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Comments (248)

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  nostrademons
  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.[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/
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  Aurornis
  This article uses the trick where you pick studies that support your argument and ignore all of the studies that disagree with it.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
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  jollyllama
  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.
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  gavinray
  "DXM does nothing", proceeds to link a study whose contents describe significant decreases in cough severity versus placebo.I am convinced that many people ask LLM's "give me a citation URL" and don't bother to read it.
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  bityard
  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.
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  robertpateii
  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.
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  Lerc
  I had a cold a year or two ago, I had used the last of a bottle of actually working cough medicine, attempting to buy a replacement failing to do so, I found it had been banned. Turns out the active ingredient was morphine, which is apparently quite an effective decongestant in very low doses(and variants have been used as such for thousands of years)That started me on a quest for a good cough medicine. My research turned up some interesting results.Different countries have their own go-to medications for decongestants. Actual different drugs, not just the same thing under a different name.None of them work.Anything that does work is banned unless the people making it have been doing so for a couple of hundred years, then it seems that they just pretend it's not there.When challenged the industry defended their sale of ineffective products by saying if they didn't work, people wouldn't buy them.Anecdotal evidence is taken as gospel in many public health circles. When an attempt to have a substance banned was rejected on the basis of no evidence of abuse, it appears that means 'try again later', not gather evidence. You only have to wait for someone who shares your ideology once and it gets done and getting it undone is too much work for anyone to consider.It's almost enough to send you off to a music festival to gather your own supplies for home remedies.
• nodamage
  > Most studies have found that dextromethorphan performs the same as a placeboThe citation linked does not support this claim. In fact it suggests the opposite:"Dextromethorphan was tested in three of the included studies (Lee 2000; Parvez 1996; Pavesi 2001). One report on a series of three successive studies on a total of 451 adults favoured dextromethorphan 30 mg given in a single dose to placebo in terms of cough counts (measured through cough acoustic signals using a microphone on the nose) and subjective visual analogue scales (Parvez 1996). Differences in mean changes of cough counts between active treatment and placebo varied from 19% to 36% (P value < 0.05) in the three studies (up to a net difference of eight to 10 coughing bouts every 30 minutes). This study did not report on side effects.A study involving 44 participants tested a single 30 mg dose of dextromethorphan versus placebo (Lee 2000). Both treatment groups showed a decline in cough frequency (from 50 to 19 per 10‐minute period in the active treatment arm compared with 42 to 20.5 in the placebo arm, P value = 0.38 at 180 minutes follow‐up). Mean subjective cough scores showed a decline from 2.0 to 1.0 in the active treatment group compared to a decline from 2.0 to 1.5 in the placebo group (mean difference in decline in cough scores 0.5 at 180 minutes, P value = 0.08).Pavesi and colleagues also tested a single 30 mg dose of dextromethorphan versus placebo (Pavesi 2001). Outcomes were measured through a three‐hour continuous cough recording, measuring cough bouts, cough components, cough effort, cough intensity and cough latency. Average treatment difference was 12% to 17% in favour of dextromethorphan for cough bouts (P value = 0.004), cough components (P value = 0.003) and cough effort (P value = 0.001), with an increase in cough latency (P value = 0.002)."Two out of the three studies found DXM was effective in adults. The studies did not find the same efficacy in children but that could be due to differences in dosage (adult dosage is 30mg, child doses vary based on body weight) or in measurement techniques (as far as I can tell the child studies measured results via parental survey as opposed to more objective techniques like cough recordings).
• fdgwhite
  The FDA did this to us by outlawing effective but problematic products and replacing them with relatively safe but ineffective products. And then letting product makers off the hook on claims and pricing
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  Hasz
  > 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 acetaminophenthis 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.
• daft_pink
  I think it’s outrageous that pseudoephedrine has become difficult and annoying to purchase while they put that ineffective garbage out through all these combo drugs.
• currymj
  OTC decongestants that actually work, some useful info for those of us with bad sinuses.- pseudoephedrine taken orally.- phenylephrine, but only as nasal spray, not if you take it orally.- Oxymetazoline (Afrin) nasal spray and others in this broad family- propylhexedrine, sold OTC as Benzedrex as a vapor inhaler. Unfortunately people crack open the inhaler and swallow the whole thing as a drug of abuse, so often they are out of stock seemingly because of shoplifting, or not sold at all because the pharmacies don't want to deal with the hassle.Anything that goes directly in your nose has the potential to cause rebound congestion after a couple days which can be pretty bad.
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  andy99
  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.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...
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  wowczarek
  I get that the discussion here focuses on doubtful decongestants, but just the mention of acetaminophen makes me think of pharmaceuticals and people's relationship with them in the US. It's a strange world to me, especially how deeply ingrained the brand names are in people's minds - years of evidently successful marketing.What, to me, should be illegal, is building expensive branding around a group of very basic analgesics - well and other groups like antihistamines.In the UK I can buy an own-brand 16-pack (8 g) of paracetamol in a supermarket for £0.35 / $0.45. At the same time, I can buy a packet of Panadol (GSK), same substance, same content, same amount, for £2.35, nearly 7 times the price of generics.How is THAT legal, and how are people so unaware as to actually buy it? "Unaware" may be the key here.
• jambalaya8
  I am still bothered that Australia limited the sale of small quantities of codeine in 2018. I had not realized it limited acetaminophen last year to limits similar to the UK.At least in the States I can still economise.On the record, I am 100% for making common painkillers, cold and flu remedies completely over the counter. It blows my mind people are making things that used to be prescription (for good reason) OTC, but limiting purchases for things like acetaminophen. I still find it burdensome to deal with the pseudoephedrine controls, and I don't even use it often.
• aunwick
  In the pharmacy in the US there are about 1000 over the counter drugs made if varios combinaciones of about 50 ingredients. Many of them contain acetaminophen. I can see how accidental liver damage can occur.On DayQuil specifically, the only time I took it I was about as useful as someone stoned. I would have been better off and less dangerous to society if I had just taken rest..As far as pain management I personally find acetaminophen does nothing for pain and only helps with fever. Similar ibuprofen only helps me with sever muscle pain associated with over exertion or bruising.Having unfortunately suffered from nerve pain I can say the pain relief opiates provide, even at low levels, is on a whole different level. My experience is that taking them only for pain, when it is unbearable, was not addictive and made pain on the level of I need to go to the hospital bearable.Just my experience.
• annzabelle
  I'm not sure what it is in the Dayquil - the DXM or the "decongestant," but there is a stimulant effect that is half of what I buy it for. It is the most effective medication I have found for getting me off the couch and able to power through a workday with a moderate cold, and definitely does something that Acetaminophen alone doesn't do.
• tshaddox
  > Historically, Sudafed has contained pseudoephedrine, the wonder drug equally good at clearing congestion and making crystal meth.It's much better at clearing congestion than at making crystal meth. And, as the joke goes, it's easier to make an effective decongestant from meth than it is to buy it from a store.
• maest
  Btw, the cosmetics industry functions similarly, but worse. Although I suppose the health dangers are lower (the monetary ones are not).For anti aging stuff, the workhorse ingredient is retinol (with a few formulation variations).However, it is very difficult to buy _just_ retinol - most beauty brands bundle up retinol with a bunch of other ingredients. This has a couple of issues:1. You won't know your retinol dosage. These creams almost never tell you the retinol proportion and concentration.2. You're overpaying by _a lot_. The luxury name brand cream will cost maybe 10x more than the similarly sized $9 bottle of retinol from the ordinary, but it will only contain some fraction of retinol.Tbf this has been slowly changing and I see even La Roche Posay sells retinol bottles for $50. Insane markup, but smaller than what was the case 5 years ago.This is all compounded with the fact that it's very difficult to tell if your anti aging cream is actually working from your own experience:- its effect is slow acting- it's difficult to compare the result with the counterfactual, unless e.g. you only use it on half your face
• dec0dedab0de
  Calling Dextromethorphan a placebo is quite a stretch. Sure, I think the point is that it makes you intoxicated so that you don't really care that you're sick, but it is definitely active.
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  shin_lao
  Oral phenylephrine is considered to be ineffective, phenylephrine in a nasal spray is considered effective.
• kube-system
  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.
• watchdarkly
  Dextromethorphan is abused to get high. Not sure how it could be a placebo.
• pkilgore
  DayQuil: Because you're sick, and the rest of the office should be too.
• chem83
  Interesting that in the US metamizole[0] (dipyrone, or Novalgin and Analgin comercially) is banned in the US due to agranulocytosis[1] risk. It's fairly common in Europe, Asia and South America.[0] https://en.wikipedia.org/wiki/Metamizole[1] https://en.wikipedia.org/wiki/Agranulocytosis
• chao-
  I go with Alka Seltzer specifically because they have an Aspirin variant instead of Acetaminophen.
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  icodestuff
  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.
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  thallavajhula
  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.
• erelong
  "Yes, legalize all drugs for adults"Simple
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  delichon
  Of course placebos should be legal, they're effective medications.https://www.health.harvard.edu/newsletter_article/the-power-...
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  robobro
  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.
• Sohcahtoa82
  > 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 ingredientsIt'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.
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  tzs
  > 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.
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  CodeWriter23
  It should be legal. Caveat Emptor applies always. to everything. I'd rather have choices available in a marketplace rather than a nanny state stifling innovation through its own incompetence.
• rustcleaner
  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.
• scythe
  The author has a point about dextromethorphan and phenylephrine. However, he does guaifenisin dirty:>You’ll also find lots of cough medication with guaifenesin, which has similarly thin scientific backing.He links ( https://pubmed.ncbi.nlm.nih.gov/24003241/ ) which shows that guaifenisin had no measurable effect on sputum volume or consistency (p = 0.12 for volume). But there are other studies with broader outcome measures which show positive effects:https://link.springer.com/article/10.1186/1465-9921-13-118>The pilot study was a randomized, double-blind study where patients were dosed with either 1200 mg extended-release guaifenesin (n = 188) or placebo (n = 190), every 12 hours for 7 days [...]>Subjective measures of efficacy at Day 4 showed the most prominent difference between treatment groups, in favor of guaifenesin.>The DCPD assessment of symptoms also indicated advantages for ER guaifenesin over placebo for the between-day changes from baseline in response to the questions “Over the last 24 hours how often did your phlegm prevent you from going to public places?” (Day 2; p = 0.0016) and “Over the last 24 hours, how difficult was it for you to bring up phlegm?” (Day 5; p = 0.0070).G tends to do well in subjective (symptomatic) assessments, even when subjects are blinded, but poorly in objective assessments. However, this isn't enough to condemn it.
• christina97
  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).
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  mindslight
  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.
• OutOfHere
  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.
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  petesergeant
  > 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.
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  deaton
  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.
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  ButlerianJihad
  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.
• PetaTech-News
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• breck
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  nekusar
  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.