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Raising Awareness Of
'Therapeutic Switching'
by Charlotte Sapp, Women in Progress

   As president of Women in
Progress, Inc., I have a strong
interest in educating low-income
women at an increased risk of
developing HIV/AIDS. Many of
these women in the Bronx have
recently been released from prison
and need someone to look out for
them and their health.

  Increasingly, I am concerned
about an issue commonly called
“therapeutic switching,” in which
medicines that have been
prescribed for a patient are
switched with a less-expensive
substitute. The problem lies in the
switch, because the drug that the
patient is switched to is not always
an exact formulation of the original.
Many times, the patient is not even
alerted of the switch, and the
doctor has not given permission.
This can have adverse effects on
health, as some drugs may require
different dosages to be taken more
or less frequently. Some may
cause different side effects or
other complications. Remember –
just because two drugs may treat
one illness, dosn’t mean the drugs
are interchangeable!
Sadly, this practice affects low-
income and minority communities
like African-Americans, because
low-income patients cannot afford
more expensive health plans. It is
unfair that therapeutic switching
disproportionately affects
minorities, but that is the reality.
Let’s work to stop this practice, and
demand that only a doctor can
make the decisions for their patient.
CONEY ISLAND FACE LIFT
by Demetria Daniels

   At one of the many recent meetings
about Coney Island, Madelyn Wils,
Executive Vice President, Planning &
Development of NYC Economic
Development Corporation welcomed
the large group and Lynn Kelly,
President of the Coney Island
Development Association outlined the
plans for Coney Island development in
her opening speech to 300 local Coney
Island residents , community members
and interested attendees.. She said,
“we are all very enthused about the
future of Coney Island which will
expand the amusements, provide
Artist rendering of the proposed development of Coney Island
  Purnima Kapur, Director, Brooklyn Office, Department of City Planning outlined in detail the new
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while abandoned buildings and vacant lots will be refurbished. and rebuilt, and a movie house
planned..

  The oceanfront neighborhood and historic district will benefit from the new installations and the
desire is to make it a “year-round” attraction. Eminent domain would not be in effect. Re-zoning
goals would maintain the history and the culture.

  The general comments from the audience were both positive and negative. A beautiful “Miss
Cyclone” and Diana Carlin of the store Lola Starr want protection of the history and the amusement.
Some suggestions included – trolley cars, express trains to Coney Island, water ways expansion, with
water taxis, ferry docking, an ice-skating rink, a saltwater pool ( like the 40’s) and a casino.

  Of course with every plan, there is always controversy. Senator Carl Kruger said:

  “there is no environmental study being done”; the infrastructure – mass transit, schools, sewage,
sanitation isn’t being dealt with., there is NO developer and there is NO financing. And what about
the boardwalk – which is in crucial dissrepair and has been that way for at least two summers.
(maybe Donald Trump can come to the rescue like he did with Wollman ice skating rink).

  The high note of the evening was the singer Amos Wengler who can be found on “My Space”
whose song about Coney Island – “Save Coney Island, they want to take it away”
brighten up the meeting and the day.
affordable housing, and create jobs for the local residents”.
Standing in front of four huge colored artists renderings of the “new Coney Island”
Another artist rendering of the proposed Coney Island development
    ''They said the insurance doesn't pay,'' she said. ''It wasn't on the formulary.'' Her doctor switched
her to nifedipine, a different drug in the class known as calcium channel blockers. But the new
medicine isn't working, and last week the doctor doubled the dose. ''It's very scary,'' Ms. Best said.
''This could be a matter of life and death with me.''

   Managed care executives call what happened to Ms. Best ''formulary management,'' or ''therapeutic
substitution.'' Consumer advocates use a less flattering term: ''drug switching.''

   With more drugs on pharmacy shelves than ever before, and with more prescriptions being written
each year, officials at the Food and Drug Administration are growing increasingly concerned about
deaths and injuries caused by medications. Much attention is being paid to medication mix-ups and
other pharmaceutical errors. But many people don't realize that pharmacists, at the behest of
insurance companies, intentionally switch medications all the time, with potentially harmful
consequences.

   These switches do not involve replacing brand name drugs with generics, which pharmacists are
allowed to do unless the doctor writes ''dispense as written'' or ''D.A.W'' on the prescription. Rather,
one chemical entity is substituted for another; the drugs may treat the same disorder but have entirely
different side effects. The practice is particularly common with some of the most often-prescribed
medications: anti-depressants, high blood-pressure medication and cholesterol-lowering drugs.

   Often, the switching, which is done to save money, is harmless. But for some people, particularly
those who have been on an established therapy for a long time, the changes can cause problems.

   ''It can be very dangerous and it is rampant,'' said Dr. Raymond Woosley, chairman of the
pharmacology department at the Georgetown University Medical Center. ''This counters everything
we teach in medicine, which is, 'Know a few drugs, know them well, pick the best medicine for your
patient, don't change unless it is medically indicated.' ''

   The idea that doctors should know a few drugs and know them well was the original concept behind
formularies, or restricted lists of medications. ''It's an old concept,'' said Susan Winckler, director of
policy and legislation at the American Pharmaceutical Association, a pharmacists' trade group, ''and
in a hospital setting it allowed physicians and other prescribers to get used to a limited number of
drugs. Managed care has taken that concept from the hospital to the community environment, and we
are not quite sure that the translation has worked as well as it could.''

   Consumer advocates say it is not working at all. Howard Metzenbaum, the former Democratic
senator from Ohio who is now chairman of the Consumer Federation of America, a nonprofit
organization in Washington, described drug switching as ''an evil practice.'' He would like to see
Congress ban it, but said, ''My guess is we'd have a hell of an uphill battle.''

   In a 1997 report entitled ''Pharmaceutical Payola,'' Mark Green, the New York City Public Advocate,
cited a string of complaints about drug switching that had been sent to the F.D.A. A 63-year-old
woman developed a joint condition after switching cholesterol-lowering drugs; a 29-year-old
schizophrenic ''began exhibiting bruises and swelling'' after changing medications, and an 86-year-old
woman who traded one high blood-pressure pill for another suffered ''nausea, weakness and
shakiness.''

   And even when there is no harm, pharmacists and doctors say, the switching is a nuisance. ''That's where the
nightmare in pharmacy comes in,'' said Bruce Roberts, the owner of Leesburg Pharmacy in Leesburg, Va. ''First we
have to determine what they will cover. Then we have to call the physician and get authorization. Most physicians are
so beat down by managed care that they say, 'O.K.' '' But when the doctor refuses, he said, ''You have to get back on
the phone.''
Ideas & Trends; Drug Switching
Saves Money, but There Is a Cost
By SHERYL GAY STOLBERG

Published: June 13, 1999    
   
   WITH a brother who died of a heart attack and
two parents who had strokes, it came as no
surprise to Joanne Best that, at age 60, she had
developed heart disease. The surprise came at
the drugstore counter, when Ms. Best, of
Concord, Calif., tried to refill her prescription for
Norvasc, the medication that kept her blood
pressure under control.
who said she already pays a $200 monthly premium for health insurance. Paying for Norvasc would cost her an
additional $80 a month.   And what happens when the insurance company and the drug company are one and the
same? When Merck, the pharmaceutical giant, purchased Medco in 1993, critics complained that the parent company
would steer its own drugs to the benefits management firm, a wholly owned subsidiary. Last year, the Federal Trade
Commission agreed; an investigation found that Medco had given favorable treatment to Merck products. Without
admitting wrongdoing, Merck-Medco signed a consent agreement that required it to maintain an ''open formulary,'' a
practice Mr. Colgan said the company already had in place. In the end, some wonder how much money is really being
saved by all this switching, and at what cost. Mr. Green, the New York City Public Advocate, concluded that drug
switching is ''likely to mean that a patient does not get well as fast,'' which drives up health care costs from additional
doctors' visits. Dr. Kathryn Bennett, who treats Ms. Best, has reached the same conclusion. ''Now she is taking this
medication twice a day,'' the doctor said, ''which may well be more expensive than what she was taking before.''
  
   Pharmacy benefits managers, who serve as middlemen between drug companies and health plans, say the
wrangling is worth it. Drug costs are spiraling upward; the pharmaceutical industry's revenues are estimated at $91.8
billion this year, up from $38.5 billion in 1990. Medications play such a big role in modern medicine, health
economists say, that some health plans are now paying more for pharmaceuticals than hospital visits. Switching is
so essential to keeping costs down that benefits managers pay pharmacists a premium for dispensing drugs that are
on a company's formulary.

 We estimate that we save our clients over $1 billion a year in prescription drug costs,'' said Kevin Colgan, a
spokesman for Merck-Medco Managed Care, which administers prescription drug benefits for more than 51 million
people. He said no one is pressured to switch; doctors are simply ''presented with an opportunity to help the health
plan to save money. ''Forty-six percent of the time, he said, they agree. Patients who don't like it, Mr. Colgan said, have
another option: ''They can always pay for it themselves, out of pocket.'' That kind of thinking enrages Ms. Best,
Drug Switching Saves
Money, but There Is a
Cost
(continued)

Correction: June 20, 1999, Sunday
An article on June 13 about how
pharmacists, at the behest of
insurance companies, sometimes
substitute a less expensive drug
for the one originally prescribed,
omitted the context for a comment
by Kevin Colgan, a spokesman for
Merck-Medco Managed Care, who
said: ''The patient is accepting a
benefit from their employer, and if
they would like no management of
their benefit, or no restrictions,
they can always pay for it
themselves out of pocket.'' Mr.
Colgan was referring to an
employee's entire drug benefit
package, not to an individual
prescription.
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