Agree with you. It is a collateral consequence of the War on Drugs™ that everything good and effective is getting locked behind a $50-$200 doctor's visit for a 'scrip. This scam medicine problem could be helped if a bunch of substances were moved out of Rx and back to OTC. The nanny state will continue to grow to meet people's definitions on how much others should be warded.
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.
Came here to say this, the author is hating on dextromethorphan like he never robotripped before. But then, overdosing dxm isn't all that healthy and I'd recommend ketamine if you want to experiment like that.
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.
"Caveat Emptor" and "Do your own research" is not a basis for a functional society. Providing reading material is not a sufficient substitute for regulation in a country like the USA where 54% of adults read below a sixth-grade level. And letting marketing decide what counts as "accurate information" is just letting the fox guard the henhouse.
> Providing reading material is not a sufficient substitute for regulation in a country like the USA where 54% of adults read below a sixth-grade level
This is obvious, but thank you for putting it so succinctly. One has to wonder how much support for "do your own research" is driven by people who want to remain proudly-in-denial about their own inabilities.
It's no surprise that the political party/forces pushing on policies that result in worse education and literacy outcomes are the same ones who want "Buyer Beware" and "Do your own research" to be fundamental product regulatory principles.
In the US at least, medicine is so highly regulated/gate-kept that I don't think caveat emptor really applies. What's happening here is more like deception of the public by the state, or by groups granted special status by the state. It's morally somewhere between fraud and treason.
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.
Making the active ingredients prominent is a good start but not sufficient. As the article points out, the word "phenylephrine" looks/sounds similar enough to "pseudoephedrine" to broadly fool the population.
That's why I said "diminish greatly" rather than solve - something basically everybody should be able to agree on regardless if you think a given product should be on the market or not.
They should probably have to split up large words with dashes or even spaces "phenyl-ephrine" "psuedo-ephedrine". Maybe even "phenyl-eph-rine" "psuedo-eph-edrine". One authoritative list published by the FDA (they already keep a list of what's allowed to be sold in the first place, right?) of how the active ingredient names have to be distinctly stylized to best inform.
It just seems like a quick patch that doesn't acknowledge or address the root cause: that the FDA is supposed to be regulating both safety and effectiveness, but it is largely abdicating the "effectiveness" role over to companies' marketing departments. If corporate marketing can convince the public that the serpensoleum drug works, then that's enough to put it in a shiny box in the drug store.
The problem is that you're butting up against the highly profitable cult of ignorance. For instance if something isn't intended to actually treat a disease, then it's basically exempt from FDA regulation as it's a "supplement". Then the seller is free to imply whatever they want, regardless of efficacy.
I'm advocating something that ideally can sit in the middle of the two philosophical/regulatory regimes with more people on board - being able to buy whatever you want, but regulation aimed at preventing companies "innovating" by simply confusing the market. And while I'm sympathetic to extending the scientific-maximalist approach onto the "supplement" industry that is currently harboring copious amounts of straight up fraud, I would also say that throwing down such a gauntlet doesn't seem like a great idea at the moment!
Yea don't even get me started on the "supplements" loophole. There are so many problems to solve. Making even small amount of progress towards fixing anything would be miraculous, given the economic forces wanting to make the problems even worse.
Nasal phenylephrine is a miracle when I am trying to sleep with a stopped up nose. A spray in each nostril and my nose is clearer than even normal within a few minutes.
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
> ignored all the studies that show honey performing similarly or slightly worse than Dextromethorphan, or studies where honey showed no measurable effect.
To be fair, you're doing pretty much the same by claiming these studies exist without proof.
An interesting new drug is Auvelity, where Dextromethorphan is proposed to help stimulate neurotropic growth factor to help the brain repair itself, and similar related drugs like dextromethorphan and ketamine and other NMDA receptor antagonists are innovative drugs to help prevent Alzheimer's.
> … similar related drugs like dextromethorphan and ketamine and other NMDA receptor antagonists are innovative drugs to help prevent Alzheimer's.
Should read “NMDA receptor antagonists _may_ give rise to treatments that _may help prevent or ameliorate the symptoms_ of Alzheimer’s.
Nobody even knows how Alzheimer’s works at all — like most diseases it’s a description of some detectable symptoms, some of which could even turn out to be the body defending itself.
Thus compounds that may have a mechanism of action that affects some concomitant, visible symptoms might potentially be useful.
The use of definitive sentences about unknown results is how we end up with wellness and some “biohacking” nonsense.
In my subjective experience, Dextromethorphan (DXM, as the robo-trippers call it) does almost nothing for me, in the 1-5% range
The only cold and cough medicine that really truly works is the over-the-counter stuff, pseudoephedrine, works amazing for me. I usually pick up a box of the stuff when school starts in the fall and I go through half a box of it by the following summer.
Pseudoephedrine is a decongestant to relieve the nasal/sinus congestion.
If it helps with your coughing, it’s because it’s stopping the postnasal drip, not suppressing the cough as DXM would by shutting down the cough reflex.
Two different, but very similar use cases. DXM is a god-send in the appropriate time.
DXM may or may not suppress coughing relative to placebo - the study cited here appears to be have been written entirely by authors from drug companies, so perhaps there is some bias. Here's a meta analysis that favors honey over DXM https://pubmed.ncbi.nlm.nih.gov/32817011/, the original study that kicked off this idea that also favors honey https://pubmed.ncbi.nlm.nih.gov/18056558/, and a different meta analysis https://pmc.ncbi.nlm.nih.gov/articles/PMC6513626/ which found little or no difference between honey and DXM. Whether its effective or not, to me there doesn't seem to be compelling evidence that it is more effective than honey.
It's funny that TFA seems to use the comparison to honey as disparagement, rather than interpret the same information as an endorsement of the helpfulness of honey.
It's worth nothing that all of the studies you linked were performed only on children. It is entirely plausible that DXM is effective in adults but not children because of the difference in dosage.
Are you sure you posted the right paper? That paper appears to present a clinically insignificant outcome for DXM in children.
I think it's perfectly reasonable to contest the research summary this article is providing. All science-based articles on interesting topics are going to be like that. But you're writing your comment as if they took a flyer on DXM, and the research consensus is in fact that DXM is not effective. It's not as bad as phenylephrine (it has detectable, if immaterial, impact in adults), but it's pretty bad.
The point of the article, of course, isn't that Dayquil should be illegal because it's dangerous; it's that it doesn't work. Having spent an unreasonable amount of time in HN pseudoephedrine threads, I think the broad consensus of this site is that phenylephrine should be taken off the shelves.
Phenylephrine was the replacement that doesn't really work but is non (or less) stimulating right ?
From what I remember it was actually quite effective topically but not through pill form. Could be wrong.
Also makes me wonder if there's an alternative function to DXM for people with colds (maybe it makes them feel better in other ways). Or it's just good marketing and associated with NyQuil having other drugs and people assuming DayQuil works
It's not that it's less stimulating, it's that pseudoephedrine basically is methamphetamine (the chemistry to reduce it to meth is truck-stop straightforward). But oral phenylephrine doesn't work at all.
The case against DXM is nowhere nearly as good as the case against phenylephrine; phenylephrine is a scam, and DXM is a drug everyone thought was the gold standard cough suppressant, but then serious studies knocked down its effectiveness.
"Total coughs over 24-hours (primary endpoint) and cough frequency during daytime were reduced by 21.0% and 25.5%, respectively, with DXM relative to placebo. Also, greater reductions in cough severity and frequency were self-reported with DXM. These findings were statistically significant and medically relevant."
Also as I mentioned in another comment, the author of original article misrepresents the conclusion of their own citation. DXM was found to be effective in adults, just not children.
I work for a large agricultural company, in my part of it we sell fertilizer, chemical, and agronomic services.
As part of this, we end up putting out a lot of trials so we can actually say something true instead of “buy our stuff it’s great I promise ;)”
One of my favorite slides is when we compiled dozens of trials on something that’s basically a nitrogen fertilizer. When compared in a graph most of the trials show an overwhelming effect on increasing yield over an untreated check, however there’s always a portion of the trials where the yield decreases compared the check.
Real life is extremely noisy for a multitude of circumstantial reasons that are either not practical or possible to control for, so a single trial is generally worth fuckall. It takes a lot of testing to see a consistent trend across them.
And, all of this, to avoid selling a little bit of the narcotic codeine. Which was technically permitted to be sold "behind the counter" without prescription, but was made Schedule II as part of cough syrup in the US not long ago. (It used to be Schedule III or IV when combined with homoatropine or promethazine).
I wonder if the cost benefit analysis would show that this is still the best policy - I.e. are more people dying because of overdose of acetaminophen than would have from “behind the counter” + controlled acquisition of codeine products.
I would also imagine that the compliance / nationwide tracking is now much easier than when the legislation was initially conceived.
I think it was a mostly innocent bystander, because they decided to put codeine-combination painkillers (Vicodin, etc.) in schedule 2 but wrote it as just opiate combination medicines.
I miss codeine cough syrup. It's the only thing that's ever been effective for me, despite my being fully immune to the "fun" aspects of opiates. They do remove pain, coughing, etc, but do not add any sensations or impair normal ones in my case. I've tried most of the gamut in one medical setting or another.
There should be a class of drug where the pharmacist gets to decide, based on some registry, whether you get to have something.
It's still available, I just don't know if it's still available without prescription. It's also gotten more expensive and not as many pharmacies stock it. Really, I find our drug policies so frustrating.
They should take all the ineffective phenylephrine products off the market and educate the consumer about asking for pseudoephedrine versions. But I think the ship has sailed and meth is being made with industrial chemicals now, so the restriction isn't as useful as it was.
I think it's not a bad idea to have a registry to prevent over-dispensing of opiate cough syrup. It's really an important drug. There are a lot of conditions that cause chronic, lifelong, unproductive coughing. Doctors end up prescribing things that are either more habit-forming or more dangerous.
Just buy poppy seeds in bulk and make a tea. They wash 'em, but not enough to get all of the opium off the outside. Okay but really maybe don't do this unless you're gonna be careful because I actually have known a guy who ended up with problematic morphine habituation this way.
That said, dextromethorphan works just fine on its own (if you take enough -- 2 tsp is nonsense). Why they feel the need to mix in a bunch of other actives is beyond me.
Isn't it a bad sign that there are such varied results? Perhaps that's only a bad sign for the state of science, but I suspect it's also a bad sign for the effectiveness of the drug.
> 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 study they cited which clearly suggests DXM is 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.
The reason to take this seriously is mentioned in the article: It is possible to OD on Tylenol, and when consumers miss the fact that these drugs are all just Tylenol+junk, they might believe they need to take several of them together to get well.
It's similar to the shampoo example (a huge selection of borderline useless products that make money purely because of marketing) but with a minor safety consideration, too.
You are ignoring the existence of consumer protection, which is not unusual as it seems like regulatory bodies around the world (but especially in Europe) have forgotten the existence of consumer protection as well.
You ask what is new about this, and the answer is, in 2026 context: nothing, but compared to the year 2000: plenty. Regulators used to issue fines for this behavior, and for worst offenders, regulators used to shut them down. Lying to customers is illegal in most jurisdiction, it used to have consequences, and it should do so again.
Not totally accurate - there are a handful of foaming agents and surfactants that are mixed and matched to make shampoos, so really it's nearly the same except that no one has ever overdosed on applying too much sodium lauryl sulfate to their scalp.
You won't OD from sulfates in shampoo, but there are serious pros and cons to using them at all:
Sulfate-containing shampoos give you a deeper clean, but can dry out your scalp and make the color in color-treated hair fade. They're ideal for most people, especially if you don't wash your hair every day.
Sulfate-free shampoos are more gentle, but if you're supremely oily and/or don't wash your hair every day, you might not feel like they clean your hair well enough. Almost all "color-safe" shampoos are sulfate-free. They're ideal if you wash your hair daily and/or have a dry scalp... and they're a must if you dye your hair and want to keep the color looking nice!
> 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.
But I don't have time to do that. I would rather have a retailer do that curation for me and provide me with effective high value products, and stand behind returns when they miss the mark. Then as a customer I can reward them for that value added work.
That's why Costco is great most of the time. Although they sometimes miss the mark with certain products they stock.
Not to mention it ignores reality. Most consumers have neither the time now knowledge to research everything they buy. That's one of the roles of government.
That's one of the important reasons - I thought - that we have the FDA in the first place. But these days I'm really not so sure. So many promising treatments rejected (or just stalled forever) while pointless placebos and worse get or remain approved.
Is the argument that because the FDA may not be perfect, the public would be better off if it didn’t exist?
The FDA handles many thousands of product categories, tens of thousands of prescription drugs, etc. Which items (and how many total) are you referring to? For many of them might there be a reason available as to why they didn’t end up as you recommended?
Sunscreen is the first thing that pops to mind. Until last week(?) we hadn't had a new sunscreen ingredient in decades, despite the RoW getting newer/better stuff for years. It was to the point that tourists to Korea and the EU would stock up on product to bring back.
Yes, that (roughly) happened because the FDA regulates sunscreen like a drug and RoW mostly treats it as a cosmetic. And FDA drug approval is expensive, so nobody was bothering.
Regardless, for those of us with pasty white skin, it kinda blows not being able to get a good daily sunscreen that doesn't make us look even more ghostly.
EDIT - Yes, the FDA needs to exist, it's WAY better than nothing. But, it's probably due for some reform.
> As the person holding the money, it's my job to look at what is effective and what the act ingredients are in any given product.
I wish the industry, our health organizations, and most people in general acted as though this were true.
The environment we live in in general is increasingly hostile to people who ask those questions, do their own research, and take responsibility for their health in this way. I have first hand experience having reversed chronic health conditions myself by doing my own research. What have and do others say about it? Everything: every person on the sidelines watching who have formed opinions about how things are supposed to be, and how doctors and nurses and pharmacists are supposed to know better, attack and ridicule me and others like me and when we "look at what is effective and what the active ingredients are" we are gaslit and told we can't possible understand and know that and to leave it to the experts. Of course the definition of expert is only ever tribal and is a moving trojan horse for whatever best allows the agenda of an industry to establish its control over you.
Let me first get our agreement on the word hostility:
> a state of unfriendliness, antagonism, or ill will
Do you agree on this definition?
Assuming so, I hear you asking how can asking particular questions get you this? I'll assume you have good will and are willing to engage with friendliness.
Simply asking specific questions about health, about diseases, about diet, about social media addiction, about controversial topics like politics, etc release hostility from a handful of people. These people engage with ill will and not friendliness. And it is assumed by them that the asker (me usually) meant unwell - this hostility represents my intentions and assumptions as ill will assumptions. Oddly enough this usually is strongest from people with strong identity attachment to a particular belief or set of beliefs that when questioned releases so much dissonance their nervous system gets hijacked and without the emotional intellgience or mindfulness skills to pause before they engage what comes out is a slop of hostility and aggression most commonly being Ad Hominem or Straw Man attacks as I've mentioned. All when all I did was asked questions.
When someone demonstrates this without actually inquiring into ones assumptions or why they asked, thats a clear demonstration of hostility.
> Simply asking specific questions about health, about diseases, about diet, about social media addiction, about controversial topics like politics, etc release hostility from a handful of people. These people engage with ill will and not friendliness. And it is assumed by them that the asker (me usually) meant unwell
Specific instantiation: during COVID after vaccines had rolled out, I asked my social network on Facebook who had experience with Ivermectin. I have used it successfully myself, and even my vaccinated parents used it successfully when their recommended treatments and advice was not successful for managing pain and symptoms. I got a lot of hostile and ridicule and mockery along with being called a murderer, by people I knew, simply by asking questions. I wasn't recommending to take it. I received people making lots of assumptions about my vaccine status simply because I was asking questions, people lumping me in with conspiracy theorists and being anti-science and more.
> 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.
Somewhere on a shampoo forum people are complaining that all computers do the same damn thing. I guess they probably just don't know what they're talking about.
If someone buys an overpriced shampoo, it only negatively affects them, but the are costs to overall society if people suffer health issues, addiction, etc.
In the past, a lot of people unknowingly ended up addicted to morphine, as it turned out both companies and individual doctors were happy to mislead them about the contents of medication.
That shampoo opinion is a sure tell that you're not a woman with long hair (men with long hair tend to be less picky). My hair behaves noticeably differently with different shampoos/conditioners even within the same brand, and depending on your specific porosity, oiliness, texture, and humidity of the local climate, different hair care products and routines make a big difference if you have hair past chin length and want it to look healthy.
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.
The other ingredients would be doing other things: making the pill/drug easer to swallow/consume, extending shelf-life, etc. You need enough of the drug for it to be effective, but not too much to overdose or exhibit side-effects.
The mass of the acetominophen isn't really important, it's just vivid writing. The point is that 8g is obtainable for orders of magnitude less when it isn't wrapped in misleading marketing.
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.
I read the main section of the lit review linked by OP, and it didn't seem to come to any real conclusions.
> The results of this review have to be interpreted with caution because the number of studies in each category of cough preparations was small. [...] There is no good evidence for or against the effectiveness of OTC medicines in acute cough.
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.
> It's not even available behind the counter anymore, presumably because they can make more money from morons buying the placebos.
What do you mean "morons"? Say I'm a normal person who doesn't habitually read magazine articles about drug effectiveness. How am I supposed to know that phenylephrine doesn't work? It's in the drug store and they're selling it as a decongestant; I have good reason to believe it will decongest my nose.
You don't need to know anything about the new stuff. You used to be able to get Sudafed; it worked. It was moved behind the counter for $REASONS. You've got enough to guess that the new stuff is some kind of inferior substitute and that you're only going to be able to get the real thing during pharmacy hours.
Then it's also been enough time to think about bringing it back again. That's my whole complaint about this article, is that it fails to reach the correct conclusion.
I've bought allergy medication at the drug store before and they don't work for me. Is this the same thing as phenylephrine, which literally doesn't do anything? or is it different because my particular allergies did not respond to this medication? I don't think these two are the same thing, and it makes far more sense that if there is a medication added to a drug, being sold in a drug store, for treating a particular symptom, it should have actual clinical evidence it treats that symptom.
Or am I just suppose to try the dozen different gobbledegook ingredients on the shelf before figuring which one isn't bullshit while wasting my time on half of them?
Sorry you're having allergy problems. I only experience mild symptoms, so can't provide any more information than you've prolly found for yourself.
> "...suppose to try the dozen different gobbledegook ingredients on the shelf before figuring which one isn't bullshit..."
When you say "on the shelf" i presume you're specifically referring to OTC medication and not prescription medication, right? A common sense question deserves a common sense answer. Yes. Companies will happily take your money and sell you snake oil (nominally, so long as the consequences are near zero). Caveat emptor. Phenylephrine as the non-regulated version of pseudoephedrine is the perfect example.
IMHO the only way to buy OTC medication (or food for that matter) is to read the labels and understand the ingredients. (I hate palm oil and sugar. yuck)
> The article mentions this but just accepts the inaccessiblity of the real thing as a given.
Reality is in fact a given. If you mean that the author is just fine with that reality, that's patently false.
> presumably because they can make more money from morons buying the placebos.
If that's your evaluation of everyone who lacks perfect information then you need to look in the mirror.
> You used to be able to get Sudafed; it worked. It was moved behind the counter for $REASONS. You've got enough to guess that the new stuff is some kind of inferior substitute and that you're only going to be able to get the real thing during pharmacy hours.
Grossly intellectually dishonest and downright unintelligent nonsense. Here's a fact that is inconvenient for this moronic argument: acetaminephen is readily available on the aisle. Things not being locked away does not imply that they have no effect. The more complex reality is actually discussed in TFA.
> 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.
The misspelling of "its" is the least egregious part of this nonsense.
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.
Ugh yup. My regular pharmacy is a pharmaprix (shoppers drug mart), which is one of the biggest chain pharmacies in canada. The cold and flu isle is right in front of the pick up counter, so when I was sick a few months ago one of the pharmacists flagged me down when they noticed me hovering around the cough drop/coldfx/oscillococcinum part of the isle. The amount of proverbial snake oil on the shelves is bad enough that she was apologizing for how confusing it was. Got me set up with OTC pseudoephedrine instead! (There's some combo PSE/acetaminophen meds they sell in front of the counter, but they're mixed in with the sugar pills.)
It's really worth talking to your pharmacist even if you know what you're buying. There's so many more options behind the counter and they're really knowledgable.
In Canada all homeopathic medicine must clearly identify itself as such and must also state that it's based on traditional form of medicine and not based on any kind of scientific evidence.
The very "medicine" you linked to in fact displays it right on the cover.
To be fair, they are clearly following that rule, yes. But also, if I went to a clinic, and got told it was my fault something didn't get treated because I spoke to the person dressed as a doctor wearing the "Aspiring Dr. Soandso (Untrained but did watch House MD all the way through)" nametag instead of the one that said "Dr. Soandso", I would be pretty pissed. They were still in the clinic, dressed like a doctor.
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.
When the hubbub about phenylephrine first started, I decided I still felt less miserable taking DayQuil/NyQuil, and switched to the "High Blood Pressure" formulation, which drops the phenylephrine, alcohol and sugar.
It takes it down to just the Tylenol, the DXM (, plus the antihistamine in the NyQuil), and the great slightly tearable taste for the ritual of "time to pretend I'm not sick for a little while".
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.
Yeah that seems odd. It's also a very different delivery mechanism. Might be easier to get a sick and snotty kid to drink some (maybe?) tasty liquid vs cheap pills.
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.
Acetaminophen should be treated with more caution in general. So many people have reacted with shock and upset when I told them that taking Tylenol (or anything with acetaminophen in it like Dayquil/Nyquil) while drinking can cause immediate liver damage.
>reacted with shock and upset when I told them that taking Tylenol (or anything with acetaminophen in it like Dayquil/Nyquil) while drinking can cause immediate liver damage.
Maybe your package needs to be clearer but here in Sweden it says to avoid taking with alcohol.
Most people grew up taking Tylenol as kids for various things and it was never a new medicine to them that they felt the need to read. Also, there's a huge difference between "don't take this with alcohol, it will make you more drowsy" and "even one beer with this will start fucking your liver up don't even think about it". I think people associate the latter with more intense medication than some OTC mild pain meds.
I didn’t know this until recently either. I grew up on a family where if there was pain, you just take tylenol to deal with it. We always followed the dosage timing and never had issues. So recently when my wife had some chronic pain I suggested taking tylenol but even after two days the pain would not go away and she went to ER. They did a blood check to see if they could find anything. They didn’t find the cause, just suspected food poisoning, but they found her liver enzymes were near dangerous levels. This was even with timing the dosages absed on instructions. Now I am super careful wtih Tylenol.
Not to chastise you or your wife, there is an actual "Liver Warning" on Tylenol Product labels. They warn against 4000mg/day or with alcohol consumption. It's not an on/off switch, the damage occurs on a ramp that achieves a critical point after so much consumption.
Saying this to encourage label reading and to refute those who might try to characterize your wife's experience as anecdotal. And for those who stop reading a page like this one, after the first paragraph that touts "no evidence": https://www.tylenolprofessional.com/safety-and-efficacy/safe... when at the bottom it reveals the Liver Warning.
Everyone's ability to metabolize drugs being different has a lot to do with why the labels end up advising less than is effective for many people. Dextromethorphan surely is NOT ineffective, but at 2 tsp, yea, it aint gonna do much of anything (unless you're CYP2D6 deficient -- then, it may still do a LOT depending on how deficient).
Alcohol can actually be protective in a paracetamol overdose. Paracetamol itself isn't relatively dangerous, the metabolic product created by the liver is.
Alcohol use acutely reduces the levels of these enzymes which convert paracetamol into it's toxic byproduct as ethanol preferentially binds to the same enzyme for it's own metabolism. Therefore, acute alcohol consumption can reduce the harmful effects of paracetamol.
The reverse is true for overdose in the context of chronic alcohol use, when the liver adapts to long-term alcohol exposure by increasing the levels of enzymes, therefore rapidly metabolising paracetamol into it's toxic byproduct and worsening harm.
Source: doctor
As a side comment, the lack of medical knowledge displayed in HN threads paired with the absolute confidence some verdicts are delivered with is worrying, and something I thought this forum would be better at than other sites (looking at you, reddit). Paracetamol and NSAIDs (including ibuprofens) are safe drugs if taken to the package directions. Some of the ideas shared in this thread about taking one over the other, or not taking one ever etc, are not rational. Please consult your doctor if you are worried about your particular situation, but generally OTC medicines are not dangerous if taken to the package instructions.
Accidental overdoses of paracetamol are exceeding rare, but intentional ones are common.
Expert fallacy: I know a lot about X, so I'm also an expert on adjoining topics V, W, Y, and Z. Also on topic "ecks". And "x-rays". And "excerpts" and "excommunication". Ah, hell: I'm smarter than most, so I'm usually right. Especially about things I'm sure I right about.
Its obviosly more dangerous with medicine but I see the same thing with other non-tech topics here like agriculture and construction trades so I always take non-tech topic comments with a grain of salt on here. There is a good diversity of experts on here but of course they can't be expected to correct everybody all the time.
Yup, did some digging on Tylenol/acetaminophen before I had some surgery, and it's a real danger. Oddly enough, it seems downing a whole bottle won't (usually) end your life as it gets mostly directly eliminated rather than metabolized, but taking just around 2-3X the high-strength dose sustained over 3-4 days can destroy your liver — at that point, you have about six weeks unless they find a new liver for you (obviously, there's wide variance in actual dosages and reactions, but that was the general median). For someone with serious acute pain, who doesn't know this hazard, it'd be pretty easy to self-medicate and load up and lose track...
OTOH Ibuprofein, doesn't have anything like that deadly profile, but enough gut and other issues.
Common advice where i am from is to alternate between acetaminaphen/paracetamol and ibuprofen based otc painkillers. One, it reduces your opporunity to overdose, but also some evidence they work better together.
Not a doctor, this is how it was explained to me by my doctor.
Paracetamol/acetaminophen has a therapeutic dose that is uncomfortably close to the fatal dose, but is otherwise as safe as any drug can possibly be. So long as you don’t take too much.
Ibuprofen is also relatively safe, but it has a number of ways that it can do damage even at the therapeutic dose, if you are taking it all the time.
The main one is that it depletes your mucus lining in your stomach, which can lead to bleeding and death (used to be a big problem here in Aus when codeine combined pills were available without prescription). It’s also harder on your kidneys and liver.
Completely fine at therapeutic doses taken as per instructions and not mixed with alcohol. But having it every day is going to be much worse for you than the paracetamol and almost certainly lead to health problems.
For acute applications, ibuprofen is at least an order of magnitude safer to administer/take. Hospitals will give a patient a double dose of ibuprofen without even really doing the math. If you've heard of dangers of ibuprofen I would think those concerns are for chronic applications, where there are concerns.
The therapeutic index for ibuprofen is considerably better: it's around 10, fairly similar to alcohol. Accidental overdoses of ibuprofen are rare.
The main issue with ibuprofen is that it can have fairly annoying (but non-life-threatening) side effects like stomach upset and GI bleeds even with normal dosing.
It can also cause kidney damage which can be life threatening, especially when you’re dehydrated (which is pretty common after drinking); tylenol is a lot safer than ibuprofin when used as directed, it only becomes dangerous when glutathione is depleted (at which point it becomes a lot more dangerous, which is why you should never drink while taking Tylenol)
> The main issue with ibuprofen is that it can have fairly annoying (but non-life-threatening) side effects like stomach upset and GI bleeds even with normal dosing.
Those side effects are more problematic when used chronically. This is when acetaminophen shines, because it has virtually no side effects at all when used as directed.
On top of that daily use brings it down to 3-5, preferably 4 or less of those a day. And they last less than 6 hours.
The 8h extended release is 650mg a tablet, and you can have 3-4 a day daily. And if you have any experience taking them you can feel the first half of the extended dose wear off before the extended one kicks in, which leads to basically NEEDING 4 a day, and staggered start times.
The folks I know who've been prescribed fentanyl weren't particularly upset about it. It is very potent, and thus measuring the dose properly is very important, but it's not particularly fussy beyond that.
The people you know may be obtaining it from less reliable apothecaries; that can be a real issue.
Reminds me of a comment I saw on a drug chemist's blog decades ago where they were talking about ACE inhibitors for Parkinsons' Disease - by dicking around with nerve conductivity and acetylcholine reuptake you could "boost" the failing nerves a bit, presumably until they fail altogether.
Anyway much of the discussion was on how hard it is to make suitable drugs, and someone said "We actually have some fairly inexpensive, reliable, and well-characterised ACE inhibitors with a nice long half-life and known efficacy, but the therapeutic window of nerve gas is pretty narrow..."
I'm grateful for you mentioning this. I grew up with ibuprofen as my default painkiller without really thinking of it too much but am about to do PRP which requires no NSAIDs for a week prior and 3 months after - but they do allow/recommend Tylenol as an alternative, especially for the post-procedure pain. I just would've assumed it was a sufficiently good substitute that I could treat them equivalently but now i know to be very careful about tracking how many I'm taking each day
I was in the hospital on Thanksgiving Day last year. I received 8 diagnoses at that time, including "Diabetic Hypertension" and "Metabolic Acidosis" and E. coli infection, and Hyponatremia.
They treated me with an antibiotic, a potassium-rich saline drip and acetaminophen. Yeah that's all they put in my orders.
The thing that pissed me off so much, firstly they insisted on calling it "Tylenol" when it was not, in fact, brand-name Tylenol but generic acetaminophen (even if they could charge $$$ per pill on it) and also that they basically refused to administer it at a rate that would keep my exquisite headache pain at bay. I was literally screaming and moaning through the entire night and day. (Actually, I was wearing one of those radio-transmitting heart monitors, and mostly the screams happened when I moved suddenly, and the electrodes tore at my chest hair...) But my head was also constantly throbbing, and that's how I knew to go to the hospital in the first place.
The nurses could tell me how long to wait between doses, but they couldn't explain to me how to know that interval, given no clocks and no written-down time of dosing. So basically I had to keep guessing throughout my sleepless nights. And they didn't really inform me of a way to just put it on automatic dosing like a normal hospital would have a schedule for.
I really didn't want acetaminophen at all; I don't like it much, and it really hasn't ever relieved any pain I've ever taken it for. My parents chomped so much of it, made me sick just watching them. I lived through the cyanide adulteration episodes and though unsolved, that guy wasn't wrong.
When I finally got to visit a sane PCP after all this madness, I told him I was taking big doses of Bayer Aspirin, and he said that's fine; just follow instructions and heed warnings, and he also warned me: for Heaven's sake don't ever take any acetaminophen, because it would seriously harm my liver!!!
Please cite the source that claims Marijuana has an established fatal dose. Assuming you're unable to do so, please stop making baseless assertions like that. Your points about the dangers of acetaminophen are well-grounded, and including a false data point unnecessarily detracts from your credibility and weakens your main argument.
It's not under appreciated in the UK and Ireland where you can only buy tiny quantities of it at a time. Cash registers will literally refuse to process a sale if there is more than one pack of acetaminophen in your groceries.
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.
Huh, looked this up as Acetaminophen is one of the only OTC painkillers I can take. I thought NAC (N-Acetyl Cysteine) sounded familiar and low and behold I already have some I've purchased as a supplement.
Anyone can buy this stuff, no need to make it sound like it's some controlled substance. I will say if I take to much Acetaminophen I'll just head to the hospital instead of winging it!
I was trying to keep it simple. Yes you can buy n-acetylcysteine but OTC versions can vary in purity and dosage and it's not the only treatment you might need. With an acetaminophen OD you really want to be in a hospital.
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."
I imagine painkillers are fairly commonly used for hangover headaches, and it’s surprisingly difficult to get guidance on how long after drinking it’s ok to take painkillers (presumably as it’s complicated) - perhaps instructions should be updated to not just say don’t take with alcohol, but don’t take within a day of alcohol?
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!
235 comments
[ 3.1 ms ] story [ 102 ms ] threadDrug prohibition has caused magnitudes more harm than decriminalization and legalization.
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.
https://www.vumc.org/poison-control/toxicology-question-week...
It definitely works for me. It'd be wild if for all 44 years of my life, it's only worked because of the placebo effect.
The article mentions phenylephrine, and that shit definitely doesn't work. Not even a placebo.
This is obvious, but thank you for putting it so succinctly. One has to wonder how much support for "do your own research" is driven by people who want to remain proudly-in-denial about their own inabilities.
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.
They should probably have to split up large words with dashes or even spaces "phenyl-ephrine" "psuedo-ephedrine". Maybe even "phenyl-eph-rine" "psuedo-eph-edrine". One authoritative list published by the FDA (they already keep a list of what's allowed to be sold in the first place, right?) of how the active ingredient names have to be distinctly stylized to best inform.
I'm advocating something that ideally can sit in the middle of the two philosophical/regulatory regimes with more people on board - being able to buy whatever you want, but regulation aimed at preventing companies "innovating" by simply confusing the market. And while I'm sympathetic to extending the scientific-maximalist approach onto the "supplement" industry that is currently harboring copious amounts of straight up fraud, I would also say that throwing down such a gauntlet doesn't seem like a great idea at the moment!
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
To be fair, you're doing pretty much the same by claiming these studies exist without proof.
Should read “NMDA receptor antagonists _may_ give rise to treatments that _may help prevent or ameliorate the symptoms_ of Alzheimer’s.
Nobody even knows how Alzheimer’s works at all — like most diseases it’s a description of some detectable symptoms, some of which could even turn out to be the body defending itself.
Thus compounds that may have a mechanism of action that affects some concomitant, visible symptoms might potentially be useful.
The use of definitive sentences about unknown results is how we end up with wellness and some “biohacking” nonsense.
The only cold and cough medicine that really truly works is the over-the-counter stuff, pseudoephedrine, works amazing for me. I usually pick up a box of the stuff when school starts in the fall and I go through half a box of it by the following summer.
If it helps with your coughing, it’s because it’s stopping the postnasal drip, not suppressing the cough as DXM would by shutting down the cough reflex.
Two different, but very similar use cases. DXM is a god-send in the appropriate time.
I think it's perfectly reasonable to contest the research summary this article is providing. All science-based articles on interesting topics are going to be like that. But you're writing your comment as if they took a flyer on DXM, and the research consensus is in fact that DXM is not effective. It's not as bad as phenylephrine (it has detectable, if immaterial, impact in adults), but it's pretty bad.
The point of the article, of course, isn't that Dayquil should be illegal because it's dangerous; it's that it doesn't work. Having spent an unreasonable amount of time in HN pseudoephedrine threads, I think the broad consensus of this site is that phenylephrine should be taken off the shelves.
From what I remember it was actually quite effective topically but not through pill form. Could be wrong.
Also makes me wonder if there's an alternative function to DXM for people with colds (maybe it makes them feel better in other ways). Or it's just good marketing and associated with NyQuil having other drugs and people assuming DayQuil works
The case against DXM is nowhere nearly as good as the case against phenylephrine; phenylephrine is a scam, and DXM is a drug everyone thought was the gold standard cough suppressant, but then serious studies knocked down its effectiveness.
"Total coughs over 24-hours (primary endpoint) and cough frequency during daytime were reduced by 21.0% and 25.5%, respectively, with DXM relative to placebo. Also, greater reductions in cough severity and frequency were self-reported with DXM. These findings were statistically significant and medically relevant."
Also as I mentioned in another comment, the author of original article misrepresents the conclusion of their own citation. DXM was found to be effective in adults, just not children.
One of my favorite slides is when we compiled dozens of trials on something that’s basically a nitrogen fertilizer. When compared in a graph most of the trials show an overwhelming effect on increasing yield over an untreated check, however there’s always a portion of the trials where the yield decreases compared the check.
Real life is extremely noisy for a multitude of circumstantial reasons that are either not practical or possible to control for, so a single trial is generally worth fuckall. It takes a lot of testing to see a consistent trend across them.
I wonder if the cost benefit analysis would show that this is still the best policy - I.e. are more people dying because of overdose of acetaminophen than would have from “behind the counter” + controlled acquisition of codeine products.
I would also imagine that the compliance / nationwide tracking is now much easier than when the legislation was initially conceived.
There should be a class of drug where the pharmacist gets to decide, based on some registry, whether you get to have something.
They should take all the ineffective phenylephrine products off the market and educate the consumer about asking for pseudoephedrine versions. But I think the ship has sailed and meth is being made with industrial chemicals now, so the restriction isn't as useful as it was.
I think it's not a bad idea to have a registry to prevent over-dispensing of opiate cough syrup. It's really an important drug. There are a lot of conditions that cause chronic, lifelong, unproductive coughing. Doctors end up prescribing things that are either more habit-forming or more dangerous.
That said, dextromethorphan works just fine on its own (if you take enough -- 2 tsp is nonsense). Why they feel the need to mix in a bunch of other actives is beyond me.
It's even worse than that, they appear not to have actually read the study they cited which clearly suggests DXM is 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.
It's similar to the shampoo example (a huge selection of borderline useless products that make money purely because of marketing) but with a minor safety consideration, too.
You ask what is new about this, and the answer is, in 2026 context: nothing, but compared to the year 2000: plenty. Regulators used to issue fines for this behavior, and for worst offenders, regulators used to shut them down. Lying to customers is illegal in most jurisdiction, it used to have consequences, and it should do so again.
i don't need to smell like grandma
Sulfate-containing shampoos give you a deeper clean, but can dry out your scalp and make the color in color-treated hair fade. They're ideal for most people, especially if you don't wash your hair every day.
Sulfate-free shampoos are more gentle, but if you're supremely oily and/or don't wash your hair every day, you might not feel like they clean your hair well enough. Almost all "color-safe" shampoos are sulfate-free. They're ideal if you wash your hair daily and/or have a dry scalp... and they're a must if you dye your hair and want to keep the color looking nice!
But I don't have time to do that. I would rather have a retailer do that curation for me and provide me with effective high value products, and stand behind returns when they miss the mark. Then as a customer I can reward them for that value added work.
That's why Costco is great most of the time. Although they sometimes miss the mark with certain products they stock.
That ignores over a century of law regarding drug safety and efficacy, and false advertising.
So - why again does the FDA exist?
Is the argument that because the FDA may not be perfect, the public would be better off if it didn’t exist?
The FDA handles many thousands of product categories, tens of thousands of prescription drugs, etc. Which items (and how many total) are you referring to? For many of them might there be a reason available as to why they didn’t end up as you recommended?
Yes, that (roughly) happened because the FDA regulates sunscreen like a drug and RoW mostly treats it as a cosmetic. And FDA drug approval is expensive, so nobody was bothering.
Regardless, for those of us with pasty white skin, it kinda blows not being able to get a good daily sunscreen that doesn't make us look even more ghostly.
EDIT - Yes, the FDA needs to exist, it's WAY better than nothing. But, it's probably due for some reform.
I wish the industry, our health organizations, and most people in general acted as though this were true.
The environment we live in in general is increasingly hostile to people who ask those questions, do their own research, and take responsibility for their health in this way. I have first hand experience having reversed chronic health conditions myself by doing my own research. What have and do others say about it? Everything: every person on the sidelines watching who have formed opinions about how things are supposed to be, and how doctors and nurses and pharmacists are supposed to know better, attack and ridicule me and others like me and when we "look at what is effective and what the active ingredients are" we are gaslit and told we can't possible understand and know that and to leave it to the experts. Of course the definition of expert is only ever tribal and is a moving trojan horse for whatever best allows the agenda of an industry to establish its control over you.
Do you agree on this definition?
Assuming so, I hear you asking how can asking particular questions get you this? I'll assume you have good will and are willing to engage with friendliness.
Simply asking specific questions about health, about diseases, about diet, about social media addiction, about controversial topics like politics, etc release hostility from a handful of people. These people engage with ill will and not friendliness. And it is assumed by them that the asker (me usually) meant unwell - this hostility represents my intentions and assumptions as ill will assumptions. Oddly enough this usually is strongest from people with strong identity attachment to a particular belief or set of beliefs that when questioned releases so much dissonance their nervous system gets hijacked and without the emotional intellgience or mindfulness skills to pause before they engage what comes out is a slop of hostility and aggression most commonly being Ad Hominem or Straw Man attacks as I've mentioned. All when all I did was asked questions.
When someone demonstrates this without actually inquiring into ones assumptions or why they asked, thats a clear demonstration of hostility.
Do you need more examples?
Hopefully I don't come off as hostile but there were no examples in your post.
What were your questions? Did you also show an open mind and willingness to engage?
> Simply asking specific questions about health, about diseases, about diet, about social media addiction, about controversial topics like politics, etc release hostility from a handful of people. These people engage with ill will and not friendliness. And it is assumed by them that the asker (me usually) meant unwell
Specific instantiation: during COVID after vaccines had rolled out, I asked my social network on Facebook who had experience with Ivermectin. I have used it successfully myself, and even my vaccinated parents used it successfully when their recommended treatments and advice was not successful for managing pain and symptoms. I got a lot of hostile and ridicule and mockery along with being called a murderer, by people I knew, simply by asking questions. I wasn't recommending to take it. I received people making lots of assumptions about my vaccine status simply because I was asking questions, people lumping me in with conspiracy theorists and being anti-science and more.
Somewhere on a shampoo forum people are complaining that all computers do the same damn thing. I guess they probably just don't know what they're talking about.
They're all Turing machines
Downvoting you isn't enough. How about we stop trying to take advantage of people and extra every dollar from them in every possible way?
In the past, a lot of people unknowingly ended up addicted to morphine, as it turned out both companies and individual doctors were happy to mislead them about the contents of medication.
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.
> The results of this review have to be interpreted with caution because the number of studies in each category of cough preparations was small. [...] There is no good evidence for or against the effectiveness of OTC medicines in acute cough.
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.
I think we need to do more around accidental overdoses than suggest that everyone should be a "shrewd consumer".
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.
But then drug makers realize they can get more sales by selling a placebo that won’t have the friction.
What do you mean "morons"? Say I'm a normal person who doesn't habitually read magazine articles about drug effectiveness. How am I supposed to know that phenylephrine doesn't work? It's in the drug store and they're selling it as a decongestant; I have good reason to believe it will decongest my nose.
After using it and you experience zero relief, unfortunately. Sniffle. It’s infuriating when you’re ill.
I wonder how anyone learns of the good stuff if they didn’t grow up prior to Sudafed being moved behind the counter.
When I’m sick and standing in that isle I long for the day when there were just two on the market: Sudafed during the day, and Actifed at night.
Or am I just suppose to try the dozen different gobbledegook ingredients on the shelf before figuring which one isn't bullshit while wasting my time on half of them?
> "...suppose to try the dozen different gobbledegook ingredients on the shelf before figuring which one isn't bullshit..."
When you say "on the shelf" i presume you're specifically referring to OTC medication and not prescription medication, right? A common sense question deserves a common sense answer. Yes. Companies will happily take your money and sell you snake oil (nominally, so long as the consequences are near zero). Caveat emptor. Phenylephrine as the non-regulated version of pseudoephedrine is the perfect example.
IMHO the only way to buy OTC medication (or food for that matter) is to read the labels and understand the ingredients. (I hate palm oil and sugar. yuck)
Reality is in fact a given. If you mean that the author is just fine with that reality, that's patently false.
> presumably because they can make more money from morons buying the placebos.
If that's your evaluation of everyone who lacks perfect information then you need to look in the mirror.
> You used to be able to get Sudafed; it worked. It was moved behind the counter for $REASONS. You've got enough to guess that the new stuff is some kind of inferior substitute and that you're only going to be able to get the real thing during pharmacy hours.
Grossly intellectually dishonest and downright unintelligent nonsense. Here's a fact that is inconvenient for this moronic argument: acetaminephen is readily available on the aisle. Things not being locked away does not imply that they have no effect. The more complex reality is actually discussed in TFA.
> 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.
The misspelling of "its" is the least egregious part of this nonsense.
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...
It's really worth talking to your pharmacist even if you know what you're buying. There's so many more options behind the counter and they're really knowledgable.
The tire stuff might be the cheap shit that's not so safe just because tires are so thick and robust. Or maybe it's actually designed for tires.
The very "medicine" you linked to in fact displays it right on the cover.
It takes it down to just the Tylenol, the DXM (, plus the antihistamine in the NyQuil), and the great slightly tearable taste for the ritual of "time to pretend I'm not sick for a little while".
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/
I like beer quite a lot and have for a very long time, so acetaminophen is banned from my medicine cabinet.
I am on a medication that's contraindicated with NSAIDs, but I made sure that a low dose of Ibuprofen was acceptable.
Sooo ya :)
Better just stay off the beer hubby.
Remember, beer makes you fat also.
Cannot believe some of his comments!
The narwal bacons!!
But thanks for the input, sweetlips!
Even in the absence of beer, I'm not choosing acetaminophen. The juice isn't worth the squeeze.
Maybe your package needs to be clearer but here in Sweden it says to avoid taking with alcohol.
Or people cannot read anymore?
Saying this to encourage label reading and to refute those who might try to characterize your wife's experience as anecdotal. And for those who stop reading a page like this one, after the first paragraph that touts "no evidence": https://www.tylenolprofessional.com/safety-and-efficacy/safe... when at the bottom it reveals the Liver Warning.
That said, everyone's physical ability to metabolise drugs is different. I might worry something else was wrong, if her liver tox screen showed that.
It is also possible that the test results were incorrect.
This part is what a lot of people miss IME
People need to read and think... I begin to wonder if I am some elite IQ intellect?
Alcohol use acutely reduces the levels of these enzymes which convert paracetamol into it's toxic byproduct as ethanol preferentially binds to the same enzyme for it's own metabolism. Therefore, acute alcohol consumption can reduce the harmful effects of paracetamol.
The reverse is true for overdose in the context of chronic alcohol use, when the liver adapts to long-term alcohol exposure by increasing the levels of enzymes, therefore rapidly metabolising paracetamol into it's toxic byproduct and worsening harm.
Source: doctor
As a side comment, the lack of medical knowledge displayed in HN threads paired with the absolute confidence some verdicts are delivered with is worrying, and something I thought this forum would be better at than other sites (looking at you, reddit). Paracetamol and NSAIDs (including ibuprofens) are safe drugs if taken to the package directions. Some of the ideas shared in this thread about taking one over the other, or not taking one ever etc, are not rational. Please consult your doctor if you are worried about your particular situation, but generally OTC medicines are not dangerous if taken to the package instructions.
Accidental overdoses of paracetamol are exceeding rare, but intentional ones are common.
OTOH Ibuprofein, doesn't have anything like that deadly profile, but enough gut and other issues.
Paracetamol/acetaminophen has a therapeutic dose that is uncomfortably close to the fatal dose, but is otherwise as safe as any drug can possibly be. So long as you don’t take too much.
Ibuprofen is also relatively safe, but it has a number of ways that it can do damage even at the therapeutic dose, if you are taking it all the time.
The main one is that it depletes your mucus lining in your stomach, which can lead to bleeding and death (used to be a big problem here in Aus when codeine combined pills were available without prescription). It’s also harder on your kidneys and liver.
Completely fine at therapeutic doses taken as per instructions and not mixed with alcohol. But having it every day is going to be much worse for you than the paracetamol and almost certainly lead to health problems.
The main issue with ibuprofen is that it can have fairly annoying (but non-life-threatening) side effects like stomach upset and GI bleeds even with normal dosing.
Those side effects are more problematic when used chronically. This is when acetaminophen shines, because it has virtually no side effects at all when used as directed.
On top of that daily use brings it down to 3-5, preferably 4 or less of those a day. And they last less than 6 hours.
The 8h extended release is 650mg a tablet, and you can have 3-4 a day daily. And if you have any experience taking them you can feel the first half of the extended dose wear off before the extended one kicks in, which leads to basically NEEDING 4 a day, and staggered start times.
The people you know may be obtaining it from less reliable apothecaries; that can be a real issue.
Anyway much of the discussion was on how hard it is to make suitable drugs, and someone said "We actually have some fairly inexpensive, reliable, and well-characterised ACE inhibitors with a nice long half-life and known efficacy, but the therapeutic window of nerve gas is pretty narrow..."
When your measurement is "that looks about right" when purity is entirely unknown, not much really is all that safe.
They treated me with an antibiotic, a potassium-rich saline drip and acetaminophen. Yeah that's all they put in my orders.
The thing that pissed me off so much, firstly they insisted on calling it "Tylenol" when it was not, in fact, brand-name Tylenol but generic acetaminophen (even if they could charge $$$ per pill on it) and also that they basically refused to administer it at a rate that would keep my exquisite headache pain at bay. I was literally screaming and moaning through the entire night and day. (Actually, I was wearing one of those radio-transmitting heart monitors, and mostly the screams happened when I moved suddenly, and the electrodes tore at my chest hair...) But my head was also constantly throbbing, and that's how I knew to go to the hospital in the first place.
The nurses could tell me how long to wait between doses, but they couldn't explain to me how to know that interval, given no clocks and no written-down time of dosing. So basically I had to keep guessing throughout my sleepless nights. And they didn't really inform me of a way to just put it on automatic dosing like a normal hospital would have a schedule for.
I really didn't want acetaminophen at all; I don't like it much, and it really hasn't ever relieved any pain I've ever taken it for. My parents chomped so much of it, made me sick just watching them. I lived through the cyanide adulteration episodes and though unsolved, that guy wasn't wrong.
When I finally got to visit a sane PCP after all this madness, I told him I was taking big doses of Bayer Aspirin, and he said that's fine; just follow instructions and heed warnings, and he also warned me: for Heaven's sake don't ever take any acetaminophen, because it would seriously harm my liver!!!
At those levels, you'd be dealing with other intense effects before you'd drop dead.
Iversen, L. L. The Science of Marijuana / Leslie L. Iversen. Oxford University Press, 2000.
On the plus side you can still buy psuedo OTC.
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.
Anyone can buy this stuff, no need to make it sound like it's some controlled substance. I will say if I take to much Acetaminophen I'll just head to the hospital instead of winging it!
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/