All drugs should be legal, full stop. And I should be able to get medical drugs on my own, without a permission slip from a doctor I have to convince.
Drug prohibition has caused magnitudes more harm than decriminalization and legalization.
And part of this article is about claims from what is likely inert or mild effect at best. Remember, we used to have amphetamines, pseudoephedrine, and much more potent drugs to alleviate colds and such. But because of the forever-drug-war , we're stuck with substandard crap, and everything good gatekept by doctors.
Dextromethorphan is definitely not a placebo. Take enough and you'll go to space and meet God. Smaller doses produce euphoria and dissociation, which, even if they don't make the cough go away, makes it easier to tolerate a cold -- same reason antitussives have historically contained alcohol, cannabis extract (which may incidentally work as bronchodilator but was not the reason I imagine it was in antitussives)
Funny amphetamine used to be an over the counter cold medicine, which the article doesn't mention despite talking about the meth precursor?
Fine article but these two details stuck out to me while reading it.
Yeah, intentionally misleading consumers should always be at least somewhat illegal. Sure caveat emptor, but consumers having accurate information is implied and a cornerstone of a competitive market.
The more general deeply-entrenched golden goose here is branding, which applies to much more than OTC medicines. Make it so the active ingredients have to be listed prominently - the largest text on the front of the product package - and these concerns diminish greatly.
It would also fix the homeopathic snake oil as well, which has started showing up as options in previously-reputable medicine aisles. So at any rate, be on guard if you don't want to end up accidentally buying a bottle of water plus flavoring in your cold-addled state.
Absolutely true. Phenylephrine liquid applied directly to nasal mucosa is a quick and effective decongestant. It doesn't last as long as oxymetazoline (the other big nasal spray ingredient), but it also doesn't cause you to become dependent on it as much as oxymetazoline does.
> If you walk down the cold and flu aisle at CVS and start looking closely at labels, you will count about 100 products and around six active ingredients
It's so utterly ridiculous how much space the Cold and Flu section of the medicine aisle takes for no reason at all.
And the whole thing about combining so many medications is just silly, especially the marketing for it. "Why take 3 medications for your cold symptoms when you can take just this one?" then gets countered with "Why take a cold medication that has ingredients for symptoms you don't have?"
IMO, DayQuil should never have existed simply for the reasons the article mentions: It leads to people being unaware of what they're taking. Yeah, the label is right there, but you gotta consider the lowest common denominator when selling things to the general public.
They also picked a study that shows honey outperforming Dextromethorphan but ignored all the studies that show honey performing similarly or slightly worse than Dextromethorphan, or studies where honey showed no measurable effect.
There are so many studies and papers published now that you can find both positive and negative results for just about anything. When someone starts pulling up singular random links to papers you should be suspicious. Be even more suspicious when someone is calling for bans or regulations based on those individually selected papers
> This article uses the trick where you pick studies that support your argument and ignore all of the studies that disagree with it.
It's even worse than that, they appear not to have actually read the analysis they cited because two of the three studies on DXM found it was effective in adults. The same efficacy was not found in children but there are other very plausible explanations for this (difference in dosage and measurement techniques).
I was wondering about that. I've taken a number of different cold medications over the years, one active ingredient at a time, to check their effectiveness while sick. Phenylephrine, as widely reported, had zero effect. But Dextromethorphan seemed to work for my kids - give it to them, stopped coughing. Started coughing again 6 hours later, etc. n=1 and it's a 4 year old, but in one of those cases my results clearly matched the studies, and in the other it didn't, at least as reported by this article.
I only know one person who has ever found phenylephrine effective. It's definitely not for me, but they've done single-blinded self-studies (with help) to see if it's a placebo effect, and it's pretty clearly not.
DXM is also not a placebo, although it might be specifically for cough.
I don't especially want the FDA to ban them, but requiring separating out the acetaminophen might not be the worst idea.
I just can't get super upset about this. Sure, OTC companies are duping customers with marketing, but what's new about that? As the person holding the money, it's my job to look at what is effective and what the active ingredients are in any given product. Or ask my doctor/nurse/pharmacist what to do, if I can't be bothered to make the effort myself.
When I want to get irrationally angry about something in a department store, I'll walk over to the shampoos, which for some reason always have a whole entire aisle dedicated to a single product, when they all do literally the same exact thing, just with different scents and advertising budgets baked into the sticker price.
While I can appreciate the principle of not blindly trusting OTC medicine marketing, it is not realistic to expect every person to be highly competent in fully understanding their medical choices. It is far more reasonable to expect the companies marketing healthcare products to be honest to their customers.
If anything, you need honesty from healthcare companies in the first place if you're even going to begin making an informed decision. You're putting the cart before the horse here: people absolutely should be doing their own research before medicating themselves, but it is the OTC companies that obstruct that.
And, secondary to all of this, your analogy about shampoo is misinformed. Still, it is fitting for this scenario, but not in the way you intended. There are lots of different hair types, including ethnic hairstyles that require specific treatments. There are also a number of lifestyle choices that can change your hair treatment needs. As a result, the shampoo aisle actually is stocked with a wildly varying assortment of haircare choices, but actually figuring out what product works best for your needs can be challenging because it is walled behind layers of marketing nonsense that don't inform the consumer adequately on what makes each product different. This isn't much different than the problems in the medicine aisle.
It took a lot of secondhand research to find the ideal hair care product for my thick, curly hair that would mitigate the damage of thrice-weekly swimming in a chlorinated pool. I can assure you, not everything in the shampoo aisle is exactly the same. It was especially hard figuring this out as a man, when so many products are arbitrarily marketed to specific genders.
> So the only ingredient that’s doing anything in that bottle of DayQuil makes up just 2% of the bottle: the roughly 8 grams of acetaminophen
this argument makes very little sense. Plenty of very potent drugs are in the single digit mg range in a tablet that weights hundreds of mg.
More importantly, as always, it is a problem of incentives. There is no strong, commercial entity focused on removing ineffective drugs from the market, but plenty of commercial pressure to keep them. The FDA has zero incentive to clean house. The magic hand of the market is supposed to be consumers choosing not to buy these drugs because they are ineffective, but for many reasons (choice, placebo effect, basic scientific literacy) this does not happen.
I don't know what the most effective entity is. I cannot personally imagine a commercial structure to support this, but perhaps one could be built.
This should be divided into three parts: marketing and selling people questionable combo drugs at insane cost (bad), the case of oral phenylephrine (idiotic + bad), and the efficacy of the other drugs in the mix (guaifanesin, etc) (unclear).
No it should not be, but not because of the dextromethorphan or the phenylephrine being ineffective. By far the biggest issue is the acetaminophen it contains, which it isn't super obvious about, and frequently leads to acetaminophen overdoses. The vast majority of acetaminophen overdoses occur because people combined different medicines containing it (like DayQuil and Tylenol) without realizing they were taking the same thing multiple times. Its a completely preventable cause of liver failure and we should not be making cocktails with it that don't clearly show exactly what they are.
> Why do we even have combination over-the-counter products at all?
In America? No idea. In the UK it's because they sell codeine+tylenol OTC, and they want it to poison you if you try and get a codeine buzz from it. Incredibly this is true.
Just bring back ephedrine and pseudoephedrine! Nobody cares if a few enterprising nerds could cook it into methamphetamine! Oh my gawd someone might experience some unapproved, unrentiered joy! Send in the SWAT teams! This is what the War on Drugs™ gets us.
Dextromethorphan is useful. The problem is solely with oral phenylephrine being sold for something that it does not work for. The precise suggestion then is for oral phenylephrine to not be sold for such indications.
The real reason that all these drugs are mixed together seemingly willy-nilly is actually to prevent people from overdosing and going wild with a singular drug, or cooking up more potent mixtures from it. Guaifenesin in particular has been mixed with decongestants, for the primary purpose of preventing use as a precursor.
If they sold these chemicals as singular treatments then the abuse would go through the roof. The "accidental OD" scenario where an innocent patient quadruple-doses is realistic, and anticipated, and the shrewd consumer will avoid this.
I injured my legs, then on top of it, had a minor cold recently, and finally grabbed a bottle of Coricidin HBP out of desperation. I have also been stocking up on 0.0% beers. Between doses of the former and bottles of the latter, I managed to get some great-quality sleep and rest.
The other thing to notice about the Cold and Flu section of your pharmacy is that most all the treatments are supposed to relieve congestion, clear phlegm, and serve as an expectorant, such as all the cough drops with lemon, or menthol. If you are a lifelong smoker with a productive cough, this is great. That includes habitual pharmacy patrons who've always purchased their cigarettes and cigarilloes right there at CVS, next to the candy aisle and the booze aisle.
If you live in a desert and/or suffer from chronic E-N-T dryness and dry coughs, then these treatments will make your life a living hell and must be avoided at all costs. Think about it.
They wouldn't be selling the placebos if the real stuff were accessible. That's the real answer. The article mentions this but just accepts the inaccessiblity of the real thing as a given.
You used to be able to get Nyquil with real sudafed in it. That was the gold standard. It's not even available behind the counter anymore, presumably because they can make more money from morons buying the placebos.
As an aside:
> In January 2011, the FDA set a maximum amount of acetaminophen that could be packaged in combination opioids like Vicodin or Percocet. The odds of hospitalization due to opioid-related acetaminophen toxicity plummeted.
Yeah, the acetaminophen was there to PREVENT abuse of the Vics and Percs 'cause you'd overdose on the acetaminophen first. Sure, there was an easy workaround, but that was it's intent.
In Canada if you go to a drug store, the shelves are literally filled with literal homeopathic medicine. You have to carefully confirm that what you’re buying isn’t water, and there is no signage or other differentiation between actual medicine and magic.
Completely unrelated, I noticed recently that tire detailing spray that makes your tires look black, and the recommended lubricant for my garage door weather stripping, which both cost $15 or more for a little bottle, are just silicon oil that costs pennies for that amount. I have no moral problem with charging higher prices for convenience plus clarity of what the use is. I do think it’s amoral, obviously, to be involved in snake oil sales and unbelievable that the government allows it.
I use DayQuil/NyQuil when I get a cold and in my case, it's always worked well. It suppresses the symptoms and lets me carry on with my day-to-day. I did try once going 1 week without it and it was hell.
I think there's one thing most people agree on: drugs should be safe and effective.
DXM is fine but oral phenylephrine should be banned. The only reason it's in any of these drugs is because they don't want to lose sales when the real version that works is locked behind the pharmacy counter after hours. It's a scam to keep sales up.
> Take your standard 12-ounce bottle of DayQuil, which costs around $15 at CVS.
...
> So the only ingredient that’s doing anything in that bottle of DayQuil makes up just 2% of the bottle: the roughly 8 grams of acetaminophen, which separately would run you about 16 cents at Costco.
Why are they comparing the price of CVS DayQuil to Costco acetaminophen? Either compare CVS DayQuil to CVS acetaminophen or compare Costco DayQuil to Costco acetaminophen.
The article kinda glossed over it, but one fact under-appreciated by the general public is just how dangerous acetaminophen overdoses can be.
Scientists often talk about the "therapeutic index" or "safety ratio" of a drug. It's the LD50 (dose at which 50% of recipients die) divided by the effective dose. Common hard drugs like heroin or methamphetamine have a safety ratio of about 6-10 [1]. "Soft" drugs like marijuana or LSD often have safety ratios of about 1000.
The safety ratio of acetaminophen is under 4. A typical dosing schedule for an adult is 4-6 500mg tablets within a 24 hour period [2], for a total of no more than 3g. 7g of acetaminophen can kill you, and 12g is likely to [3]. Acetaminophen is the leading cause of liver failure in the U.S, causing 50% of cases and 20% of transplants.
When they tell you "don't exceed 6 doses daily", they really mean it, and it's across all acetaminophen-containing products. The margin for error is narrower than heroin.
Replacing Aspirin with Acetaminophen/Paracetamol was absurd. Reyes’s syndrome was nowhere as prevalent as acetaminophen overdoses, which are a horrible way to go.
There is an antidote available for acetaminophen overdose, but it's only available in the hospital. So if you think you took too much, get to a hospital quickly before your liver suffers permanent damage.
Untreated acetaminophen overdose is an extremely unpleasant way to die.
The safety ratios listed in reference [1] are exaggerated, as can be determined by the following qualification: "The majority of published reports of acute lethal toxicity indicate that the decedent used a co-intoxicant (most often alcohol)."
The vast majority of so-called drug overdoses are due to polydrug intoxication. It's much harder to die by consuming a single substance. This is clear from the statistics of the few jurisdictions that report all substances in the blood in coroner's reports. See, for example, the Scottish data from 2020 (https://www.drugsandalcohol.ie/34642/7/ndrdd_report.pdf ): "In 2020, almost all (96%) [drug-related deaths] occurred after the consumption of multiple substances."
Liver failure is the worst way to go, it's slow and painful. if someone accidentally takes too much you can give them activated charcoal before you get them to the ER to give them a better chance of not going through liver failure
Perhaps it's useful to know that NAC is the treatment for acetaminophen toxicity, should you happen to find yourself in the middle of a zombie apocalypse with a Tylenol ODed friend and a supplements isle handy but no readily available medical support. :D
There has been some suggestions that acetaminophen products should contain NAC to offset some of the toxic effects, but I dunno where they've gone-- there probably isn't any money in it to study it formally.
I try to make an effort to know what the treatment/antidote is for any hazardous substance in my home... things you hope you never need to know but are glad if you do.
The thing about it is, _if taken as directed_ it's extremely safe, moreso than just about any other painkiller. In some countries it's the only one available in supermarkets.
> 7g of acetaminophen can kill you, and 12g is likely to [3]
I agree that people should be cautious, but I think you are significantly misunderstanding [3].
"Toxicity" != death -- toxicity is merely "some evidence of a toxic effect" -- possibly as simple as a transiently abnormal blood test with no symptoms or sequelae, ever.
Single (accidental) doses of up to 200 mg / kg are routinely recommended to be managed at home [0], i.e. "you don't really need to go to the emergency department for this." For me, a fairly average 79kg male, this would be about 16g.
Please consult with your local poison control if you have concerns or questions!
66 comments
[ 3.1 ms ] story [ 76.7 ms ] threadDrug prohibition has caused magnitudes more harm than decriminalization and legalization.
And part of this article is about claims from what is likely inert or mild effect at best. Remember, we used to have amphetamines, pseudoephedrine, and much more potent drugs to alleviate colds and such. But because of the forever-drug-war , we're stuck with substandard crap, and everything good gatekept by doctors.
Funny amphetamine used to be an over the counter cold medicine, which the article doesn't mention despite talking about the meth precursor?
Fine article but these two details stuck out to me while reading it.
It would also fix the homeopathic snake oil as well, which has started showing up as options in previously-reputable medicine aisles. So at any rate, be on guard if you don't want to end up accidentally buying a bottle of water plus flavoring in your cold-addled state.
https://www.health.harvard.edu/newsletter_article/the-power-...
It's so utterly ridiculous how much space the Cold and Flu section of the medicine aisle takes for no reason at all.
And the whole thing about combining so many medications is just silly, especially the marketing for it. "Why take 3 medications for your cold symptoms when you can take just this one?" then gets countered with "Why take a cold medication that has ingredients for symptoms you don't have?"
IMO, DayQuil should never have existed simply for the reasons the article mentions: It leads to people being unaware of what they're taking. Yeah, the label is right there, but you gotta consider the lowest common denominator when selling things to the general public.
There are other studies where Dextromethorphan improves both objective and subjective measures of coughing: https://pubmed.ncbi.nlm.nih.gov/37232330/
They also picked a study that shows honey outperforming Dextromethorphan but ignored all the studies that show honey performing similarly or slightly worse than Dextromethorphan, or studies where honey showed no measurable effect.
There are so many studies and papers published now that you can find both positive and negative results for just about anything. When someone starts pulling up singular random links to papers you should be suspicious. Be even more suspicious when someone is calling for bans or regulations based on those individually selected papers
It's even worse than that, they appear not to have actually read the analysis they cited because two of the three studies on DXM found it was effective in adults. The same efficacy was not found in children but there are other very plausible explanations for this (difference in dosage and measurement techniques).
DXM is also not a placebo, although it might be specifically for cough.
I don't especially want the FDA to ban them, but requiring separating out the acetaminophen might not be the worst idea.
When I want to get irrationally angry about something in a department store, I'll walk over to the shampoos, which for some reason always have a whole entire aisle dedicated to a single product, when they all do literally the same exact thing, just with different scents and advertising budgets baked into the sticker price.
If anything, you need honesty from healthcare companies in the first place if you're even going to begin making an informed decision. You're putting the cart before the horse here: people absolutely should be doing their own research before medicating themselves, but it is the OTC companies that obstruct that.
And, secondary to all of this, your analogy about shampoo is misinformed. Still, it is fitting for this scenario, but not in the way you intended. There are lots of different hair types, including ethnic hairstyles that require specific treatments. There are also a number of lifestyle choices that can change your hair treatment needs. As a result, the shampoo aisle actually is stocked with a wildly varying assortment of haircare choices, but actually figuring out what product works best for your needs can be challenging because it is walled behind layers of marketing nonsense that don't inform the consumer adequately on what makes each product different. This isn't much different than the problems in the medicine aisle.
It took a lot of secondhand research to find the ideal hair care product for my thick, curly hair that would mitigate the damage of thrice-weekly swimming in a chlorinated pool. I can assure you, not everything in the shampoo aisle is exactly the same. It was especially hard figuring this out as a man, when so many products are arbitrarily marketed to specific genders.
this argument makes very little sense. Plenty of very potent drugs are in the single digit mg range in a tablet that weights hundreds of mg.
More importantly, as always, it is a problem of incentives. There is no strong, commercial entity focused on removing ineffective drugs from the market, but plenty of commercial pressure to keep them. The FDA has zero incentive to clean house. The magic hand of the market is supposed to be consumers choosing not to buy these drugs because they are ineffective, but for many reasons (choice, placebo effect, basic scientific literacy) this does not happen.
I don't know what the most effective entity is. I cannot personally imagine a commercial structure to support this, but perhaps one could be built.
In America? No idea. In the UK it's because they sell codeine+tylenol OTC, and they want it to poison you if you try and get a codeine buzz from it. Incredibly this is true.
I am convinced that many people ask LLM's "give me a citation URL" and don't bother to read it.
If they sold these chemicals as singular treatments then the abuse would go through the roof. The "accidental OD" scenario where an innocent patient quadruple-doses is realistic, and anticipated, and the shrewd consumer will avoid this.
I injured my legs, then on top of it, had a minor cold recently, and finally grabbed a bottle of Coricidin HBP out of desperation. I have also been stocking up on 0.0% beers. Between doses of the former and bottles of the latter, I managed to get some great-quality sleep and rest.
The other thing to notice about the Cold and Flu section of your pharmacy is that most all the treatments are supposed to relieve congestion, clear phlegm, and serve as an expectorant, such as all the cough drops with lemon, or menthol. If you are a lifelong smoker with a productive cough, this is great. That includes habitual pharmacy patrons who've always purchased their cigarettes and cigarilloes right there at CVS, next to the candy aisle and the booze aisle.
If you live in a desert and/or suffer from chronic E-N-T dryness and dry coughs, then these treatments will make your life a living hell and must be avoided at all costs. Think about it.
You used to be able to get Nyquil with real sudafed in it. That was the gold standard. It's not even available behind the counter anymore, presumably because they can make more money from morons buying the placebos.
As an aside:
> In January 2011, the FDA set a maximum amount of acetaminophen that could be packaged in combination opioids like Vicodin or Percocet. The odds of hospitalization due to opioid-related acetaminophen toxicity plummeted.
Yeah, the acetaminophen was there to PREVENT abuse of the Vics and Percs 'cause you'd overdose on the acetaminophen first. Sure, there was an easy workaround, but that was it's intent.
Completely unrelated, I noticed recently that tire detailing spray that makes your tires look black, and the recommended lubricant for my garage door weather stripping, which both cost $15 or more for a little bottle, are just silicon oil that costs pennies for that amount. I have no moral problem with charging higher prices for convenience plus clarity of what the use is. I do think it’s amoral, obviously, to be involved in snake oil sales and unbelievable that the government allows it.
Edit: this is the first result from a Canadian pharmacy searching for cough medicine. Worse it’s for kids: https://well.ca/products/homeocan-kids-0-9-cough-cold-day_88...
DXM is fine but oral phenylephrine should be banned. The only reason it's in any of these drugs is because they don't want to lose sales when the real version that works is locked behind the pharmacy counter after hours. It's a scam to keep sales up.
...
> So the only ingredient that’s doing anything in that bottle of DayQuil makes up just 2% of the bottle: the roughly 8 grams of acetaminophen, which separately would run you about 16 cents at Costco.
Why are they comparing the price of CVS DayQuil to Costco acetaminophen? Either compare CVS DayQuil to CVS acetaminophen or compare Costco DayQuil to Costco acetaminophen.
Scientists often talk about the "therapeutic index" or "safety ratio" of a drug. It's the LD50 (dose at which 50% of recipients die) divided by the effective dose. Common hard drugs like heroin or methamphetamine have a safety ratio of about 6-10 [1]. "Soft" drugs like marijuana or LSD often have safety ratios of about 1000.
The safety ratio of acetaminophen is under 4. A typical dosing schedule for an adult is 4-6 500mg tablets within a 24 hour period [2], for a total of no more than 3g. 7g of acetaminophen can kill you, and 12g is likely to [3]. Acetaminophen is the leading cause of liver failure in the U.S, causing 50% of cases and 20% of transplants.
When they tell you "don't exceed 6 doses daily", they really mean it, and it's across all acetaminophen-containing products. The margin for error is narrower than heroin.
[1] http://politicsofsin.50megs.com/risk/Toxicity.Comparison_Add...
[2] https://pmc.ncbi.nlm.nih.gov/articles/PMC3585765/
[3] https://www.ncbi.nlm.nih.gov/books/NBK441917/
Can't read or follow simple instructions? Well maybe modern society is not for you anymore.
Untreated acetaminophen overdose is an extremely unpleasant way to die.
The vast majority of so-called drug overdoses are due to polydrug intoxication. It's much harder to die by consuming a single substance. This is clear from the statistics of the few jurisdictions that report all substances in the blood in coroner's reports. See, for example, the Scottish data from 2020 (https://www.drugsandalcohol.ie/34642/7/ndrdd_report.pdf ): "In 2020, almost all (96%) [drug-related deaths] occurred after the consumption of multiple substances."
There has been some suggestions that acetaminophen products should contain NAC to offset some of the toxic effects, but I dunno where they've gone-- there probably isn't any money in it to study it formally.
I try to make an effort to know what the treatment/antidote is for any hazardous substance in my home... things you hope you never need to know but are glad if you do.
Also works wonders for COVID spike protein detox.
I agree that people should be cautious, but I think you are significantly misunderstanding [3].
"Toxicity" != death -- toxicity is merely "some evidence of a toxic effect" -- possibly as simple as a transiently abnormal blood test with no symptoms or sequelae, ever.
Single (accidental) doses of up to 200 mg / kg are routinely recommended to be managed at home [0], i.e. "you don't really need to go to the emergency department for this." For me, a fairly average 79kg male, this would be about 16g.
Please consult with your local poison control if you have concerns or questions!
[0]: https://pubmed.ncbi.nlm.nih.gov/16496488/