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Comment by deaton | Hacker News Reader

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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Acetaminophen (Tylenol) is probably the OTC drug that is at the top of the list to be made RX-only due to its dangers.

It should be replaced with Dipyrone, which is much safer and more effective, but was restricted in the 70s in the US and parts of Europe.

In fact, it’s so effective against pain and fever, it keeps doctors from having to resort to prescribing opioids. Countries that haven’t restricted its use do not have nearly the same problem with opioid abuse.

It makes me wonder if its continued restriction is motivated by profits off the opioid crisis, rather than patient safety.

Please no. We need to be going the other way on that trend: converting things which won't easily outright kill/maim you (and dare I say, even potentially addictive ones) at normal doses from Rx to OTC! Acetaminophen is one of the few cheap, easy, and working products on the shelf!

We can do both - and already do. Ibuprofen is perfectly fine for non prescription. Super dose ibuprofen pills are prescription.

And then there's OTC drugs which are sort of in a weird middle area - and where some of these I feel personally might work best. Make them easily accessible to anyone without a prescription but at least a pharmacist has to hand it to you. They are the experts at dosing and what combinations of drugs are safe after all !

A concern with OTC drugs is specifically that they won't be taken at normal doses. People confuse brand names and drug names, and don't realize they are taking more than the reccomended amount. This is especially problematic with combination drugs.

There are people who don't know that Tylenol and acetaminophen are the same thing. That is not a reason for us to make everyone's quality of life and access to healthcare worse because some people are ignorant.

The desire to nanny-state things to the lowest common denominator is ruining everything, and it's a major driver for various problems all the way to the housing crisis and the cost of healthcare in the first place.

OTC drugs should be both available and regulated to be sold in such a way to minimize harm to people who use it.

Honestly, combination drugs are out of fucking control. Some people don't know Advil is ibuprofin. Some people think all Advil is ibuprofin. Both are wrong!

It used to be true that doctors could tell people that it was okay to take [X] brand drug with [Y] brand drug but anymore, there are a half dozen formulations of each in varying combinations on the shelf and half of them have some of the same ingredients. Basically every brand has a "fuck it lets just mix everything together, flu" version on the shelf now.

I agree that drugs should be regulated, but that regulation should be primarily about ensuring that they are effective, safe when taken as instructed, and that they contain the ingredients they say that they do and don't contain ingredients that aren't listed.

It is not the government's responsibility, nor should it be, to try to solve the fact that someone can do something stupid with medication and harm themselves. Medication, by its very nature, interacts with and changes your body: that's the entire point. There is no way for something to be effective and also impossible to abuse or misuse. Regulating drug safety should always be based on following the instructions for how to use that drug.

That's not to say we can't do more the educate people, but ignorance should not lead to inaccessibility. There are tens of millions of people in this country that are fully capable of reading a box and following instructions and they should not have to live a worse quality of life because some people are not willing or able to do so.

We don't have to prevent people from being stupid, but we do want to mitigate it, because medicine is supposed to be accessible to everyone, and part of the safety profile of a medication plainly is the ability for it to be administered safely.

> safe when taken as instructed

Part of that means that instructions and ingredients should be clear.

I am educated and knowledgeable and a trip to the pharmacy is more complicated than it needs to be. You damn near have to pick up every damn box to see what is actually in things, if your pharmacy doesn't have things locked up, and half of the time I ask a pharmacist for pseudoephedrine even they give me combination drugs instead.

I don't think we should take anything off the shelf (except oral phenylephrine). If anything, I think we should make more drugs available OTC.

I blame doctors and nurses. At least the ones I personally know tell patients "Advil" and "Tylenol" and never mention ibuprofen or acetaminophen. Actually, it's true for pretty much all OTC medications - they just use the branded names Immodium, not loperamide. Claritin. Zyrtec. Benadryl. Dramamine (drowsy/non-drowsy). The list goes on.

When asked, they always tell me one of two things:

1. They were trained on these names instead of the ingredient (scary!)

2. They want the "easiest" thing for the patients (i.e. so they don't have to look at the label).

Eh, from what I gather from the healthcare professionals I know, I think that is mostly doctors adapting to the language accessible to their clientele. I don’t think it’s about being “easy” as much as it is “doable”. I’ve heard that it’s often hard to even get an accurate list of current medications out of a person, brand name or not.

Now I suppose ibuprofen/acetaminophen is common enough that people may be familiar with it, but I could see how in a clinical setting defaulting to brand names is the only reasonable default for accessibility.

I’ve had multiple doctors remark specifically about my use of generic drug name in discussion. “So I presume you’re a little bit familiar already”, etc.

> I’ve had multiple doctors remark specifically about my use of generic drug name in discussion. “So I presume you’re a little bit familiar already”, etc.

And since I was always more familiar with acetaminophen and ibuprofen, when a doctor would say "Take Tylenol", I would have to ask what the active ingredient is because I didn't know.

They'd actually have to think about it before telling me.

Tylenol is second nature to them. Acetaminophen makes them think.

Oh, and forget about something like dramamine. I'd be told "Non-drowsy dramamine". I'd ask "So you mean meclizine?", and I've literally been told (multiple times) "I actually don't know what the ingredient is."

Ditto for some of the antihistamines (I still don't know what Claritin vs Zyrtec is - are they the same?)

I haven't had that experience. I use generic names with all of my doctors and family who work in healthcare; they follow suit.

Also meclizine causes drowsiness and you should have been warned that this is a common side effect, I was warned when I was prescribed this (it's also on the drug information sheet that comes from the pharmacy). So it might just be that your doctor isn't that good.

Regular dose shouldn't cause much drowsiness in most people. I take it all the time when flying (even double dose sometimes). I once took a double dose of regular dramamine and I was out within 30 minutes.

I just checked - Dramamine actually calls it "less drowsy". They have non-drowsy be ginger, which is mostly a placebo (there's a lawsuit about it!).

But this highlights my point: Telling someone "less drowsy" dramamine and there is a good chance they'll buy either the regular or the non-drowsy. Just tell them the ingredient to look for!

Most side effects don't happen to people taking a drug. The warning isn't because of the likelihood of drowsiness, but the magnitude of risk caused by someone who may become drowsy when doing some other dangerous activity.

Either way, what you describe doesn't sound like a good experience. When I had some issue that necessitated meclizine, the PA wrote a prescription, explained what it was, warned me to be aware of drowsiness until I knew how it affected me, and I picked it up for $1-2 after insurance.

If I had a provider who was anything less than 100% confident and knowledgable about what they wanted me to take, I would be seeing someone else.

> Most side effects don't happen to people taking a drug.

Which is why most doctors don't mention them, either.

Look, everything I've been prescribed has a long list of side effects - many quite serious. Just read the pamphlet that comes with it. It's rare that a doctor mentions any, unless the side effect is decently common.

> When I had some issue that necessitated meclizine, the PA wrote a prescription, explained what it was, warned me to be aware of drowsiness until I knew how it affected me, and I picked it up for $1-2 after insurance.

Could it be possible your dose was higher than normal? For me, meclizine is like buying regular ibuprofen - insurance doesn't even enter into the picture. It's not what one normally considers a "prescription medication". Just like being prescribed Tylenol, you typically don't go to the pharmacist with it and say "Give me some" (and if you do, they just tell you to browse the aisles).

> If I had a provider who was anything less than 100% confident and knowledgable about what they wanted me to take, I would be seeing someone else.

I would suggest you re-evaluate your stance. The best doctors (and professionals), are the ones who are always doubting themselves, and the most confident ones are usually the ones who are just faking it - it takes only a few probing questions to expose their facade.

I agree that you want a provider to be humble. But, not knowing what freekin' meclizine is isn't a healthy level of self-doubt. It's a pretty fundamental drug.

Doesn't OTC specifically mean the ones that can't just be on the shelf ? Where you do not need a prescription but a pharmacist still has to be asked to hand it to you "over the counter" ?

No, OTC means a drug available on the shelf, that people can buy without a prescription.

It's funny, I never thought about it, but you're right, it does sound backwards.

In the US, OTC means the drugs available on the shelf.

The ones you have to ask a pharmacist for are “BTC”: behind the counter. e.g. pseudoephedrine.

Tylenol is one of the things on the shelf most likely to kill you from liver failure. It is way more dangerous than many prescription drugs.

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