos that make you squint to figure out what’s really in them.

I like some non-medicines for everyday symptoms too, like honey for cough past age one, saline for snot, popsicles for sore throats, and a heating pad for belly aches or ear pain. Bet you won’t hear about any popsicle recalls any time soon!

Acetaminophen safety alert

The Pediatric Insider

© 2009 Roy Benaroch, MD

Kelly posted, “After the FDA’s recent announcement about the dangers of acetaminophen overdose, I now think twice before using it for me or my family.  What’s your take on whether the drug is safe in the prescribed dosages – particularly for kids?”

In June, 2009 the FDA released information from an advisory committee studying the safety of medications containing acetaminophen (most commonly known by the brand name Tylenol.) They pointed out that acetaminophen can cause acute and chronic liver injury, which can be fatal. Since then, the manufacturer has started an advertising campaign defending the safety of their product. So who to believe?

Acetaminophen is very, very safe—when taken correctly by people who are not already at risk for liver problems. But it turns out in practice that many, many people have been injured because they didn’t take the medicine right, or didn’t realize that acetaminophen isn’t always safe for everyone.

Who shouldn’t take acetaminophen? Anyone with chronic liver damage or liver disease. The main group are adults who consume too much alcohol. It turns out that not everyone tells their doctor about their alcohol habits, so doctors haven’t necessarily warned people about this. Other causes of chronic liver problems are obesity (so-called “fatty liver” has become the most common cause of liver disease in adolescents), the use of other medicines that affect the liver, and hepatitis. For most children (excluding overweight adolescents), the chance of having liver disease is very, very small.

How do you take acetaminophen correctly? Read the label. Use the included dosing device, and if you’re not sure how to use it, ask your doctor or pharmacist. Don’t combine multiple medications that contain acetaminophen, and make sure that if your child does take other medicines every day, you know if there are interactions between that and acetaminophen (or any other over-the-counter meds you might try.)

One specific recommendation from the FDA committee was to insist that all children’s and infant’s acetaminophen products be sold at the same concentration, simplifying dosing instructions. Right now there are several different strengths of liquids, chewables, and “Junior” tablets that are unnecessary and confusing.

Also, don’t use acetaminophen (or any other medicine) unless you really need to. Fever itself doesn’t necessarily need to be treated with medication (see here and here), but if your child feels lousy, you ought to try to help her feel better.

Alternatives to Tylenol include Motrin or Advil (both are brands of ibuprofen, see here for comparisons), or a non-medical approach like cool towels to reduce a fever, or a gentle heating pad to reduce ear pain.

If your child is in pain or has a fever, acetaminophen is a good safe medication to use. Just use it carefully and correctly, and check with your doctor or pharmacist if there’s any reason to think that your child has liver disease or is on any other chronic daily medication.

How to save money on prescriptions

Costs of prescription medications are heading up. Health insurance pharmacy benefits—if you have any—are heading down. Copays and deducibles? Up. Extra income? Down. It’s a tough time for many families who need prescription medicines.

There are many good ways to minimize your prescription expenses. Feel free to add your own in the comments section, below!

Always ask if a generic is available! Older medications often have a generic version at a much lower cost, and generic products are perfectly fine. There are many docs and many people who believe that brand-name products are superior, but in almost all cases it’s just a matter of marketing and packaging. The drug companies want you to believe only the newest, fanciest, and most-expensive medicines are for you. Don’t believe it!

Buying generic is safer, too. Generic medicines have been on the market longer, and are much less likely to have some kind of surprise side effect that hasn’t been noticed yet. It is very rare that a new medicine has any real advantages over the older products.

If a pharmacist tells you that a prescribed medication is expensive, ask if there are similar therapeutic substitutions. These won’t be exactly the same, but will be very similar. You’ll want the pharmacist to be in touch with your doctor before switching a medicine, but often there are cheaper choices available on your formulary. Don’t assume that your doctor knows what medicines are in the lower tiers for your plan.

Ask for samples: but watch out. Samples will always be for the new, expensive medicines—so once the samples run out, you’ll want to switch to a generic. Samples might get you “hooked” on an expensive medicine that you’ll stay on for a while, which is exactly why the drug companies give samples to the doctors to distribute.

For long term medicines, you may be able to order a larger quantity through a mail-order service. Ask your insurance company if you have a mail-order pharmacy benefit. It’s a hassle, but it can save money.

Sometimes, a larger quantity can be prescribed for the same copay. This won’t work for pills taken every day—the pharmacist won’t give you > 30 days on the same copay—but for prescription skin creams or medicines taken “as needed”, your doctor could prescribe a larger amount at once.

Many drug manufacturers offer “patient assistance programs” to help low-income families afford medications. An excellent web site with clear instructions for finding and using these programs is www.needymeds.org. It’s a non-profit, and they don’t collect any personal information. Go there to look up by medication what sorts of programs might be available for your family.

Info in this post was adapted from the chapter “Choosing insurance and paying bills” in A Guide to Getting the Best Health Care for Your Child, by me. Makes a great holiday gift!

Cold medicines, weasels, and a flaming piano

Captain Joe visited the site, and posted: “What’s Dr. Roy’s take on the recent announcement by the FDA and drug companies that children under 4 should not be given over-the-counter cough and cold remedies?”

Joe, what’s happened was a sneaky end-around by a very clever industry. You’ve got to give them credit for coming up with a truly weasely way of handling what would have soon become a sales nightmare for them. And they did it in a way that will hamstring the FDA and keep the money rolling in.

First, some background: in an older post I reviewed the best current evidence: so called “cold medicines” do not work. These include “cough suppressants”, “expectorants”, “decongestants”, and “antihistamines” used to treat the symptoms of the common cold. Almost all of the well designed studies looking at these products have shown that they don’t work in children; the few studies that have shown effectiveness were done decades ago in adults, and have serious design flaws.

The only reason we think these products work is because we’ve been hoodwinked by their manufacturers. Years of pervasive advertising have reinforced the image of a caring mommy offering a sniffly child Dimetussiminic, with dad hovering, concerned, nearby. Doctors have contributed to this, too, by prescribing and suggesting prescription and OTC meds that most of us know are just expensive placebos.

What changed a few years ago wasn’t new science showing the meds don’t work—we already knew that—it was a series of reports of serious and sometimes deadly side effects. Now, we couldn’t just look at these products as benign placebos. Genuine side effects can happen, and can kill.

Almost all of these side effects occurred with overdoses in children less than two. Many of the overdoses occurred because so many of these products actually contain multiple ingredients that are hard to figure out from the labels. So a dad might give three “cold medicines”, not realizing that they all contain the same ingredient. A triple dose lands Junior in the Emergency Room, or worse.

A few years ago, the FDA starting looking critically at the data, and in 2007 an advisory committee concluded that because there was zero evidence that these medicines worked, and considerable evidence of their potential harm. The FDA advisory committee recommended banning the sale of cold medicines to children less than SIX years of age.

The FDA didn’t take that step. In conjunction with industry leaders, an interim decision was made to stop marketing and selling cold medicines to children under two, and to allow a time period for further input before taking further steps. The FDA scheduled public hearings, the most recent of which was October 2, 2008, to consider input regarding the best way to proceed—that is, whether to take the advisory committee’s suggestion to extend the ban up to age SIX.

Over a year has passed since the advisory committee’s recommendation. Knowing that the FDA would eventually follow its advisory committee, the pharmaceutical industry realized that having at least part of a money-making pie was better than losing the whole thing. Rather than wait for the FDA’s decision, they voluntarily announced that they will change their labels to say that the products shouldn’t be used under age FOUR. Of course, until the new labels are made, existing products won’t be pulled.

Now, what would you do if you were in the FDA’s shoes? They had to announce that they support this industry decision—doing less would make them seem less concerned about children than the drug sellers. But now, can they really come back in a few months and raise the age to six? If they do, they’ll look ridiculous. It will seem to most people that the FDA has no idea what they’re doing: after all, didn’t “they” just announce you shouldn’t take these meds less than four? And now it’s less than six?

Clever.

To summarize:

• Serious reactions can occur if “cold medicines” are used in children, especially under age 2.
• For older kids, they’re pretty harmless as long as the correct doses are used.
• They don’t work.
• The companies that sell them are apparently staffed by clever weasels.

Related posts of mine:

Treating cough less than two

A cold lasts longer than you think

An unrelated video of a rich British guy throwing a flaming piano with a giant catapult. Go on, you know you want to see it.

Treating cough less than two

Here’s a question from Holly: “What can you recommend, if anything, for nighttime coughing? Adults can just knock back some cough medicine, but there doesn’t seem to be any equivalent solution for young children (under 2). It’s sad when the coughing is bad enough that they wake themselves up and then start crying because they really just want to sleep. I’m not asking about chronic coughing, just the kind related to a regular cold.”

This question is also addressed in this post from last month. Cough and cold medicines really don’t work very well at any age, but for children less than two there are none that are approved for use in the United States. Cough medicines that have been prescribed in the past are ineffective, and even worse, they’re potentially dangerous.

Cough and cold medicines don’t work

Health authorities are reporting that commonly-used cough and cold medications are not safe and are not effective. Since colds are so common and affect all of our children at least a few times a year, parents ask me every day about the new guidelines, and about the safest ways to help their children feel better.

First, some details. The medications that are commonly suggested to relieve the symptoms of the common cold fall into just a few groups. Within each group, the available choices are all essentially the same. Often, medications from several groups are combined to make what is optimistically sold as a “multisymptom cold reliever.”

Decongestants include products with the active ingredients pseudoephedrine and phenylephrine. They are supposed to work by shrinking the lining of the nose and decreasing nasal mucus secretions. Decongestants also raise a child’s heart rate and blood pressure, and may cause hyperactivity, agitation, and sleeplessness. Good studies have never shown decongestants to be effective in children, and even in adults their clinical effect is probably very small.

Cough suppressants are another group of medications purchased to help with the symptoms of the common cold. The most widely used over-the-counter product, dextromethorphan, has become a drug of abuse among young adults. Good studies have never shown that dextromethorphan is effective in stopping a cough; in fact, a recent study showed that in children, honey may be just as good or better than this medication. There are some prescription-strength cough suppressants as well. These are usually narcotics with strong sedating effects and some potential for abuse and addiction. Even these potent drugs, with all of their side effects, are very effective at actually helping a child who has a cough.

Antihistamines can certainly help with symptoms of nasal allergy, and are often used for colds as well. If you’re not sure if your child has allergies or a cold, a safe dose of an antihistamine may be worth trying. But it won’t help if your child’s runny nose is caused by a cold. Some families may find that the sedating effect of antihistamines can allow better sleep, at least for the parents. Newer, non-sedating antihistamines like Claritin and Zyrtec are expensive and offer no benefit whatsoever to children with the common cold.

Expectorant medications include those with the active ingredient “guaifenesin”, sold under the brand name Robitussin. These are supposed to thin secretions and help clear mucus. Unfortunately, no studies have ever shown that these medications actually work; and the liquid forms taste horrible. Among the medications reviewed so far, expectorants are the least likely to cause any side effects. Even though they’re unlikely to be effective, at least they’re safe enough to be worth trying in some cases.

The medicines reviewed so far—decongestants, cough suppressants, antihistamines, and expectorants—are collectively called “cold medicines.” They’re combined in all sorts of ways in products marketed to children, including common brands like Dimetapp, Triaminic, Pediacare, and many others. These are the medications that have generated some increased controversy over the last years because of questions of their safety and effectiveness, and the way they’re marketed to children.

In 2004 and 2005, about 1500 children less than two years of age were treated for adverse events triggered by cold medications. While many of these reactions were mild, more serious reactions including seizures, stroke, and death have occurred. Though industry representatives feel confident that these more severe reactions are not possible if the medications are dosed correctly, safe doses of these medications are not well-established or agreed upon by pharmacists and pediatricians.

In August, 2007 an FDA advisory panel recommended that cold medications not be used under age six, citing both a lack of evidence that they work and concerns about their safety under age two. Shortly after that, several large manufacturers of these products voluntarily recalled cold medications that were packaged for use in babies and toddlers. In January, 2008, the FDA formally announced that they advised against the use of these products under age two, and that later this year they will make recommendations for older children.

So what can a parent do to help the miserable symptoms of the common cold in a child? First, several non-medicine approaches can really help. Frequent use of non-medicated saltwater (also called saline) drops can help clear mucus from the nose and is safe at any age. You can buy these drops over-the-counter, or mix them up inexpensively yourself. Other methods to keep nasal secretions runny and loose will also help. Encourage a child to drink more fluids, use a humidifier, and sit together in a steamy bathroom. Honey can be used safely in children past their first birthday to help settle a child’s cough. (Honey should never be given to infants less than one year of age.) Though these are many other alternative or “natural” medicines that are marketed for children with cold symptoms, many of these have unknown safety and effectiveness. If you’re interested, we can cover more details about these products in a future post.

Medicines that reduce fever and relieve aches and pains are safe and effective, and can help with some of the symptoms of a cold. These include acetaminophen (found in Tylenol, and safe at any age), and ibuprofen (found in Motrin and Advil, and safe for use in babies six months and up.) Confirm the correct dose for these based on your child’s weight with your pediatrician.

In summary, many of the medications commonly sold to reduce symptoms of the common cold just don’t work, and they can be unsafe especially if used under age two. To help your child feel better, rely on simple home remedies that thin secretions and help clear out stuffy noses. If you do want to use a medication, follow the dosing guidelines of your pediatrician or pharmacist closely, and always keep medicine bottles away from children. As miserable as it can be, a cold is going to get better all on its own. It’s not worth it to use approaches that might lead to far more serious consequences than a cold itself.

© 2008 Roy Benaroch, MD from www.PediatricInsider.com