More than 3/4 believe that drug switching is occurring without physician consent

I recently conducted a survey on drug switching, which occurs when a patient from the drug originally prescribed by his or her physician is switched to an entirely different chemical entity.

Drug switching (aka therapeutic substitution) is not the switching of a branded drug for its generic equivalent. Rather, it occurs when your pharmacist, health plan or health insurer gives you a drug that is different from the one that your doctor prescribed. Switching from a brand name drug to its chemically equivalent is generic substitution and is generally allowed by law. However, switching to a drug that is not chemically equivalent is generally not allowed without your doctor’s approval — whether that be from branded to generic, generic to another generic, generic to branded, or branded to another branded.

In answer to the question “Do you believe that therapeutic substitution is occurring without the authorization of the attending physician?”, more than 3/4 responded “yes”. In other words, 3/4 believe that therapeutic substitution is occurring without physician consent.

What is particularly alarming about this finding is that I ran this survey mostly with physicians and physician organizations from all across the US — all told more than 100. For the record, it did include some patient advocates. However, those polled represent a particular well-informed group, at least as far as healthcare is concerned.

We as a society ask doctors to go through rigorous educational training and certification — all because we want to ensure that only those qualified can diagnose and treat.

So, if someone else is changing the prescription of the attending physician (i.e. therapeutically substituting), that means that person or organization is practicing medicine without a license. What do you think?

7 Responses to “More than 3/4 believe that drug switching is occurring without physician consent”
  1. Michael Wong says:

    @thenursesnurse comments:
    “Oh no good. Need to follow the chain of command & go back to the MD and report the switch”

  2. Michael Wong says:

    Dr Michael Cassaro (@PainlessLiving comments:
    “My personal opinion is that we already have too much legislation. Adding another patchwork of regulations is more likely to make things worse. What we need to do is to repeal legislation. Specifically, repeal the patchwork of regulations that allows insurance companies, retail pharmacies, and bean counter consultants to make the substitutions to begin with. Was it not for those authorizing regulations, the outsiders would, indeed, be guilty of practicing medicine without a license.”

  3. Walter Valliere says:

    No doubt drug switching occurs. No doubt the practice benefits the insurer, PBM, and pharmacy. Unclear is the benefit to the patient. Say, if the ‘switch’ is on, does the liability move from the physician to the ‘switcher?’ Hmmm

    Walter Valliere
    Managing Director

    • Michael Wong says:

      @Medikidz (the world’s first and ONLY medical information provider for children), in response to Walter’s question, comments:

      It’s an interesting thought with regards to drug switching and these are purely my opinions.

      I personally believe that healthcare should be led by the physician, though that’s not to say he is in sole charge. He must work closely with the patient and  their needs as well as the rest of the healthcare team. There is a reason the doctor is the specialist…he/she makes specialist decisions based on years of specialist training.

      However, once they have prescribed a particular drug that should be the only thing the patient takes. The prescription should not be changed by anyone who is not in a qualified position to do so ie. the physician themselves or another doctor.

      Once the drug has been switched, the liability is definitely out of the hands of the original prescribing doctor particularly if it happens without his knowledge. It is then the sole responsibility of the person who has made the switch and no blame or liability should be placed on the physician unless he has been involved in the switch.

      This, to me, is a solid legal and ethical stand point to have. How can a doctor be responsible for someone else’s actions particularly if they contradict his own advice?

      The only liability I can see the is that the physician should be aware of decisions being made about his patients. This is obviously difficult to do when there are so many point of contact for the patient at Pharmacies, nurse led clinics, hospital clinics and even on line information.

      My over-riding view is that if patients are switching from prescribed drugs to new medications the responsibility does not sit with the original physician.

  4. Michael Wong says:

    Dr Matthew Mintz (Associate Professor of Medicine, Director, Primary Care Clerkship, George Washington University School of Medicine) wrote me an email in response to Walter’s great question. His opinion is just that – not legal advice – just one doctor’s opinion:

    “this is more of a legal question, and I am not a lawyer. from a physician (or at least my) perspective, if the pharmacist gave the patient something that I did not write for, then I think the liability switches to the pharmacist. If I write a prescription for erythromycin because my patient is allergic to penicllin, and the pharmacist switches this to pencillin and the patient dies; I don’t think I am liable for this. Same should be the case is I write for Lipitor and the pharmacist switches to simvastatin. I think one confusing thing might be the Dispense as Written or DAW. Normally, we indicate DAW if we don’t want the patient to get the generic version. However, for drugs that don’t yet have generic, like Lipitor, I would never think about writing a DAW. However, in locations where Eswitching is allowed, it could be interpreted that lack of a DAW means that the physician is OK with a class switch, and therefore might share in the liability.”

  5. Michael Wong says:

    Dr. Melissa Hunt (Associate Director, Clinical Training, University of Pennsylvania) comments:
    “I’ve had a few patients be prescribed one thing and be given something related, but different by the pharmacist without prior approval/authorization of the prescribing physician. Makes me crazy and messes with patient care. there are subtle differences between brands within the same class and a skilled psychiatrist (the only kind I work with) often chooses a subtype for a specific reason. It comes down to availability sometimes – the pharmacy happens to have zyprexa on hand but is out of seroquel for example. I think it’s outrageous.”

  6. Michael Wong says:

    The Pharma Letter has just posted a story on this survey. It can be found at

    (Note: sign up for their free trial to view the entire story)

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