America's Most Popular Drugs

A narcotic painkiller tops Forbes' list of the most prescribed medicines.

The most popular medicine in the U.S. was prescribed 128 million times last year, even as a panel of experts called together by the Food and Drug Administration recommended that regulators ban it.

The drug is Vicodin, a 40-year-old addictive medicine that combines the narcotic hydrocodone with acetaminophen, the active ingredient in Tylenol; the prescription tally also includes numerous generic versions. It is emblematic of the trend that emerges from our look at the most popular prescription pills: the death of the blockbuster drug.

Forbes' list of the 15 most popular drugs comes from IMS Health ( RX - news - people ), a company that tracks sales at the pharmacy level for drug companies. The list shows how medicine makers are rapidly losing their grip on the average consumer. Only one drug in the top 15, Pfizer's ( PFE - news - people ) Lipitor, is a big-selling brand-name medication. The rest are cheap generic versions of one-time big sellers that have lost their patent protection and become commodities. Generic copies of Vicodin go for 30 cents a pill, compared to $4 per pill for Lipitor.

Vicodin is a drug that is crying out to be replaced. Vicodin has a supporting role on the television show House, M.D. because the protagonist, a Sherlock Holmes-like doctor, is hooked on it. It is particularly dangerous because when patients develop a tolerance for the narcotic they start taking too much. This can lead to liver failure from overdoses of the acetaminophen component of the combo. Most of the 400 deaths due to acetaminophen poisoning each year result from misuse of the Vicodin or similar drugs. Last June an FDA advisory panel recommended banning Vicodin. The FDA is still deciding whether to take this advice.

"People are taking this as if they're taking a strong Tylenol," says Michel Dubois, director of pain medicine at New York University Langone Medical Center. There's nothing wrong with Vicodin after a surgery or tooth extraction, he says, but it's being used too often by primary care physicians with "minimal training" in dealing with chronic pain. "It has been trivialized, and its wrong to trivialize this strong a pain medication," he says.

The failure to replace Vicodin is not for lack of trying. Pfizer once hoped its painkiller Bextra could be an alternative. But in 2005 Bextra, a chemical cousin of Merck's ( MRK - news - people ) Vioxx pill, was pulled from the market because it increased the risk of heart attacks and allergic skin reactions. Pfizer paid a $1.2 billion criminal fine last year for marketing Bextra for unapproved uses like dental pain. Other efforts to replace Vicodin have come up short. Vicodin-maker Abbott Laboratories ( ABT - news - people ) worked for years on a delayed release formulation but has not been able to get it through the FDA.

The second most popular drug in the U.S. is generic Zocor, or simvastatin. The cholesterol-lowering drug was once Merck's biggest seller, but Merck lost its patent protection in 2006. Doctors prescribed it 83 million times last year. One reason: It is proven to save lives, and it costs only $1 a pill, far less than Lipitor.

Zocor used to play second fiddle to Lipitor but became more popular after it went generic and health insurers pushed it as a cheaper option. Merck, Pfizer and others tried to develop new types of cholesterol drugs with little success; the cholesterol drug market is now dominated by generics.

Lipitor still wracks up $7.5 billion in annual sales, more than any other drug but only ranks seventh by popularity, with 51.1million prescriptions last year, down from 75 million in 2005. The second-biggest seller by dollar sales is the heartburn drug Nexium from AstraZeneca ( AZN - news - people ). But it is a lackluster No. 19 in popularity. Overall, only 8 of the 50 most popular drugs are still branded, compared to 20 in 2003, IMS says. 75% of all prescriptions are for generic drugs.

The third most popular drug, with 81.3 million prescriptions, is the blood-pressure-lowering medicine linsinopril, which used to be sold under the brand names Zestril and Prinivil. Overall, 6 of the top 15 most prescribed meds are blood-pressure-lowering drugs. There are so many good generic blood pressure drugs that it is difficult for brand-name drugmakers to improve upon them.

The No. 5 drug, azithromycin, is the generic version of Pfizer's popular antibiotic Zithromax. It tallied 53 million prescriptions last year. Like Vicodin, it's a much maligned medicine whose popularity was once blamed on overmarketing. It's not being advertised to doctors or consumers anymore, but it's still overused.

Brand name drug companies are inventing fewer drugs--a third as many were approved in 2009 as in 1999--and the ones they are inventing aren't selling. The last good year for new medicines was in 2006. Drugs launched that year generated $1.2 billion in first-year sales, says IMS. In none of the years since have drugmakers come close to this figure.

Companies are responding by trying to focus on medicines they can sell to small numbers of people at a higher price for rarer diseases like cancer, multiple sclerosis and ultra-rare genetic diseases. Ironically, that may include the next big painkiller: an injected protein drug that blocks nerve growth. It is being developed by Pfizer and could hit the market in a couple years.

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