Letter to the AG: Changes in pill appearance pose potential danger for consumers

Mary Woolford to Attorney General Marc Dann, June 1, 2007
Subject: Pharmacy generic drug packaging

Dear Mr. Dann,

I am a retired teacher who uses the mail-order pharmacy system authorized by STRS. At the present time, that company is Caremark.

Yesterday, I received a packaged prescription for a drug I have been taking since 1988 for depression. I take a 10 mg. capsule at noon and a 25 mg. capsule at bedtime. They have differed in color and size for years. Well, yesterdays' refill for the 25 mg. capsule came, and it's the SAME color as the 10 mg. and is SMALLER.

For years, there was no danger of confusing the dosage, due to the different colors and sizes, but now, the larger size is the SMALLER DOSAGE, and the smaller size is the LARGER DOSAGE! And, they are now both the SAME COLOR! Boy, I'll have to watch carefully, or I will mistakenly take too much and that will be a disaster, as this is a psychotic drug that alters the brain chemistry. It's the generic form of Pamelor, which I don't object to using, but I DO object to this new wrinkle and will have to use a magnifying glass to see the numbers 10 or 25 clearly so as not to confuse them.

The size difference is subtle enough that they could be mistakenly considered the same dosage. I don't need more complicated things to figure out with such a serious thing as medicating myself using my doctor- recommended prescription drugs. I am concerned about older retirees who may be less sharp than I am and the danger of putting them in the same predicament with their drugs, which could lead to accidental overdosing. It's scary, and I think it's a concern that needs to be carefully looked at by those who are in a position to require companies to adhere to specific regulations that will prevent seniors from being put in jeopardy with their use of prescribed drug treatment.

I will add that the prescription was accompanied by a letter stating that the appearance of the drug was different from before, but that disclaimer statement doesn't excuse drug companies from the fact that such confusion could easily result in accidental death for some unfortunate retiree.

I appreciate anything that you can do to see that generic drug companies conform to some stiffer regulations that will help the consumer and not further complicate the correct use of medications.

Sincerely,

Mary F. Woolford
Delaware, OH