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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.

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

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.

"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.

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.

> 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.

Oral phenylephrine is considered to be ineffective, phenylephrine in a nasal spray is considered effective.

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.

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.

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.

> 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.

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.

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).

> 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.

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.

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.

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.

Of course placebos should be legal, they're effective medications.

https://www.health.harvard.edu/newsletter_article/the-power-...