Brand names are widely used when we want to refer to a specific product — an Apple computer, a Tesla car. Sometimes brand names are so widely used that they take over — we ask for a Kleenex instead of a tissue.
Drugs have two names. The brand name is the one that’s chosen by the company making it and that company is the only one allowed to use the name. (The name that the company proposes is reviewed by Health Canada.) Brand names are almost always short and catchy so that doctors will remember them.
Generic names are assigned at the global level by the World Health Organization in conjunction with national naming authorities. These names are often long, but part of the reason for the length is that they tell doctors about the pharmacologic property and/or chemical structure of the medication.
The generic name for the new US$2-million-per-patient drug for spinal muscular atrophy is onasemnogene abeparvovec. The brand name is Zolgensma. Which one are doctors (and patients) going to remember and use? The answer is obvious.
One of the associate editors at the Canadian Medical Association Journal makes the point that “some brand names are created to be reassuring or promising — so-called ‘benefit-led’ names such as Paxil, Celebrex and Gluconorm — when they actually need to be prescribed with great care and consideration of the drug’s potential effects on the individual patient.”
Is the use of brand names the right way to talk about prescription drugs? Apparently, Health Canada thinks so. Want information about safety problems with a medicine? On Canada’s recall site, you’ll see the brand name in CAPITALS and the generic name in lower case and in brackets.
Want to see if there is a shortage of the drug that your doctor just wrote you a prescription for? Go to Drug Shortages Canada and you’ll find the brand names of the drugs, again in capitals.
If you’re interested in why Health Canada approved a particular drug, the Summary Basis of Approval document will help you understand. But once more the brand name is the most prominent one, and again it’s in capitals.
What’s in a name?
In medical school, students are taught to use generic names. Medical journals tell authors to use generic names in the articles that they write. Does it matter which name doctors use? The answer is yes.
When Australian anaesthetists and doctors training to be anaesthetists in two teaching hospitals were given the brand names of drugs, they could only correctly identify the therapeutic group that the drug came from in just over half the cases. Without knowing what therapeutic group the drug came from, doctors could accidentally have used another drug from the same group or they could have used the drug incorrectly.
The more money that doctors receive from drug companies in the form of meals, travel arrangements and ownership royalties, the less likely they were to prescribe by generic name. Seeing drug company sales representatives more frequently is associated with more brand name prescribing, which translates into more expensive prescribing. Sales reps also usually leave out important safety information about drugs they are promoting, so besides prescriptions costing more, they might also be more likely to harm patients.
Brand names, drug regulation (the domain of Health Canada) and pharmaceutical promotion have come together in a particularly egregious way in the case of buprenorphine-naloxone, brand name Suboxone — an opioid medication used to treat opioid addiction.
Even though generic formulations of the drug have been available in Canada since 2013 (and even earlier in the United States), the drug is widely referred to by its brand name, including in the media, by policy makers and by doctors.
One way this happened was through the promotion of an “educational” program developed and delivered by Indivior, the company that holds the rights to Suboxone. In some provinces, completing this branded program is a pre-requisite to being able to prescribe buprenorphine-naloxone. The same strategy has been executed for a related injectable form of buprenorphine, also owned by Indivior.
This use of the branded program is the case even though there are perfectly good, accredited, non-industry educational programs already available to teach appropriate opioid addiction care and prescribing to doctors, nurses and pharmacists.
Yet, the branded program is fully sanctioned by Health Canada through that body’s review and approval of the Suboxone product monograph. This document, which describes the nature of the drug and its approved uses in Canada, includes a description of the requirement for participation in the branded “training program.”
As has been documented in the U.S., Indivior and its parent company Reckitt Benckiser have engaged in a variety of unscrupulous practices to promote their multibillion-dollar buprenorphine product line — ultimately paying some of the largest fines in U.S. pharmaceutical history. In this light, a branded “educational” program seems to be one more vehicle for brand name promotion, and one in which Health Canada is directly complicit.
When doctors use brand names they may be less knowledgeable about the drugs they are prescribing, their prescriptions cost more and patients may be more likely to suffer side-effects. When Health Canada prioritizes brand names over generic names it is actively contributing to all these problems.
Health Canada should know better and must do better.
In 2018-2021, Joel Lexchin received payments for writing a brief in an action for side effects of a drug for Michael F. Smith, Lawyer and a second brief on the role of promotion in generating prescriptions for Goodmans LLP and from the Canadian Institutes of Health Research for presenting at a workshop on conflict-of-interest in clinical practice guidelines. He is currently a member of research groups that are receiving money from the Canadian Institutes of Health Research and the Australian National Health and Medical Research Council. He is a member of the Foundation Board of Health Action International and the Board of Canadian Doctors for Medicare. He receives royalties from University of Toronto Press and James Lorimer & Co. Ltd. for books he has written.
Abhimanyu Sud has received funding from or consulted with the Canadian Institutes of Health Research, Health Canada, Association of Faculties of Medicine of Canada, University of Toronto, Centre for Effective Practice, and Mississauga-Halton Local Health Integration Network for research and medical education relating to opioid use and drug policy.