The Uselessness of Phenylephrine(science.org)
science.org
The Uselessness of Phenylephrine
https://www.science.org/content/blog-post/uselessness-phenylephrine
609 comments
I've recently had to deal with the medical profession a lot more than in the past and I'm finding this sort of thing everywhere. OTC medicines that by current standards would not be made OTC, surgeries that are extremely common but have never had quality randomized trials, official sounding diagnoses that on inspection are actually defined as "we have no idea", lack of consensus about how to treat some of the most common conditions in the human population (e.g. back pain), medical device approvals abusing the shortcut of being "substantially similar" to an existing device to evade regulatory scrutiny, the complete lack of enforcement of what goes in supplements... I feel like my entire understanding of the medical system in the US was a lie. We're constantly touting that we have the most advanced technology but if you have a complex condition you are likely to fall prey to multiple kinds of grift.
You seem to be under the impression that there is some 'advanced technology' out there that will magically solve your problems that the US fails to have.
In my experience, many people have a quasi-religious belief in the capability of modern medicine to perform what would otherwise be called a miracle. This belief is typically held without any evidence whatsoever.
In reality, there are a plethora of conditions, some very common and serious, that medicine simply has no idea how to treat. The set of completely treatable / curable conditions is much much much smaller than the set of all possible diseases, yet people act as if it's the opposite. This is why things like 'evidence based' medicine is so dangerous -- we don't have evidence for the vast majority of impactful conditions, simply ignoring patients with these conditions is not a workable solution.
In my experience, many people have a quasi-religious belief in the capability of modern medicine to perform what would otherwise be called a miracle. This belief is typically held without any evidence whatsoever.
In reality, there are a plethora of conditions, some very common and serious, that medicine simply has no idea how to treat. The set of completely treatable / curable conditions is much much much smaller than the set of all possible diseases, yet people act as if it's the opposite. This is why things like 'evidence based' medicine is so dangerous -- we don't have evidence for the vast majority of impactful conditions, simply ignoring patients with these conditions is not a workable solution.
The messaging in the US most commonly used to justify the lack of universal coverage and unreasonable cost of care is that we pay the most because we get the best treatments and best doctors and best outcomes, so I don’t think it’s fair to blame laymen for believing that.
Also, it’s not just patients that think this way. (Or, at least, if the clinicians know, they aren’t saying much to their patients.)
I’ve had docs gush about amazing wonder drugs, then I go and read the actual Phase 3 trial data on the patient information sheet and it has a 15% response (not remission) rate. I’ve been told I’m being given a “gold standard” treatment—but not that the “gold standard” response rate is actually only about 33%, and in another ~33% of cases it makes things worse.
I’ve had doctors refer me for surgery, tell me about how amazing the surgeon is, what a great job they’ll do, that if their own kids were sick they’d send them to this person. When I ask for hard data on the surgeon’s actual success rate for this type of surgery, well, they don’t track that—but look, just trust me, the guy’s realllyyy good.
Out of dozens of specialists I’ve seen over the years, I’ve only had one ever explicitly acknowledge that, yes, I had a real problem, but modern medicine just was not advanced enough yet to identify the cause, so they’re just kind of winging it. For the rest, there are “many new options”, “great responses”, “positive outcomes”, “extremely effective”—or there’s nothing wrong with you, it’s all in your head, and the princess is in another castle.
Also, it’s not just patients that think this way. (Or, at least, if the clinicians know, they aren’t saying much to their patients.)
I’ve had docs gush about amazing wonder drugs, then I go and read the actual Phase 3 trial data on the patient information sheet and it has a 15% response (not remission) rate. I’ve been told I’m being given a “gold standard” treatment—but not that the “gold standard” response rate is actually only about 33%, and in another ~33% of cases it makes things worse.
I’ve had doctors refer me for surgery, tell me about how amazing the surgeon is, what a great job they’ll do, that if their own kids were sick they’d send them to this person. When I ask for hard data on the surgeon’s actual success rate for this type of surgery, well, they don’t track that—but look, just trust me, the guy’s realllyyy good.
Out of dozens of specialists I’ve seen over the years, I’ve only had one ever explicitly acknowledge that, yes, I had a real problem, but modern medicine just was not advanced enough yet to identify the cause, so they’re just kind of winging it. For the rest, there are “many new options”, “great responses”, “positive outcomes”, “extremely effective”—or there’s nothing wrong with you, it’s all in your head, and the princess is in another castle.
> When I ask for hard data on the surgeon’s actual success rate for this type of surgery, well, they don’t track that—but look, just trust me, the guy’s realllyyy good.
For good reason. Tracking of clinical outcomes is the wet dream of insurance companies. It's very toxic to the healthcare system, because it pushes practitioners to focus on easy cases where a good outcome is expected and causes major inequalities in access to healthcare.
I'm not saying the present situation is ideal, but for the system as a whole in its current form, tracking clinical outcomes is a very bad idea.
For good reason. Tracking of clinical outcomes is the wet dream of insurance companies. It's very toxic to the healthcare system, because it pushes practitioners to focus on easy cases where a good outcome is expected and causes major inequalities in access to healthcare.
I'm not saying the present situation is ideal, but for the system as a whole in its current form, tracking clinical outcomes is a very bad idea.
To some degree, there's an even more toxic element of this already in play with the amount of weight the wider US medical system puts behind patient satisfaction surveys.
Many times, things that a patient wants and would make a patient happy are medically contraindicated and lead to worse outcomes, yet there's immense pressure on clinicians to maintain patient satisfaction metrics.
I'm not disagreeing with you at all; more suggesting that we're currently relying on metrics that are even more perilous than actual clinical outcomes.
Many times, things that a patient wants and would make a patient happy are medically contraindicated and lead to worse outcomes, yet there's immense pressure on clinicians to maintain patient satisfaction metrics.
I'm not disagreeing with you at all; more suggesting that we're currently relying on metrics that are even more perilous than actual clinical outcomes.
In patient satisfaction surveys, treatments like invasive surgery usually ranks very low, while treatments like massage rank very highly. One probably saved your life, the other just felt nice, and yet the second one is rated higher.
It's complete insanity to even being comparing treatments that are so different.
It's complete insanity to even being comparing treatments that are so different.
Also getting antibiotics for something gets rated pretty high, even if it did worse than nothing.
This is even true when we're not talking about patient satisfaction. There's definitely conflicts for things like infection control, where what we should probably should be measuring (process measures) conflict with what patient advocacy groups care about and are pushing for (deaths).
I could see that problem occurring if the metric was “what is the success rate of everything that Surgeon X does”. I can’t see that problem occurring for “Surgeon X performing Procedure Y has N% of patients reporting relief and M% of patients reporting complications after the surgery”. What am I missing here?
Edit: Follow-up question: notwithstanding the dysfunction of congress and the ability of companies to find loopholes, and assuming no universal health care to eliminate the role of insurers, surely a solution would be to prohibit the use of this information in the same way that ACA prohibits the use of pre-existing conditions to deny coverage?
Edit: Follow-up question: notwithstanding the dysfunction of congress and the ability of companies to find loopholes, and assuming no universal health care to eliminate the role of insurers, surely a solution would be to prohibit the use of this information in the same way that ACA prohibits the use of pre-existing conditions to deny coverage?
I'm guessing you haven't heard of Goodhart's Law? (https://en.wikipedia.org/wiki/Goodhart%27s_law) Under your proposal, surgeons will be incentivized to selectively operate on easier patients and minimize their complication rates while not performing surgery on very sick patients who may also need the same surgery.
Different surgeons in different areas treat different kinds of patients. It's hard to accurately measure anything in a meaningful way that should influence decision making. To use your example, surgeon Z may also perform procedure Y but has (N-5)% of patients reporting relief and (M+5)% of patients reporting post-op complications. However, surgeon Z works at a community hospital and treats a poorer patient population with more co-morbidities. Can you really say if surgeon X is better than surgeon Z?
Different surgeons in different areas treat different kinds of patients. It's hard to accurately measure anything in a meaningful way that should influence decision making. To use your example, surgeon Z may also perform procedure Y but has (N-5)% of patients reporting relief and (M+5)% of patients reporting post-op complications. However, surgeon Z works at a community hospital and treats a poorer patient population with more co-morbidities. Can you really say if surgeon X is better than surgeon Z?
This is also known as confounding by indication, and is something the pharmacoepidemiology field contents with a lot.
And it shows up all the time in things like the Consumer Reports hospital rankings and the like, where hospitals with particularly uncomplicated patient populations come off looking like they're the best hospitals.
And it shows up all the time in things like the Consumer Reports hospital rankings and the like, where hospitals with particularly uncomplicated patient populations come off looking like they're the best hospitals.
Is it really too "hard" to perform rigorous statical analysis? Why can't you factor in patient genetics + background + circumstances to come up with some expected chance of success for each procedure (in fact, isn't that why doctors have such detailed patient histories?). Isn't it the doctor's job to estimate and inform the patient of the expected outcomes?
Doctor's historical success rate exceeds expected success rate on average => Good (or lucky) doctor.
Doctor's historical success rate exceeds expected success rate on average => Good (or lucky) doctor.
Yes, it's absolutely very difficult to do rigorous statistical analysis.
Genetics is oversimplified to non-physicians. It's cool that we can diagnose and predict the likelihood of getting Huntington's disease using our knowledge of genetics, but extremely few diseases are this simple. There are huge swaths of the human genome that we don't understand but are likely playing some important role in the regulation of other genes and diseases. We are nowhere close to being able to look at a patient's genome to predict anything useful outside of a handful of exceptions.
Patient histories are honestly often garbage—I say that as a physician. I look through dozens of patients' charts every day, and there are constantly errors, incomplete documentation, and fragmented records across multiple institutions. Just last week I read a chart for a patient who had a documented hysterectomy from years ago. The brand new CT scan I saw showed a perfectly normal uterus. Once something goes in a patient's history it's nearly impossible to correct or remove. If some doctor from ages ago said the patient is allergic to medication X, but the patient denies it, what do I do? Usually, we opt to leave the allergy listed out of fear of the consequences if the patient is wrong.
Genetics is oversimplified to non-physicians. It's cool that we can diagnose and predict the likelihood of getting Huntington's disease using our knowledge of genetics, but extremely few diseases are this simple. There are huge swaths of the human genome that we don't understand but are likely playing some important role in the regulation of other genes and diseases. We are nowhere close to being able to look at a patient's genome to predict anything useful outside of a handful of exceptions.
Patient histories are honestly often garbage—I say that as a physician. I look through dozens of patients' charts every day, and there are constantly errors, incomplete documentation, and fragmented records across multiple institutions. Just last week I read a chart for a patient who had a documented hysterectomy from years ago. The brand new CT scan I saw showed a perfectly normal uterus. Once something goes in a patient's history it's nearly impossible to correct or remove. If some doctor from ages ago said the patient is allergic to medication X, but the patient denies it, what do I do? Usually, we opt to leave the allergy listed out of fear of the consequences if the patient is wrong.
Yup. As a patient I've found a bunch of bogus allergies in my records once that I was able to get fixed, but I know there's other stuff I've tried but the doc wasn't interested in listening. He felt he had "proved" I was mistaken/faking when he didn't listen in the first place. How am I supposed to identify the evil item in a challenge when it isn't even present? (I had said "ham". The challenge was with pork. I didn't say pork--whatever the actual evil item it was something that got added in the process of turning pork into ham.) How do you get a mistake like that out of your records?
I've had doctors make up things as egregious as my height.
I had one doc I had only met remotely who entered a height into my online, shared record that was several inches shorter than I was...back when I was an 11-year-old child. It's been 25 years since I was that short.
I pressed them that they could at least have asked me how tall I am, or even consulted the previous entries by other doctors in their same system.
There wasn't even an attempt at an excuse. It was plain, simple negligence.
That doctor had also been insisting I needed to let him do an exploratory surgery, despite never even having had me come to the office in person, so I noped right out of there and started telling that story to everyone I thought might consider seeing him.
I had one doc I had only met remotely who entered a height into my online, shared record that was several inches shorter than I was...back when I was an 11-year-old child. It's been 25 years since I was that short.
I pressed them that they could at least have asked me how tall I am, or even consulted the previous entries by other doctors in their same system.
There wasn't even an attempt at an excuse. It was plain, simple negligence.
That doctor had also been insisting I needed to let him do an exploratory surgery, despite never even having had me come to the office in person, so I noped right out of there and started telling that story to everyone I thought might consider seeing him.
Are you aware of any attempts to use machine learning in medical analysis and outcome prediction? I feel like this is one of the few applications where it could shine. I have no formal training in data science, but everything I've read so far seems to indicate that noisy and unreliable data is not an insurmountable problem.
All of this talk about how "hard" the statistical analysis is, is strange to me. Maybe "advanced" would be a better term? If you get a patient with a contradictory medical history that somehow also contradicts what they are telling you, simply adjust your expected chance of success appropriately (to zero perhaps). In that extreme case, if you get a good outcome, congrats you got lucky. If you don't, it should have 0 impact on how you are evaluated as a doctor.
All of this talk about how "hard" the statistical analysis is, is strange to me. Maybe "advanced" would be a better term? If you get a patient with a contradictory medical history that somehow also contradicts what they are telling you, simply adjust your expected chance of success appropriately (to zero perhaps). In that extreme case, if you get a good outcome, congrats you got lucky. If you don't, it should have 0 impact on how you are evaluated as a doctor.
Before you can even do the statistical analysis you suggest, you need large amounts of high quality data—which we don't have. One place where the US (and the world?) gets data privacy right is in healthcare, but unfortunately that also means it's nearly impossible to create the data sets we need to do the statistical analysis you want.
Institutions face severe penalties for wrongfully sharing patient data, so most opt to just not share any data. Any research that is performed is done internally on local populations with de-identified data sets. A few brave institutions go well out of their way to create and share de-identified data sets publically, but these data sets still undersample the general population. This is a critical problem because certain diseases are highly prevalent in certain regions (e.g., Lyme disease in New England) but unheard of in other regions (e.g., Lyme disease in Colorado). If your ML model is trained on data largely from New England, it's going to diagnose a patient with the classic "target-shaped" rash with Lyme disease even if the patient is from Colorado (high false positive rate). If the model is trained on data from Colorado, it will underdiagnose Lyme disease in patients from New England (high false negative rate). The only way I know to overcome this problem is to create even larger data sets, but this just isn't possible with data privacy laws.
Institutions face severe penalties for wrongfully sharing patient data, so most opt to just not share any data. Any research that is performed is done internally on local populations with de-identified data sets. A few brave institutions go well out of their way to create and share de-identified data sets publically, but these data sets still undersample the general population. This is a critical problem because certain diseases are highly prevalent in certain regions (e.g., Lyme disease in New England) but unheard of in other regions (e.g., Lyme disease in Colorado). If your ML model is trained on data largely from New England, it's going to diagnose a patient with the classic "target-shaped" rash with Lyme disease even if the patient is from Colorado (high false positive rate). If the model is trained on data from Colorado, it will underdiagnose Lyme disease in patients from New England (high false negative rate). The only way I know to overcome this problem is to create even larger data sets, but this just isn't possible with data privacy laws.
> If the model is trained on data from Colorado, it will underdiagnose Lyme disease in patients from New England (high false negative rate). The only way I know to overcome this problem is to create even larger data sets, but this just isn't possible with data privacy laws.
My understanding is that high dimensionality in the domain is exactly where ML excels (so add location as an input), and that is exactly what a medical diagnosis involves. Perhaps the legislation will get there one day.
My understanding is that high dimensionality in the domain is exactly where ML excels (so add location as an input), and that is exactly what a medical diagnosis involves. Perhaps the legislation will get there one day.
Re data privacy, as of last summer in the UK we had to opt out of data sharing of our NHS records with third parties. I am conflicted about this because as you suggested, large amounts of data could be beneficial for things like statistical analysis and machine learning to help medical research. On the other hand, what we know about human nature seems to indicate that there will already be sociopaths slavering over this data in order to enrich themselves at the expense of everybody else.
https://inews.co.uk/opinion/nhs-data-shared-third-parties-we...
Anyway, its out there now.. so watch this space, I guess!
https://inews.co.uk/opinion/nhs-data-shared-third-parties-we...
Anyway, its out there now.. so watch this space, I guess!
Statistics are not the problem. The data is. 'Big healthcare data' does not exist. Building what you are thinking of would require huge data gathering capabilities, that are very clearly out of reach.
Most big medical co do a lot of data science (Kaiser and others). Very efficient from a managerial pov. Totally useless, medically speaking.
Most big medical co do a lot of data science (Kaiser and others). Very efficient from a managerial pov. Totally useless, medically speaking.
I am.
In that I have several CDC funded projects using machine learning in medical analysis and outcome prediction.
Even on extremely well curated data sets this is a fairly hard problem.
In that I have several CDC funded projects using machine learning in medical analysis and outcome prediction.
Even on extremely well curated data sets this is a fairly hard problem.
> I feel like this is one of the few applications where it could shine.
Read “The Alignment Problem”, a very good just above pop sci level book about machine learning. They have one example where ML determined seniors with COPD were at reduced risk from pneumonia, and obviously non-sensical result. Patients with COPD wound up in the hospital at a lower rate than average because doctors know they need careful attention right away.
Read “The Alignment Problem”, a very good just above pop sci level book about machine learning. They have one example where ML determined seniors with COPD were at reduced risk from pneumonia, and obviously non-sensical result. Patients with COPD wound up in the hospital at a lower rate than average because doctors know they need careful attention right away.
Yeah: https://www.nature.com/articles/d41586-019-03228-6
I’m reluctantly pessimistic about humanity’s near-term capability to appropriately weight input from technology as imperfect but inscrutable as current ml.
I’m reluctantly pessimistic about humanity’s near-term capability to appropriately weight input from technology as imperfect but inscrutable as current ml.
Everyone and their mother is working on ML applications in medicine.
> patient histories are often garbage
This is a little like programmers calling the programming language they invented and write in every day garbage. Separate from patient-reported histories, you medical doctors are the ones documenting these histories and hold the decision making power for how it’s done!
This is a little like programmers calling the programming language they invented and write in every day garbage. Separate from patient-reported histories, you medical doctors are the ones documenting these histories and hold the decision making power for how it’s done!
I think your analogy is a bit off here.
Your first sentence would be the equivalent of the inventor of patient history data keeping calling patient history keeping a garbage tool. Which is actually something that would be totally OK to do and say if suffixed with "and unfortunately so far nobody has come up with a better tool and it's not for lack of trying".
I'm assuming you didn't mean "you medical doctors" in the sense it's easy to read in. In any case, what you are doing here is telling one doctor that he is bad at the medical history writing and reading job when in fact he is the one telling you how he is able to spot other doctor's mistakes and trying to correct them. This is like telling one developer that he's bad at his job, that "you developers are the ones writing bad code and hold the decision making power for how it's done" when that developer is actually someone that tries to make things better both through his own maintainably written code (medical histories) and helping others in code reviews to make their code better and not let bad code get into Prod (finding errors in existing medical histories and trying to correct them).
That can be very discouraging, being thrown in with the bad apples. And even good apples can have a bad day or misunderstand something. But I guess you are perfect and have never produced a bug in your life.
Your first sentence would be the equivalent of the inventor of patient history data keeping calling patient history keeping a garbage tool. Which is actually something that would be totally OK to do and say if suffixed with "and unfortunately so far nobody has come up with a better tool and it's not for lack of trying".
I'm assuming you didn't mean "you medical doctors" in the sense it's easy to read in. In any case, what you are doing here is telling one doctor that he is bad at the medical history writing and reading job when in fact he is the one telling you how he is able to spot other doctor's mistakes and trying to correct them. This is like telling one developer that he's bad at his job, that "you developers are the ones writing bad code and hold the decision making power for how it's done" when that developer is actually someone that tries to make things better both through his own maintainably written code (medical histories) and helping others in code reviews to make their code better and not let bad code get into Prod (finding errors in existing medical histories and trying to correct them).
That can be very discouraging, being thrown in with the bad apples. And even good apples can have a bad day or misunderstand something. But I guess you are perfect and have never produced a bug in your life.
The number of factors you'd have to consider to achieve that is huge enough that it makes it completely unrealistic, both practically and financially speaking. In fact, I'm 100% convinced that it's currently impossible to build such a system, given the extent of medical knowledge.
I'm skeptical. I concede it's probably a hard problem but there is an entire field dedicated to hard statistical problems called data science. What is the point of having detailed patient histories and data if it can't be used to inform decisions?
If data science was that efficient on healthcare records, we'd know it by now and everyone would do it. There is no 'big healthcare data'. We gather mostly noise, and records are full of blatant mistakes. Medicine is still more art than science today, and records mostly give you a 'feeling' for the patient's condition in light of your MD education, with a little hard data sprinkled on top.
This is a fallacy. At any point in history you can say “if X field was so good, we’d have Y by now”. In 1925 you could’ve said, “if biology’s understanding of bacteria is so good, we’d have antibiotics by now”. Within 5 years, they did.
There is certainly noise in healthcare data especially when patient-reported, but is it noise to say that a patient having X procedure later does or doesn’t have serious complications? Analyzes of medical care and their consequences can be evaluated and it’s not noise
And big healthcare data has lagged, partially because privacy concerns trump sharing. There are companies selling anonymized medical records for basically every American now though. Big data is coming
There is certainly noise in healthcare data especially when patient-reported, but is it noise to say that a patient having X procedure later does or doesn’t have serious complications? Analyzes of medical care and their consequences can be evaluated and it’s not noise
And big healthcare data has lagged, partially because privacy concerns trump sharing. There are companies selling anonymized medical records for basically every American now though. Big data is coming
> Big data is coming
Big _bad_ data... Let's see how we fare in 5y, then. My prediction as a clinician with a special interest in stats: close to zero medical progress. But insurance priced by a ML algorithm, and much greater efficiency in coverage and claim denials.
Big _bad_ data... Let's see how we fare in 5y, then. My prediction as a clinician with a special interest in stats: close to zero medical progress. But insurance priced by a ML algorithm, and much greater efficiency in coverage and claim denials.
The first flu vaccine came about in 1945. Knowing as much as we did about viruses then, you might think we would have a cure for influenza (or the common cold) by now. Here we are almost 80 years later... big data may be coming but if takes that long it won't be in my lifetime.
My impression is that data science on healthcare records is mostly illegal due to HIPAA and other regulations.
It's not illegal. It's just very complicated to do correctly, and you risk large fines if you do it incorrectly.
We mostly don't have detailed patient histories. Most of the relevant clinical data that would be needed for such a rigorous statistical analysis isn't recorded as discrete data elements, it's just unstructured text. NLP can be used to extract concept codes but the error rate is high so you still need an experienced (expensive) human to manually fix the errors. No one wants to pay for that.
The codes we do have are mostly CPT4 and ICD-10 for billing purposes. Those are generally pretty accurate, but not detailed enough to reliably assess whether one surgeon is better than another at a particular procedure.
The codes we do have are mostly CPT4 and ICD-10 for billing purposes. Those are generally pretty accurate, but not detailed enough to reliably assess whether one surgeon is better than another at a particular procedure.
As someone who works on the methodological basis for a number of "Observed/Expected" healthcare metrics in the infection control and antibiotic stewardship space - just, this is pretty hard, even if you are trying to do a rigorous statistical analysis.
Yup, most of the data is junk, and even if the data isn’t junk - it usually doesn’t at all mean what you think it means.
Goodhart's law means you need to gather more data, not less. The more and diverse metrics you have, the more Goodhart pressure you can take.
> Under your proposal, surgeons will be incentivized to selectively operate on easier patients and minimize their complication rates while not performing surgery on very sick patients who may also need the same surgery.
Isn't that already the case, even without formal tracking of outcomes?
Isn't that already the case, even without formal tracking of outcomes?
Does the fact it's already a problem mean it's ok to make it worse?
[deleted]
No, I haven’t, thanks for mentioning it. Would Goodhart’s Law actually apply here though, since right now the data (as far as I can tell) isn’t being measured at all?
To your counter-example, maybe the metrics I described aren’t good enough and should integrate some disease severity criteria or site-weighting or comorbidity score (although as one continues to subdivide the population this way eventually you end up with n=1 and the results are useless again) but like, surely we should be trying to measure something other than the good feels and word-of-mouth of people who have to work with each other?
It physically hurts my brain when I think about how we measure the dumbest shit in software engineering, like which shade of blue to use to improve clickthroughs[0], but when it comes to even attempting quantification of activities which are literally life or death, sorry, too hard, can’t do it. Surgeons will refuse to do hard procedures, insurers will destroy careers, EMRs are full of bad data (so what is the point of the bloody records if they have become that useless‽), surveying patients would cost too much…
I will ultimately defer to the experience of people in the field—I am not a physician or statistician—but sometimes I feel like I’m just being fed arguments repurposed from the bad cops playbook. Oh, we can’t ever possibly start quantifying individual officers’ use of force, because some parts of the city have more crime, and if we do that then those officers will look worse, so they will stop responding to violent calls in those areas, and there’ll be even more crime, so get off our backs man and stop trying to create more objective metrics for accountability.
To be clear I don’t think you are arguing in bad faith and I don’t intend my statement about accountability to suggest that you personally are trying to avoid it or shield bad actors or anything. What you are saying is probably true and I may be wrong to challenge it at all since I have no personal insight into what is going on behind the scenes, and I genuinely appreciate you answering my questions from your perspective and giving me additional perspectives and things to think about. It just feels so, so frustrating as a patient. All I want is some ability to measure risk that’s better than looking up studies on procedure X on pubmed that I’m unqualified to interpret (and which don’t apply anyway because the lead author of the research won’t be doing my procedure), or shaking the magic eight ball.
If I were a physician, I would absolutely want to track the shit out of my own patient outcomes so I could improve, and the amount of resistance that seems to exist (this is not the first time I’ve talked to docs about this and received similar fatalistic answers) is just baffling to me.
We’re not talking about Frogger here, metrics aren’t some high score, if you have an 80% complication rate for some procedure that isn’t necessarily a reflection on you as a practitioner but it would suggest that there is a problem that needs to be identified (bad procedure, bad training, bad support, bad patient, bad luck). Right now, it seems like no one really knows.
This isn’t bullshit alternative medicine, so why, when I scratch beneath the surface, does it so often feel like it is anyway?
[0] https://www.zeldman.com/2009/03/20/41-shades-of-blue/
To your counter-example, maybe the metrics I described aren’t good enough and should integrate some disease severity criteria or site-weighting or comorbidity score (although as one continues to subdivide the population this way eventually you end up with n=1 and the results are useless again) but like, surely we should be trying to measure something other than the good feels and word-of-mouth of people who have to work with each other?
It physically hurts my brain when I think about how we measure the dumbest shit in software engineering, like which shade of blue to use to improve clickthroughs[0], but when it comes to even attempting quantification of activities which are literally life or death, sorry, too hard, can’t do it. Surgeons will refuse to do hard procedures, insurers will destroy careers, EMRs are full of bad data (so what is the point of the bloody records if they have become that useless‽), surveying patients would cost too much…
I will ultimately defer to the experience of people in the field—I am not a physician or statistician—but sometimes I feel like I’m just being fed arguments repurposed from the bad cops playbook. Oh, we can’t ever possibly start quantifying individual officers’ use of force, because some parts of the city have more crime, and if we do that then those officers will look worse, so they will stop responding to violent calls in those areas, and there’ll be even more crime, so get off our backs man and stop trying to create more objective metrics for accountability.
To be clear I don’t think you are arguing in bad faith and I don’t intend my statement about accountability to suggest that you personally are trying to avoid it or shield bad actors or anything. What you are saying is probably true and I may be wrong to challenge it at all since I have no personal insight into what is going on behind the scenes, and I genuinely appreciate you answering my questions from your perspective and giving me additional perspectives and things to think about. It just feels so, so frustrating as a patient. All I want is some ability to measure risk that’s better than looking up studies on procedure X on pubmed that I’m unqualified to interpret (and which don’t apply anyway because the lead author of the research won’t be doing my procedure), or shaking the magic eight ball.
If I were a physician, I would absolutely want to track the shit out of my own patient outcomes so I could improve, and the amount of resistance that seems to exist (this is not the first time I’ve talked to docs about this and received similar fatalistic answers) is just baffling to me.
We’re not talking about Frogger here, metrics aren’t some high score, if you have an 80% complication rate for some procedure that isn’t necessarily a reflection on you as a practitioner but it would suggest that there is a problem that needs to be identified (bad procedure, bad training, bad support, bad patient, bad luck). Right now, it seems like no one really knows.
This isn’t bullshit alternative medicine, so why, when I scratch beneath the surface, does it so often feel like it is anyway?
[0] https://www.zeldman.com/2009/03/20/41-shades-of-blue/
I share your frustration and agree with a lot of your points, and in fact I was motivated to solve a lot of these problems while in med school. My thought was that all you need is technical expertise on healthcare data to revolutionize the field. We have the technical expertise, but we just don't have the healthcare data for several reasons.
First, patient privacy laws (while a net good) scare institutions from sharing high quality data. The best you'll get is small batches of de-identified data released infrequently. Patient notes are unlikely to ever be released in large quantities since they can so easily pinpoint some patients.
Second, you need to coordinate thousands of physicians and/or healthcare facilities across the US (or world) to record data on their own performance in a standardized way. Many hospitals do this on some agreed upon metrics (30-day readmission rate, hospital-acquired pneumonia rate, average HbA1c level for a doctor's diabetic patients etc.) largely because they're used to determine government funding/penalties. But at the end of the day, there's no direct incentive for physicians or institutions to collect any other data on their own performance and release it publicly. In fact, there are more risks to doing this than benefits. To solve this problem you need to tie hospital funding with requirements to collect and publicly share performance data while also mitigating punishment.
To physicians' credit, many of us are actually motivated to at least privately collect data on our own performance so that we can improve. But this is incredibly difficult and time consuming—especially for those of us who come into contact with dozens and dozens of patients every day. Sure, better data collection tools would dramatically help us monitor our own metrics, but the only entity with the cash to purchase or create these tools is the hospital, and its reply is going to be, "What's the ROI?" And the answer is honestly probably negative. You may suggest buying/building small relatively inexpensive tools (as I've personally tried), but the hospital isn't interested. Like most large enterprises, hospitals want long-term contracts, dedicated support teams, and tried and true tools. Small tools pose too much of a security risk and maintenance headache.
First, patient privacy laws (while a net good) scare institutions from sharing high quality data. The best you'll get is small batches of de-identified data released infrequently. Patient notes are unlikely to ever be released in large quantities since they can so easily pinpoint some patients.
Second, you need to coordinate thousands of physicians and/or healthcare facilities across the US (or world) to record data on their own performance in a standardized way. Many hospitals do this on some agreed upon metrics (30-day readmission rate, hospital-acquired pneumonia rate, average HbA1c level for a doctor's diabetic patients etc.) largely because they're used to determine government funding/penalties. But at the end of the day, there's no direct incentive for physicians or institutions to collect any other data on their own performance and release it publicly. In fact, there are more risks to doing this than benefits. To solve this problem you need to tie hospital funding with requirements to collect and publicly share performance data while also mitigating punishment.
To physicians' credit, many of us are actually motivated to at least privately collect data on our own performance so that we can improve. But this is incredibly difficult and time consuming—especially for those of us who come into contact with dozens and dozens of patients every day. Sure, better data collection tools would dramatically help us monitor our own metrics, but the only entity with the cash to purchase or create these tools is the hospital, and its reply is going to be, "What's the ROI?" And the answer is honestly probably negative. You may suggest buying/building small relatively inexpensive tools (as I've personally tried), but the hospital isn't interested. Like most large enterprises, hospitals want long-term contracts, dedicated support teams, and tried and true tools. Small tools pose too much of a security risk and maintenance headache.
In my mind it gets worse when the procedure is identified: A difficult shoulder surgery by an orthopedic surgeon gets refused because it might be result in a mediocre outcome and lower his 'success' rate. The patient can't get the surgery because no surgeon wants to 'risk' his success rate numbers.
Seems like a good system to me. If a doctor expects a lower than average success rate for performing some specific operation, he should let some other doctor do it anyway.
In my mind it is not a good system, because if the surgeon is looking at a much-more-difficult than average circumstance, than he could reasonably expect a lower-than-average result, but a result that might be much better than average for a case so difficult.
As a separate observation, any time data is kept, turned into metrics that then become the basis for goals ("I want to have a better-than-average success rate, as a surgeon") then the system gets gamed.
I had a boss once propose to down-rate agile teams that didn't get done everything they took on in a sprint. He apparently didn't realize that teams would immediate game the system by taking on less actual work. They could up their 'point' estimates for each task, and always get the work done.
As a separate observation, any time data is kept, turned into metrics that then become the basis for goals ("I want to have a better-than-average success rate, as a surgeon") then the system gets gamed.
I had a boss once propose to down-rate agile teams that didn't get done everything they took on in a sprint. He apparently didn't realize that teams would immediate game the system by taking on less actual work. They could up their 'point' estimates for each task, and always get the work done.
I think you are right that there is a natural and understandable psychological resistance to a data-based evaluation system. I understand that the doctor may realize something about the patient that will lower his/her chances of success.
I'm arguing that a sufficiently comprehensive system would take in to account whatever that doctor realized (and perhaps much more) and compensate for it when determining expected outcomes.
I'm arguing that a sufficiently comprehensive system would take in to account whatever that doctor realized (and perhaps much more) and compensate for it when determining expected outcomes.
This assumes a level of knowledge that simply doesn't exist.
A simple illustration: I have medical issues with no meaningful diagnosis, despite seeing many doctors. If the medical community can't figure out what's wrong, how can they have an understanding of all the relevant factors in determining risk?
A simple illustration: I have medical issues with no meaningful diagnosis, despite seeing many doctors. If the medical community can't figure out what's wrong, how can they have an understanding of all the relevant factors in determining risk?
> I have medical issues with no meaningful diagnosis, despite seeing many doctors.
This isn't directly related to your point, but why is this even the norm? Why are you going from human to human seeking answers to some arcane mystery like you're on a Skyrim quest.
Imagine a system where you wouldn't need to see any doctors. You would type in all of your symptoms as accurately as you can with as much detail as you can, perhaps with a timeline, and as output you'd get the most likely causes (a diagnosis). Maybe that system would even have your medical history (and that of other people and related diagnoses) to better predictions.
It seems to me that a system like this would be significantly better than going to a couple of humans that are arbitrarily local to you and asking them to figure it out. It is slowly improving all the time just in the form of Google and WebMD. Even before 2010 I accurately diagnosed myself with Bell's palsy with the internet and the doctor begrudgingly asked how I had made that diagnosis. Confirmation from the human doctor was nice but redundant.
This isn't directly related to your point, but why is this even the norm? Why are you going from human to human seeking answers to some arcane mystery like you're on a Skyrim quest.
Imagine a system where you wouldn't need to see any doctors. You would type in all of your symptoms as accurately as you can with as much detail as you can, perhaps with a timeline, and as output you'd get the most likely causes (a diagnosis). Maybe that system would even have your medical history (and that of other people and related diagnoses) to better predictions.
It seems to me that a system like this would be significantly better than going to a couple of humans that are arbitrarily local to you and asking them to figure it out. It is slowly improving all the time just in the form of Google and WebMD. Even before 2010 I accurately diagnosed myself with Bell's palsy with the internet and the doctor begrudgingly asked how I had made that diagnosis. Confirmation from the human doctor was nice but redundant.
I'm guessing that the bureaucracy of such a system would be a significant burden. To avoid having the system badly gamed, you'd need a second evaluation, yes? By a _neutral_ party, (not a doctor working in the same practice, e.g.) At added cost and time. Not to mention I've heard more than one surgeon say "That was more difficult than I expected based on the imaging ... once we got in there we found <>".
I'm also arguing that it's not just a psychological resistance to a data-based evaluation system. That people understand the system would be subject to being gamed, and the overall quality of the work would actually suffer. (A bit analogous to how peer-review and the tenure game has interfered with good science practices.)
I'm also arguing that it's not just a psychological resistance to a data-based evaluation system. That people understand the system would be subject to being gamed, and the overall quality of the work would actually suffer. (A bit analogous to how peer-review and the tenure game has interfered with good science practices.)
Other doctors? And where will you find those? No one will ever touch you, except if you pay more. Pay more for worse outcomes, really.
Agree if there is another doctor who feels they could have a better success . And this does happen, doctor will say "I don't feel comfortable doing this".
But there may be no other doctor.
Think of this way - if you're a doctor specializing in the treatment of septicemia, a lot of your patients will die. If you're really good, you'll likely get the hardest cases. So your "success rate" may be lower than another doctor who isn't as good but doesn't see such tough cases.
But there may be no other doctor.
Think of this way - if you're a doctor specializing in the treatment of septicemia, a lot of your patients will die. If you're really good, you'll likely get the hardest cases. So your "success rate" may be lower than another doctor who isn't as good but doesn't see such tough cases.
If a doctor estimates that this particular patient+disease+procedure combination has a lower chance of success than the average patient who needs a similar category of procedure, then unless they're severely mistaken, every other doctor will also estimate the same way and refuse that difficult case.
Surgeons would steer away from difficult, lower-percentage-outcome procedures which is precisely what you don't want.
You want risk-takers who repeatedly tackle the surgeries and (ideally) get a more positive outcome percentage than a newbie.
You want risk-takers who repeatedly tackle the surgeries and (ideally) get a more positive outcome percentage than a newbie.
Meaning they will not take over my risky surgery, and I will still be choosing among risk takers, but with clear stats in my hands.
Surgeons will concentrate on easy procedures and will basically all have an almost identical track record of quasi perfection. So there will be nobody left to perform procedure Y, where Y has an intrinsically high rate of failure. Same thing for difficult patients. No one will touch Mr X who's got a complex problem.
Doctors that work on older patients or worse cases will have worse numbers. Usually that effect far outweighs the skill difference between doctors.
Is the aggregate number reported, i.e. aggregated across all surgeons for procedure Y?
It's also a bad idea because the best surgeons often take on the most difficult cases you can't necessarily compare doctor to doctor without knowing the types of patients they treat.
Have one person do nothing but estimate the difficulty of a case(and be tracked and judged for the quality of their estimates), and the surgeon be tracked and judged on the relative performance given the difficulty.
Then you could make a career out of doing well on difficult cases, or out of doing better-than-average on easy cases, and either would be viable.
Then you could make a career out of doing well on difficult cases, or out of doing better-than-average on easy cases, and either would be viable.
There are some things that are helpful that they will answer that have steered me away from a surgeon:
How many of these surgeries do you do per year? An answer of 50 or above is good.
What is YOUR rate of <specific complication mentioned in the consent>? Keep pushing until they tell you their rate, not the overall rate.
They almost universally don't know their own rate. I don't know my own rates of complications. But, if I want you to go away because you seem to be the kind of guy that will come back to bite me, I'll gladly tell you I have a huge rate of complication.
For a colonoscopy I asked about the risk of a perforated bowel. Their first response was, “that is meaningless, if it happens to you the rate is 100%.” I said if the chances are 50:50, then I am not doing it. They said it has happened twice in their career and based on my lack of risk factors, it would not happen to me.
For my daughters tonsillectomy, the doctor was very happy to share how her stats for post surgery bleeding compared to both other doctors in her group, and the national average. But I live in a Boston suburb and every doctor is a lecturer at either Harvard or Mass General.
Another question to ask is will an intern take part in the surgery. At teaching hospitals the answer is almost always yes. You can ask if they operate at any other hospitals, and again the answer is almost always yes, they operate at a suburban, non-teaching hospital where they will be the only one operating.
I got a little bit humbled at Boston Childrens Hospital. I was doing some Googling about the risks of a CAT scan and asked if they did low-dose ones. They informed me that they in fact invented that procedure. Sure enough, the paper I was looking at was authored by a doctor on their staff.
For my daughters tonsillectomy, the doctor was very happy to share how her stats for post surgery bleeding compared to both other doctors in her group, and the national average. But I live in a Boston suburb and every doctor is a lecturer at either Harvard or Mass General.
Another question to ask is will an intern take part in the surgery. At teaching hospitals the answer is almost always yes. You can ask if they operate at any other hospitals, and again the answer is almost always yes, they operate at a suburban, non-teaching hospital where they will be the only one operating.
I got a little bit humbled at Boston Childrens Hospital. I was doing some Googling about the risks of a CAT scan and asked if they did low-dose ones. They informed me that they in fact invented that procedure. Sure enough, the paper I was looking at was authored by a doctor on their staff.
I have 10+ years of clinical experience in academic hospitals, and have worked in Boston at Brigham and Women's. From this experience, I can tell you 2 things:
1. Being a lecturer at Harvard does not correlate with being a skillful clinician
2. Your view of the clinical system is very skewed, and will bring you more risks than benefits.
1. Being a lecturer at Harvard does not correlate with being a skillful clinician
2. Your view of the clinical system is very skewed, and will bring you more risks than benefits.
Completely agree with point 1. There are many researchers in the area who like to also practice, that lead me to ask the # of surgeries question.
My bias is towards surgery at a good regional hospital (Newton-Wellesley for example) with a surgeon who teaches downtown and does lots of surgeries.
What is my skew that that is bringing me more risk? I used to think all doctors were about the same. Now I realize that is about as true as all baseball players are the same. There are hall of famers as well as some who could be sent down to the minors. The trick is figuring out who is who, because other docs won’t say.
My bias is towards surgery at a good regional hospital (Newton-Wellesley for example) with a surgeon who teaches downtown and does lots of surgeries.
What is my skew that that is bringing me more risk? I used to think all doctors were about the same. Now I realize that is about as true as all baseball players are the same. There are hall of famers as well as some who could be sent down to the minors. The trick is figuring out who is who, because other docs won’t say.
> The trick is figuring out who is who, because other docs won’t say
Precisely. And I assure you, as a patient you can't possibly figure out who's who. Your bias is you think you can.
Precisely. And I assure you, as a patient you can't possibly figure out who's who. Your bias is you think you can.
unfortunately if you need a rare surgery (to treat a rare condition), this doesn't work very well. it also isn't enough for surgeries with subjective outcomes (such as vaginoplasty.) with the former you look for a competent surgeon with many good outcomes on related surgeries of similar complexity, and who keeps up with or participates in research. with the latter... image boards? word of mouth? whoever your insurance covers? I get hung up on that kind of choice.
Wouldn't that be rectifiable by also tracking the statistics of cases which a practitioner reneges or refuses.
Then somebody with high success rate and high refusal rate stands out as a red flag.
Then somebody with high success rate and high refusal rate stands out as a red flag.
> For good reason. Tracking of clinical outcomes is the wet dream of insurance companies.
Sounds like a sufficient reason for single payer healthcare and single payer malpractise compensation even if all the imagined downsides were real.
Sounds like a sufficient reason for single payer healthcare and single payer malpractise compensation even if all the imagined downsides were real.
On the other hand: tracking clinical outcomes actually tells us if a treatment actually works - a net positive for the species, I'd have thought.
Doing RCTs of a treatment tells you if it works. Without random assignment (or some clever experimental design) tracking outcomes really doesn't tell you anything.
You can forbid insurance from using that data by policy. It sounds like the same argument against measuring teacher performance because "toxic".
Risk adjusted scoring is entirely viable in this age of data science, there is just no appetite for it. Doctors fight very hard against it because who actually wants to be held accountable for outcomes?
Insurance companies really aren't the villains in the US healthcare system, they're going to make money no matter what because they pass cost increases on to their subscribers and are capped in how much profit they can make via regulation.
Insurance companies really aren't the villains in the US healthcare system, they're going to make money no matter what because they pass cost increases on to their subscribers and are capped in how much profit they can make via regulation.
Risk adjusted scoring is currently absolutely not viable. You underestimate the messiness of the healthcare system by a huge margin. We don't even manage to record basic vital signs consistently, so believe me when I tell you that you can forget about any kind of nice statistical trick given the weakness of our data gathering processes. Plus it's not a matter of objectivity. Surgeons will subjectively assess that doing easy cases will be better. And in addition, they'll be correct. That's what really matters.
>Risk adjusted scoring is entirely viable in this age of data science
It's just not unviable, I don't think it's even possible. As soon as a metric becomes tracked, people are incentivized to game it.
From my own experience as a very high-volume eBay seller, mandating a certain return rate led us to simply discourage customers from using the (convenient, well-designed) integrated returns systems. Mandating that only a tiny fraction of a percentage of items can be cancelled due to being out of stock leads to sellers sending either the wrong item or a fake tracking number (this gets us all the time on AliExpress).
If data-driven software companies can't handle it for something as simple as eCommerce, I have no idea how the medical industry is supposed to get it right.
It's just not unviable, I don't think it's even possible. As soon as a metric becomes tracked, people are incentivized to game it.
From my own experience as a very high-volume eBay seller, mandating a certain return rate led us to simply discourage customers from using the (convenient, well-designed) integrated returns systems. Mandating that only a tiny fraction of a percentage of items can be cancelled due to being out of stock leads to sellers sending either the wrong item or a fake tracking number (this gets us all the time on AliExpress).
If data-driven software companies can't handle it for something as simple as eCommerce, I have no idea how the medical industry is supposed to get it right.
A good portion of the largest insurance companies are non-profits, look at Blue Cross Blue Shield and their affiliated companies. They still make tons of money, keep tons of cash on hand, enjoy the same high salaries as for-profits (not saying they necessarily shouldn't), and get special tax statuses/breaks.
And the for profit ones are making plenty of money whatever regulations theyre subject to:
>During 2010, Health Care Service Corporation, the parent company of BCBS in Texas, Oklahoma, New Mexico, Montana and Illinois, nearly doubled its income to $1.09 billion in 2010, and began four years of billion-dollar profits.
I'm not saying they're villains, but "they're going to make money no matter what" isn't a compelling argument to me, and I have precisely 0 faith in the government to meaningfully regulate them.
And the for profit ones are making plenty of money whatever regulations theyre subject to:
>During 2010, Health Care Service Corporation, the parent company of BCBS in Texas, Oklahoma, New Mexico, Montana and Illinois, nearly doubled its income to $1.09 billion in 2010, and began four years of billion-dollar profits.
I'm not saying they're villains, but "they're going to make money no matter what" isn't a compelling argument to me, and I have precisely 0 faith in the government to meaningfully regulate them.
Risk adjusted scoring is done in some areas where we have the data for this (healthcare associated infections and antibiotic usage). And this is a place where hospitals and doctors actively do want it to work, because there are financial penalties associated with it.
It's still a fairly hard problem. I've had several very clever data scientists on teams who have gone "Oh, this is just an X problem..." and then 9 months later they're still trying to get a model to perform better than "Just take the average".
It's still a fairly hard problem. I've had several very clever data scientists on teams who have gone "Oh, this is just an X problem..." and then 9 months later they're still trying to get a model to perform better than "Just take the average".
But if the alternative to a 15% response rate is “no treatment” then you are getting the gold standard. In many other countries those medicines aren’t even considered or paid for.
Only if Gold Standard means "not quite as bad as the other options," which I'm not sure is a definition that'd stick.
But that's true in general.
What's another way to describe the "best doctor in the country"?
"Marginally better than the next best option".
What's another way to describe the "best doctor in the country"?
"Marginally better than the next best option".
If it has a word like 'standard' in it, you would assume there is a measure or definition for that standard, not just 'not the worst.'
Best doctor in the country can quite easily still be "bronze standard."
There's an expectation of quality in saying something is Gold Standard, it's not an entirely arbitrary label.
Best doctor in the country can quite easily still be "bronze standard."
There's an expectation of quality in saying something is Gold Standard, it's not an entirely arbitrary label.
Maybe it’s a lingo thing. “Standard of care” is used all the time and just means “standard” in the sense of “best supported by data”.
But the standard of care might just be “give morphine to ease pain until death”.
But the standard of care might just be “give morphine to ease pain until death”.
All of this points to one thing
You are being sold
Thanks for sharing, love the % success rate question for surgeons.
You are being sold
Thanks for sharing, love the % success rate question for surgeons.
I also think that doctors tend to dumb-down and downplay the actual truth of the effectiveness of treatments. Partly because for the majority of patients, being told that a treatment is realllyyy good can actually make it more effective, by the placebo effect. It also makes the patient happier and more confident in the abilities of the doctor.
I noticed that since I got "Dr." put in front of my name on my medical records, doctors tend to firstly ask what I'm a "Dr." in, and secondly tell it to me straight.
I noticed that since I got "Dr." put in front of my name on my medical records, doctors tend to firstly ask what I'm a "Dr." in, and secondly tell it to me straight.
I've noticed that too. I went to the ER with a dog bite and the triage nurse was keen to know if I was a medical doctor before she looked at it.
The problem with empowering people medically is that 10% of people will benefit from it but 90% of people will get info from Facebook and infomercials and fall victim to quacks. Hence everything being gated behind credentials and prescriptions (along with some good old regulatory capture).
I disagree with the characterization of medicine not being able to treat so many things. Many things are incurable but a lot of medicine/public health is so effective we barely think about it. Of course we are going to notice and pay more attention to the things medicine sucks at treating, because they’re real problems that inflict a lot of pain due to the lack of treatment.
But medicine is very good at treating plenty of things like infections (of many different kinds), traumatic/acute injuries, and many disabilities. Most of the chronic issues that medicine fails to address are simply lifestyle issues that medicine tries to alleviate the symptoms for. Yes there are certain conditions medicine doesn’t begin to fully understand like Alzheimer’s or various chronic pain conditions, or where treatment is still pretty middling like Cancer, but a lot of the biggest things are treatable very well - we just don’t notice them much because they are treated so well.
I disagree with the characterization of medicine not being able to treat so many things. Many things are incurable but a lot of medicine/public health is so effective we barely think about it. Of course we are going to notice and pay more attention to the things medicine sucks at treating, because they’re real problems that inflict a lot of pain due to the lack of treatment.
But medicine is very good at treating plenty of things like infections (of many different kinds), traumatic/acute injuries, and many disabilities. Most of the chronic issues that medicine fails to address are simply lifestyle issues that medicine tries to alleviate the symptoms for. Yes there are certain conditions medicine doesn’t begin to fully understand like Alzheimer’s or various chronic pain conditions, or where treatment is still pretty middling like Cancer, but a lot of the biggest things are treatable very well - we just don’t notice them much because they are treated so well.
I feel like autoimmune, endocrine, and GI issues, and various combinations of those are the biggest frustration to people, along with complicated surgeries/replacements that we just haven't figured out yet. But those first three are horribly complicated and interrelated systems whose disorders affect probably close to a third of the population, maybe half. Just autoimmune thyroid issues affect about a fifth of women. Not to mention all thyroid issues, autoimmune diabetes, other diabetes, chrons, ibs, fibro myalgia, maybe long covid, etc. You are right to point out that many suffering from those conditions wouldn't even be alive without modern treatments and that we don't notice all that modern medicine can solve. But we also need to acknowledge there are many people for whom we dont have answers yet, and we are using evidence based medicine to say that because we don't have studies yet, there is nothing to be tried. I also think diet and lifestyle changes get undersuggested due to ebm. No one seems as eager to fund a study that tests a diet or activity to treat a condition as they are to fund investigation into a new drug, surgery, or diagnostic equipment.
> I disagree with the characterization of medicine not being able to treat so many things. Many things are incurable but a lot of medicine/public health is so effective we barely think about it. Of course we are going to notice and pay more attention to the things medicine sucks at treating, because they’re real problems that inflict a lot of pain due to the lack of treatment.
> But medicine is very good at treating plenty of things like infections (of many different kinds), traumatic/acute injuries, and many disabilities.
I agree that medicine is very good at treating infections and traumatic/acute injuries. Which disabilities are you referring to? Outside of these categories, what can we we effectively treat or cure? It seems to be very little.
> But medicine is very good at treating plenty of things like infections (of many different kinds), traumatic/acute injuries, and many disabilities.
I agree that medicine is very good at treating infections and traumatic/acute injuries. Which disabilities are you referring to? Outside of these categories, what can we we effectively treat or cure? It seems to be very little.
Hip replacements? Cataract surgery? Disfigurements (cosmetic surgery)? - just off the top of my head. My own mother had "cosmetic" surgeries to re-set her toes which had been deformed by decades of fashionable shoes, and to remove varicose veins which are painful. Occasionally one reads about someone's hearing, sight, or power of speech being restored also.
Maybe only a few things, but still affecting millions, if not tens of millions of people.
I also think that medicine is a victim of its own success, in two ways.
One, how many funerals of people in their thirties to fifties does the average person go to, these days, compared to say the 1920s? It's hard to see things that don't happen.
Two, success breeds hubris which breeds a sense of being right whatever the evidence may say.
Maybe only a few things, but still affecting millions, if not tens of millions of people.
I also think that medicine is a victim of its own success, in two ways.
One, how many funerals of people in their thirties to fifties does the average person go to, these days, compared to say the 1920s? It's hard to see things that don't happen.
Two, success breeds hubris which breeds a sense of being right whatever the evidence may say.
I agree on all of the above as useful as well.
I feel proponents of evidence based medicine are perfectly aware of the enormity of the problem, and are working hard to improve the situation.
But the point is that laymen are not, and they put too much faith, on average, into our medical institutions.
Our understanding of the human body has advanced enormously with the advent of modern science, but it is still far less complete than most people probably realize when they interact with doctors. Not to mention systemic issues (common to any technical discipline) where medical professionals have to effectively practice with a degree of faith because no one has time to actually review the literature underpinning any given consensus, and that occasionally breeds long lived orthodoxies which do more harm than good...
Our understanding of the human body has advanced enormously with the advent of modern science, but it is still far less complete than most people probably realize when they interact with doctors. Not to mention systemic issues (common to any technical discipline) where medical professionals have to effectively practice with a degree of faith because no one has time to actually review the literature underpinning any given consensus, and that occasionally breeds long lived orthodoxies which do more harm than good...
Who exactly should the laymen put their faith into if not medical institutions? That, and the scientific process, are all we’ve got.
Medical practice and research can be decades away from each Other. Use your own judgement. Smoking was a weight cure before it wasn't.
>In my experience, many people have a quasi-religious belief in the capability of modern medicine to perform what would otherwise be called a miracle. This belief is typically held without any evidence whatsoever.
I found the same thing for science in general. When I did my PhD and saw how the sausage was made, I was blown away by how obviously unscientific and irrational the entire process of science was.
I found the same thing for science in general. When I did my PhD and saw how the sausage was made, I was blown away by how obviously unscientific and irrational the entire process of science was.
> many people have a quasi-religious belief in the capability of modern medicine to perform what would otherwise be called a miracle.
That's probably because miracles are being pulled off on ocassion
That's probably because miracles are being pulled off on ocassion
Since when is "evidence based medicine" defined as ignoring patients with currently untreatable conditions. There are enormous amounts of funding and effort constantly devoted to developing new treatments. I'm not sure how else you want to practice medicine other than "evidence based".
> many people have a quasi-religious belief in the capability of modern medicine to perform what would otherwise be called a miracle. This belief is typically held without any evidence whatsoever.
The thing is, application of the germ theory of disease and Harvey's theory of circulation of the blood by action of the heart (and consequent developed understanding of the role of the blood, and of blood types) did produce miracles. Reliably safe milk and meat. Penicillin. Reliably useful blood transfusions. The tetanus vaccine. The polio vaccine.
The great polio epidemic was only four-ish generations ago. In my childhood I knew one or two people in iron lungs, having contracted polio before the vaccine. The vaccine was miraculous to every parent at the time.
The evidence has been culturally transmitted through the generations.
The thing is, application of the germ theory of disease and Harvey's theory of circulation of the blood by action of the heart (and consequent developed understanding of the role of the blood, and of blood types) did produce miracles. Reliably safe milk and meat. Penicillin. Reliably useful blood transfusions. The tetanus vaccine. The polio vaccine.
The great polio epidemic was only four-ish generations ago. In my childhood I knew one or two people in iron lungs, having contracted polio before the vaccine. The vaccine was miraculous to every parent at the time.
The evidence has been culturally transmitted through the generations.
"This is why things like 'evidence based' medicine is so dangerous -- we don't have evidence for the vast majority of impactful conditions, simply ignoring patients with these conditions is not a workable solution."
Citation needed.
Citation needed.
What kind of citation are your looking for? It's just obvious to anyone who works in the medical field. There are only evidence based treatment guidelines for a minority of conditions, and those often don't account for individual variations between real patients. So physicians often have to resort to trial and error in order to find an effective treatment.
Ignoring them is unethical.
Treating them with an unscientific treatment is unethical.
And the ethical alternative is, for chronic conditions, someone who suffers for their entire life and is not allowed to do anything about it?
Look at every wastebasket diagnosis (yes, that's a real term) out there. There is no "ethical", approved treatment. In fact, there's not even an understanding of what the condition is. Instead, doctors work down a list of bad ideas with their patients: all the various medications, supplements, and even surgeries that have ever reputedly worked. Many have uncertain evidence, many more have no evidence at all. Some patients eventually hit on something that works for them. Others don't.
According to your short statement: that's unethical. Bad. Stop!
So what's the alternative? Suicide? Doing nothing is intolerable.
Look at every wastebasket diagnosis (yes, that's a real term) out there. There is no "ethical", approved treatment. In fact, there's not even an understanding of what the condition is. Instead, doctors work down a list of bad ideas with their patients: all the various medications, supplements, and even surgeries that have ever reputedly worked. Many have uncertain evidence, many more have no evidence at all. Some patients eventually hit on something that works for them. Others don't.
According to your short statement: that's unethical. Bad. Stop!
So what's the alternative? Suicide? Doing nothing is intolerable.
I think you're being a little unfair to wastebasket diagnoses. you need something for insurance codes, for drug indications, for publishing research on. having a bucket of similar syndromes is a start for drilling down further. and often you can treat things supportively, even if you can't modify the disease itself.
doctors need to be up front with patients about wastebaskets though, and rule out other diagnoses. it's wrong to chalk someone's fits up to FND until you've ruled out epilepsy and other organic causes, for example. and even things like FND are probably "real", we just don't know enough about them yet.
doctors need to be up front with patients about wastebaskets though, and rule out other diagnoses. it's wrong to chalk someone's fits up to FND until you've ruled out epilepsy and other organic causes, for example. and even things like FND are probably "real", we just don't know enough about them yet.
It really depends on how wastebasket diagnoses are used. I've seen doctors lean on them without telling the patient, and the patient turned out to have some other valid diagnosis. It's an awful situation and significantly erodes relationships.
Even someone's fits might not be an FND after ruling everything else out. There are atypical presentations of organic diseases we don't have tests for. It's fine to use wastebasket codes as long as the patient understands, but I've also seen doctors lean on certain things really early in notes (eg FNDs) without much consideration, and it's a little much to me.
Even someone's fits might not be an FND after ruling everything else out. There are atypical presentations of organic diseases we don't have tests for. It's fine to use wastebasket codes as long as the patient understands, but I've also seen doctors lean on certain things really early in notes (eg FNDs) without much consideration, and it's a little much to me.
I'm criticizing the parent's comment that it's not ethical to treat people with "unscientific" treatments. This is in the context of an article criticizing phenylephrine, which differs from really, deeply unscientific stuff like, say, acupuncture or homeopathic remedies, in that it has studies going both ways but the balance (according to meta-analyses) is that it's useless as a decongestant, and is thus unscientific to have on the shelves.
How does that relate to wastebasket syndromes? At least for the one I have (a migraine variant) -- every single accepted treatment falls in the same basket. Some evidence, but not enough that it's really a good idea to use it. Unless, that is, the syndrome is ruining your life.
And behind this argument that yet more things should be taken off the shelves and regulated, I'll note that the US has one of the most restrictive, patient-unfriendly regulatory atmospheres in the world. It's goddamned ridiculous, pardon my French, that the "solution" to phenylephrine not being a good decongestant would be to regulate it so that it can't be sold without a prescription. Doubly so, in a country with a healthcare industry that's so thoroughly corrupt and dysfunctional that a vast swathe of patients can't afford to even go to a doctor to get whatever tenuous recommendation they may have. (Phenylephrine, by the way, has a number of uses other than decongestion.)
... that was a rant. But this system is truly screwed up, that fact has affected my life quite negatively, and it's annoying that the knee-jerk reaction so many people have is to keep playing along with this completely broken ethical system.
How does that relate to wastebasket syndromes? At least for the one I have (a migraine variant) -- every single accepted treatment falls in the same basket. Some evidence, but not enough that it's really a good idea to use it. Unless, that is, the syndrome is ruining your life.
And behind this argument that yet more things should be taken off the shelves and regulated, I'll note that the US has one of the most restrictive, patient-unfriendly regulatory atmospheres in the world. It's goddamned ridiculous, pardon my French, that the "solution" to phenylephrine not being a good decongestant would be to regulate it so that it can't be sold without a prescription. Doubly so, in a country with a healthcare industry that's so thoroughly corrupt and dysfunctional that a vast swathe of patients can't afford to even go to a doctor to get whatever tenuous recommendation they may have. (Phenylephrine, by the way, has a number of uses other than decongestion.)
... that was a rant. But this system is truly screwed up, that fact has affected my life quite negatively, and it's annoying that the knee-jerk reaction so many people have is to keep playing along with this completely broken ethical system.
And note that such things don't always remain wastebasket diagnosis. Sometimes we figure out what's actually going on.
Personally, I think many of the cases where something works for one patient but not another is actually saying there's more than one possible cause for the situation.
Personally, I think many of the cases where something works for one patient but not another is actually saying there's more than one possible cause for the situation.
Or, that the cause is known but there are several potential mechanisms behind it. Usually those mechanisms are not well understood and may in turn be triggered by something that may not have been explained by science yet -- an infection, genetic abnormality or even an injury earlier in life.
Depends heavily on your definition of unscientific. There are many treatment modalities that exist that are considered "ineffective" simply because they don't work en mass on large populations. AKA they don't scale for identified conditions. This can be as much a problem with diagnostics and labels which create cohorts as much as the effectiveness of treatments.
In practice the rest of my life is probably going to be playing whack-a-mole with symptoms without any understanding of what's causing the underlying issues. I have no meaningful diagnosis so by your standard there can be no treatment.
> This is why things like 'evidence based' medicine is so dangerous -- we don't have evidence for the vast majority of impactful conditions, simply ignoring patients with these conditions is not a workable solution.
Maybe that's true at a population level, but I can take it. Just tell me the truth. If you can't treat me, then just say that. I don't want to be "ignored," but I'm not interested in being placated, either.
This, basically: https://www.youtube.com/watch?v=NyugCJ40IIw
Maybe that's true at a population level, but I can take it. Just tell me the truth. If you can't treat me, then just say that. I don't want to be "ignored," but I'm not interested in being placated, either.
This, basically: https://www.youtube.com/watch?v=NyugCJ40IIw
Indeed.
My experience has been that 75%-90% of US doctors are borderline incompetent and that I can and do routine out-diagnose my own maladies better. Of course this also means I can lead them by the nose to get them to diagnose anything I please. Which is horrifying - they are Epic Fail if I can do that.
Admittedly I was at one time planning to become a doctor myself so I ravenously consumed everything about biology and medicine while a teen but it seems very few doctors were anything like THAT with passion I had.
Even worse few seem to know what the scientific method is, let alone practice it in any as doctors. This is equally horrifying.
My experience has been that 75%-90% of US doctors are borderline incompetent and that I can and do routine out-diagnose my own maladies better. Of course this also means I can lead them by the nose to get them to diagnose anything I please. Which is horrifying - they are Epic Fail if I can do that.
Admittedly I was at one time planning to become a doctor myself so I ravenously consumed everything about biology and medicine while a teen but it seems very few doctors were anything like THAT with passion I had.
Even worse few seem to know what the scientific method is, let alone practice it in any as doctors. This is equally horrifying.
Honestly, the "lead the by the nose" situation is a large improvement from many of the doctors I've met, who will actively ignore any evidence that doesn't fit their favourite diagnosis. Classic example: my partner was impaled through the leg in a workplace accident and had to go to the ER. The doctor declared that the wound was, in fact, a diabetic sore and that my partner had faked the accident to cover it up. Since the "diabetes" had reached the point of developing sores, he was prescribing insulin. However, the insurance company, "as a formality", insisted that he measure her blood sugar. After TWENTY blood tests came back with a perfectly healthy blood sugar level, he stuck with the diabetes diagnosis and just prescribed a different drug for it.
A runner up was a co-worker who WAS diabetic after a pancreatic infection. He later went to the doctor to complain about some knee pain. The doctor looked at the symptoms (e.g. joint paint, diabetes, shortness of breath) and diagnosed asymptomatic obesity. The "asymptomatic" part comes from the fact that my co-worker was built like David Bowie. However, the doctor declared that the remaining symptoms pointed towards obesity and that losing forty pounds would clear up all his issues.
A runner up was a co-worker who WAS diabetic after a pancreatic infection. He later went to the doctor to complain about some knee pain. The doctor looked at the symptoms (e.g. joint paint, diabetes, shortness of breath) and diagnosed asymptomatic obesity. The "asymptomatic" part comes from the fact that my co-worker was built like David Bowie. However, the doctor declared that the remaining symptoms pointed towards obesity and that losing forty pounds would clear up all his issues.
For reals. I have alpha and beta thalassemia minor. It causes funny bloodwork (namely, it looks like I'm anemic). When I first got my results, doctors wanted me to see an oncologist and cardiologist and do all these tests and procedures. I thought it was odd because my bloodwork had always come back this way, so I researched a bunch of conditions that could cause the numbers I had (because my numbers weren't quite conducive to cancer or heart problems either). Anyway, I realized after making lots of lists and ruling things out that I likely had mild thallassemia, and when I finally got tested, it turned out I did.
No surprise there given my ethnic background (which frankly should have been a dead giveaway, because thalassemias are not uncommon at all), but I saved myself from being put on iron supplementation which is already potentially dangerous for a man, but especially dangerous to someone with thalassemia.
No surprise there given my ethnic background (which frankly should have been a dead giveaway, because thalassemias are not uncommon at all), but I saved myself from being put on iron supplementation which is already potentially dangerous for a man, but especially dangerous to someone with thalassemia.
The closest we currently get to scientific method in medicine is via double-blind large randomized trials, which is not applicable for a single doctor's practice.
> In my experience, many people have a quasi-religious belief in the capability of modern medicine to perform what would otherwise be called a miracle. This belief is typically held without any evidence whatsoever.
Modern medical results would absolutely be viewed as a miracle to someone just a few decades back. Something like 90% of cancer cases are either cured or successfully suppressed (to the extent that the sufferer ends up dying of some other cause). Almost all endemic diseases have vaccines. Virtually no one dies of a bacterial infection today. Even most autoimmune disorders have effective treatments now.
The fact that there are problems yet to solve in medicine, and remaining voodoo in its practice, still doesn't change the fact that we're living in a miraculous age.
Modern medical results would absolutely be viewed as a miracle to someone just a few decades back. Something like 90% of cancer cases are either cured or successfully suppressed (to the extent that the sufferer ends up dying of some other cause). Almost all endemic diseases have vaccines. Virtually no one dies of a bacterial infection today. Even most autoimmune disorders have effective treatments now.
The fact that there are problems yet to solve in medicine, and remaining voodoo in its practice, still doesn't change the fact that we're living in a miraculous age.
> Something like 90% of cancer cases are either cured or successfully suppressed (to the extent that the sufferer ends up dying of some other cause).
This is not correct. It's true in the US for prostate cancer, which is one of the most notoriously treatable forms of cancer, but it's not true for cancer at large.
(It's also not true for prostate cancer in many other developed countries, which actually have a worse track record at treating cancer than the US does)
This is not correct. It's true in the US for prostate cancer, which is one of the most notoriously treatable forms of cancer, but it's not true for cancer at large.
(It's also not true for prostate cancer in many other developed countries, which actually have a worse track record at treating cancer than the US does)
90% of cancer cases are cured or suppressed? I have to call BS. Cancer is the number two cause of death in the US.
UK data from 2010-2011:
"Half (50%) of people diagnosed with cancer in England and Wales survive their disease for ten years or more" [0]
Since lots of cancers and lots of deaths are in old people, 10 year survival is quite a high bar.
[0] https://www.cancerresearchuk.org/health-professional/cancer-...
"Half (50%) of people diagnosed with cancer in England and Wales survive their disease for ten years or more" [0]
Since lots of cancers and lots of deaths are in old people, 10 year survival is quite a high bar.
[0] https://www.cancerresearchuk.org/health-professional/cancer-...
> "Half (50%) of people diagnosed with cancer in England and Wales survive their disease for ten years or more" [0]
Lumping all forms of cancer together is misleading, because cancers have dramatically different mortality rates. You need to separate by type of cancer, or else you're really just measuring the relative prevalence of different cancers.
As it turns out, the UK has a relatively low survival rate of cancers compared to other developed countries, including the US.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6...
Lumping all forms of cancer together is misleading, because cancers have dramatically different mortality rates. You need to separate by type of cancer, or else you're really just measuring the relative prevalence of different cancers.
As it turns out, the UK has a relatively low survival rate of cancers compared to other developed countries, including the US.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6...
That just goes to show how unfair the medical system there is. Not everyone can afford treatment, and those who cannot are already otherwise more at risk due to the affordability of processed foods imposing unhealthy ”lifestyle choices” as well as downright hazardous living and working conditions.
> That just goes to show how unfair the medical system there is. Not everyone can afford treatment, and those who cannot are already otherwise more at risk due to the affordability of processed foods imposing unhealthy ”lifestyle choices” as well as downright hazardous living and working conditions.
I get that this explanation fits with a common preconception of the US, but it doesn't bear out in reality. The US has a higher survival rate for all common types of cancer than all other developed countries, and this has been consistently the case for the last three decades.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6...
I get that this explanation fits with a common preconception of the US, but it doesn't bear out in reality. The US has a higher survival rate for all common types of cancer than all other developed countries, and this has been consistently the case for the last three decades.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6...
> Even most autoimmune disorders have effective treatments now.
As someone who has autoimmune diseases, you must be getting your information from a source I'm not familiar with. Auto-immune disease are a long game of guess, test, and adjust.
As someone who has autoimmune diseases, you must be getting your information from a source I'm not familiar with. Auto-immune disease are a long game of guess, test, and adjust.
Evidence based is good if you can get it. If not things that are suspected or even experimenting with your own body is worth it.
For example if there is no evidence that a better diet or reducing EMF or strength exercise or drinking pure water etc. will help your condition but there is no harm and fairly low cost to try.
Stay sceptical and open minded too.
For example if there is no evidence that a better diet or reducing EMF or strength exercise or drinking pure water etc. will help your condition but there is no harm and fairly low cost to try.
Stay sceptical and open minded too.
We have miracle cures for many things, but medicine is worse than ever.
I grew up with ER doctors. There are dozens of things that would have killed you on 1990 that you’ll walk away from today.
But in the slow transition from a professional discipline to a sort of IT help desk for health delivery, billing comes first, and even that sucks.
I grew up with ER doctors. There are dozens of things that would have killed you on 1990 that you’ll walk away from today.
But in the slow transition from a professional discipline to a sort of IT help desk for health delivery, billing comes first, and even that sucks.
My impression of the medical system (both here in Germany, and through reports from the US) is that it's very much like everything else: much is crap, much is mediocre, some good, and a very small, excellent sliver.
This goes for doctors, drugs, surgeries, devices.
If you want good results, you really have to take matters into your own hands, search for possible treatments yourself, evaluate several doctors until you find a competent one, research possible adverse side effects yourself etc.
Example: somebody in my family had two different surgeries by non-standard methods that gave her significant advantages over the regular methods; one of them offered (to our knowledge) in only one hospital in Germany, the other in three. In both cases her regular doctors didn't know about these methods, and were really surprised to hear about them afterwards. In both cases, she learned about these methods through some non-medical channel (a relative read about it in a newspaper, stuff like that).
If you just go to the next specialist for the field you need, chances are you don't get the optimal treatment, and the rarer the disease, the less like you get a good treatment.
This goes for doctors, drugs, surgeries, devices.
If you want good results, you really have to take matters into your own hands, search for possible treatments yourself, evaluate several doctors until you find a competent one, research possible adverse side effects yourself etc.
Example: somebody in my family had two different surgeries by non-standard methods that gave her significant advantages over the regular methods; one of them offered (to our knowledge) in only one hospital in Germany, the other in three. In both cases her regular doctors didn't know about these methods, and were really surprised to hear about them afterwards. In both cases, she learned about these methods through some non-medical channel (a relative read about it in a newspaper, stuff like that).
If you just go to the next specialist for the field you need, chances are you don't get the optimal treatment, and the rarer the disease, the less like you get a good treatment.
Can you share what surgery advances these were specifically? I'm really curious.
One was a minimally-invasive surgery that removes old pace maker cables attached to the heart. The alternative would have been to cut up the sternum for a regular open heart surgery. Which is both more taxing on the circulatory system, and takes about half a year to fully heal again.
The other was a "tissue engineered" heart valve. They take a human donor valve, and over the course of a few weeks remove the human cells in some kind of soap bath, only the collagen matrix remains. This reduces rejection to basically zero, and allows the patient to live without immune suppressants for the rest of their lives.
Alternatives would be a regular human valve (+ immune suppressants indefinitely), animal valves (same problem) or artificial valve (typically don't last for longer than 10 years, and always has increased risk of persistent settlement with bacteria, so need to take antibiotics for every minor thing).
(sorry, medical English is really hard for me, hope this makes sense; if not, feel free to ask).
The other was a "tissue engineered" heart valve. They take a human donor valve, and over the course of a few weeks remove the human cells in some kind of soap bath, only the collagen matrix remains. This reduces rejection to basically zero, and allows the patient to live without immune suppressants for the rest of their lives.
Alternatives would be a regular human valve (+ immune suppressants indefinitely), animal valves (same problem) or artificial valve (typically don't last for longer than 10 years, and always has increased risk of persistent settlement with bacteria, so need to take antibiotics for every minor thing).
(sorry, medical English is really hard for me, hope this makes sense; if not, feel free to ask).
Robot?
This is the reason why the US system is better than Canada. In Canada you can't shop around and need referrals for specialists.
You can find the best medical care in the world in the US if you have the means to pay for it. I don't think people will agree though that it is the indicator for the best healthcare system.
I would even say that any person of any country with enough financial resources could afford and get the best treatment in whatever country of the world would happen to be offered.
That involves flying to the US in many cases
And flying out of the US in most cases.
Indeed, I have just realized that the main problem of the US healthcare system is that their inhabitants cannot even imagine that anything better even exists.
Healthcare is much more than being operated or receiving some treatment for a rare condition, both things that are very much researched and done outside the US both privately and with public money. Healthcare is also about allowing people with health problems to live with dignity and allow then to function in society. To care for the weak and not only to restore productivity of a broken cog. Healthcare is about a strong first line of care that prevent conditions to get worse and irreparable. Many countries with a thousand or less of US's GDP can teach a lesson or two on that. In any case, most countries are slowly copying many aspects of US healthcare, I guess it must be indeed be better, or perhaps more profitable.
Healthcare is much more than being operated or receiving some treatment for a rare condition, both things that are very much researched and done outside the US both privately and with public money. Healthcare is also about allowing people with health problems to live with dignity and allow then to function in society. To care for the weak and not only to restore productivity of a broken cog. Healthcare is about a strong first line of care that prevent conditions to get worse and irreparable. Many countries with a thousand or less of US's GDP can teach a lesson or two on that. In any case, most countries are slowly copying many aspects of US healthcare, I guess it must be indeed be better, or perhaps more profitable.
IIUC the vast majority of Americans don't have that privilege either and need referrals. You have to be on more expensive health plans to be able to pick your specialist. (That's been my past experience with HMOs). I finally got on a PPO recently and it was a bizarre but pleasant experience to just ... refer myself to a specialist :)
Canada is indeed very frustrating. It's great for simple things like a broken arm. But the reality is that it's years behind in treatment of complex illnesses. There are a lot of people in Canada that travel to US to see specialists, when they can afford.
US is also able to attract the best professionals, including MDs. Here in Canada we're left with the "leftovers". Those that did not make it big in life.
US is also able to attract the best professionals, including MDs. Here in Canada we're left with the "leftovers". Those that did not make it big in life.
I think you can shop around in Canada, if you have private insurance. the universal healthcare system is just a baseline, to keep people from dying on the street after medical bankruptcy. many jobs offer supplementary health insurance as a benefit.
the US just uses ERs as an infinitely shittier but equally costly version.
the US just uses ERs as an infinitely shittier but equally costly version.
You can't book an appointment directly with a specialist.
You can't even shop around for a family doctor. You have to sell them accepting you as a patient. With that power inbalance you better follow what they suggest and avoid questioning too much or you won't have a doctor.
You can't even shop around for a family doctor. You have to sell them accepting you as a patient. With that power inbalance you better follow what they suggest and avoid questioning too much or you won't have a doctor.
I've had the same experience with non-HMO coverage in the US.
With HMO's, you're guaranteed someone will be assigned to you. With traditional insurance, there's a big labor shortage, and there are often <= 1 doctors accepting patients in some towns.
With HMO's, you're guaranteed someone will be assigned to you. With traditional insurance, there's a big labor shortage, and there are often <= 1 doctors accepting patients in some towns.
Wealthy Canadians tend to just come to the US in order to skip the waiting lines.
Why can't you shop around? You aren't forced to go to a specific doctor. It certainly might be challenging but that's also the case in the USA.
You have a family doctor who you are signed up with. You can't signup with another without losing your family doctor. You can't just go see any doctor. They have to decide to take you. Then if you are lucky you get a referral for a year later. You do have places you can walk in but there ability to refer is much lower.
In the USA you literally shop around. They advertise. You can literally look for the best surgeon and ask around.
In the USA you literally shop around. They advertise. You can literally look for the best surgeon and ask around.
How do you find the "best" surgeon in the US? There is massive information asymmetry, and little repeat business, so it is a perfect market for lemons.
I guess I don't see why your family doctor won't be open to referring you to another specialist. My experience was probably not normal in Canada since my parents are doctors.
> OTC medicines that by current standards would not be made OTC
Acetaminophen would almost certainly be in this category, if it could even get FDA approval at all. The effective dose is dangerously close to a toxic dose that causes liver damage, and not comfortably-far from the LD50. The only reasons acetaminophen is OTC is that it's been informally grandfathered in, makes an absolute fortune for pharmaceutical companies, and doesn't get you high.
Acetaminophen would almost certainly be in this category, if it could even get FDA approval at all. The effective dose is dangerously close to a toxic dose that causes liver damage, and not comfortably-far from the LD50. The only reasons acetaminophen is OTC is that it's been informally grandfathered in, makes an absolute fortune for pharmaceutical companies, and doesn't get you high.
> doesn't get you high.
this is the big one. Phenyl-epinephrine doesn't work at all, it's consistently failed to outperform placebo, and the only reason it's on the market is because the FDA doesn't like pseudo-ephedrine (sudafed) because it can be used as a precursor for meth. Same reason they've required individual blister packs for sudafed (if only there was some illicit drug which gave you the focus and drive to perform repetitive tasks for hours on end...)
Same thing for imodium. The reason all of a sudden it's in blister packs? People found a way to abuse it and the FDA is going to ruin it for the rest of us.
In the case of acetaminophen, the FDA actively uses it as a poison to "discourage" addicts from taking large doses of painkillers or cough syrup. The point is explicitly that if you take too much, you'll burn out your liver, the FDA is actively inserting poison into the medicine to "discourage abuse".
In all of these cases, the common factor is that it makes things much more annoying or even dangerous/lethal for average people, while addicts are completely unaffected. No opiate addict in the world is going to get clean because of individual pill blister packaging. Meth addicts will just pop some pills and churn through the sudafed blister packaging, etc.
I am waiting for the other shoe to drop on imodium, now that the FDA is targeting it, it can't be too long until it's behind the counter or pulled entirely. And as someone who (TMI warning) suffers from what I'd term as moderately frequent IBS (never diagnosed but maybe I should) that's really going to suck for me.
The FDA is simply an instrument of drug-war policy, they're not oriented towards patient care and outcomes at all.
this is the big one. Phenyl-epinephrine doesn't work at all, it's consistently failed to outperform placebo, and the only reason it's on the market is because the FDA doesn't like pseudo-ephedrine (sudafed) because it can be used as a precursor for meth. Same reason they've required individual blister packs for sudafed (if only there was some illicit drug which gave you the focus and drive to perform repetitive tasks for hours on end...)
Same thing for imodium. The reason all of a sudden it's in blister packs? People found a way to abuse it and the FDA is going to ruin it for the rest of us.
In the case of acetaminophen, the FDA actively uses it as a poison to "discourage" addicts from taking large doses of painkillers or cough syrup. The point is explicitly that if you take too much, you'll burn out your liver, the FDA is actively inserting poison into the medicine to "discourage abuse".
In all of these cases, the common factor is that it makes things much more annoying or even dangerous/lethal for average people, while addicts are completely unaffected. No opiate addict in the world is going to get clean because of individual pill blister packaging. Meth addicts will just pop some pills and churn through the sudafed blister packaging, etc.
I am waiting for the other shoe to drop on imodium, now that the FDA is targeting it, it can't be too long until it's behind the counter or pulled entirely. And as someone who (TMI warning) suffers from what I'd term as moderately frequent IBS (never diagnosed but maybe I should) that's really going to suck for me.
The FDA is simply an instrument of drug-war policy, they're not oriented towards patient care and outcomes at all.
What makes you say the FDA is actively adding poison to other drugs, are there first hand sources from them? This sounds like it could also be a case where they want to lower opiate consumption, and so adding some Tylenol increases pain relief without increasing opiate intake.
I am not sure that’s wise policy, but if you don’t think Tylenol is all that bad (again, I’m not sufficiently informed to say this, but the FDA obviously thinks it’s safe), then it’s not a bad overall policy.
It sounds like it could be either situation, I’m just looking for more evidence before making up my mind. (Yes, I am aware the US government poisoned people during prohibition in this exact manner, but I dispute that has any relevance as the decision makers and cultural awareness is very different now. We’ve come a long way since the 30s)
I am not sure that’s wise policy, but if you don’t think Tylenol is all that bad (again, I’m not sufficiently informed to say this, but the FDA obviously thinks it’s safe), then it’s not a bad overall policy.
It sounds like it could be either situation, I’m just looking for more evidence before making up my mind. (Yes, I am aware the US government poisoned people during prohibition in this exact manner, but I dispute that has any relevance as the decision makers and cultural awareness is very different now. We’ve come a long way since the 30s)
Why can you go to the store and buy rubbing alcohol to drink? It’s primary ingredient is just ethanol. The FDA literally mandates that the ethanol is not able to be safely consumed and is cut with poison that is not easily separated from ethanol.
Similarly, cutting opioids with Tylenol is not actually intended to be a deterrent to someone who gets their hands on the pills rather it deters people involved with illicit drug manufacture and distribution from using it as a base to grind up and sell.
Tylenol is really not super safe, at least by todays approval standards. Most official sources, which unsurprisingly have a huge bias towards Tylenol’s safety, state that allergic reactions are very uncommon, but recent meta-analysis’ are beginning to uncover that mild to moderate allergic reactions to acetaminophen is more common that originally thought. It does not get reported because if you’re already feeling like crap when you take it, some mild itchiness, redness, and discomfort would not be out of the ordinary without the Tylenol. As mentioned before, the toxic dose is much too close to the effective dose, I’ve heard from medical professionals that doubling a single recommended dose on extra strength Tylenol is enough to cause long-term damage to your liver. On top of all that, the fact that it is a weak pain reliever at best would solidly put this as a drug that’s not super useful.
I have a very low opinion of how we go about drug policy in the US. I am on a very controlled medication due to a sleep disorder (that causes hypersomnia) which I cannot go off for safety reasons. I also cannot get it filled more than 24 in advance without complicated authorization procedures that must be completed in the correct order. It’s a goddamn mess and serves only as a punishment to law-abiding patients for needing this medication. It also does nothing to curb illicit use because synthesis of a more potent product is so trivial.
This is an example of poorly targeted legislation, which was put into place because it’s the only thing they could exert control over. It does not further the stated goals of drug enforcement because it’s so easy to manufacture this stuff and the resulting product is so easy to move, bad actors can simply avoid this system. While I’m spending 3 hours every month orchestrating the complicated dance of my prescription between my providers, the pharmacy, and my insurance, someone is making a batch of shake-and-bake meth in about 3 minutes.
Similarly, cutting opioids with Tylenol is not actually intended to be a deterrent to someone who gets their hands on the pills rather it deters people involved with illicit drug manufacture and distribution from using it as a base to grind up and sell.
Tylenol is really not super safe, at least by todays approval standards. Most official sources, which unsurprisingly have a huge bias towards Tylenol’s safety, state that allergic reactions are very uncommon, but recent meta-analysis’ are beginning to uncover that mild to moderate allergic reactions to acetaminophen is more common that originally thought. It does not get reported because if you’re already feeling like crap when you take it, some mild itchiness, redness, and discomfort would not be out of the ordinary without the Tylenol. As mentioned before, the toxic dose is much too close to the effective dose, I’ve heard from medical professionals that doubling a single recommended dose on extra strength Tylenol is enough to cause long-term damage to your liver. On top of all that, the fact that it is a weak pain reliever at best would solidly put this as a drug that’s not super useful.
I have a very low opinion of how we go about drug policy in the US. I am on a very controlled medication due to a sleep disorder (that causes hypersomnia) which I cannot go off for safety reasons. I also cannot get it filled more than 24 in advance without complicated authorization procedures that must be completed in the correct order. It’s a goddamn mess and serves only as a punishment to law-abiding patients for needing this medication. It also does nothing to curb illicit use because synthesis of a more potent product is so trivial.
This is an example of poorly targeted legislation, which was put into place because it’s the only thing they could exert control over. It does not further the stated goals of drug enforcement because it’s so easy to manufacture this stuff and the resulting product is so easy to move, bad actors can simply avoid this system. While I’m spending 3 hours every month orchestrating the complicated dance of my prescription between my providers, the pharmacy, and my insurance, someone is making a batch of shake-and-bake meth in about 3 minutes.
> Why can you go to the store and buy rubbing alcohol to drink? It’s primary ingredient is just ethanol.
AFAIK most/all rubbing alcohol (at least that which is sold in the US) is isopropanol, not ethanol. You can buy ethanol in not-for-consumption form, as denatured alcohol.
AFAIK most/all rubbing alcohol (at least that which is sold in the US) is isopropanol, not ethanol. You can buy ethanol in not-for-consumption form, as denatured alcohol.
And it’s chemistry that forces the additional benzene in denatured alcohol. Water- ethanol forms an Azeotrope at 95% ethanol. Benzene is added to break the azeotrope and get to 99.99% ethanol. Chemistry not a conspiracy
No one is selling 99.99% grade alcohol as an antiseptic in the US. Its usually 70%.
There are additives in ethanol sold as an antiseptic to discourage drinking (various bitterants, not benzene).
There are additives in ethanol sold as an antiseptic to discourage drinking (various bitterants, not benzene).
No one is selling 70% ethanol as an antiseptic, it's isopropyl alcohol. Those additives in ethanol not intended for consumption are 8 parts acetone and 1.5 parts methyl isobutyl ketone to 100 parts ethanol. There are some rare ethanol based rubbing alcohols sold but the vast majority is isopropyl because it's not just denatured with bitterants, they add toxic substances as well.
Here's the actual formula they have to use that's enshrined in the law. https://www.law.cornell.edu/cfr/text/27/21.49
Here's the actual formula they have to use that's enshrined in the law. https://www.law.cornell.edu/cfr/text/27/21.49
Ethanol as an antiseptic is less common, but its definitely a thing: https://www.amazon.com/Amazon-Brand-Rubbing-Alcohol-Antisept...
Its general sold as "ethyl alcohol" not ethanol, but its the same thing.
Its general sold as "ethyl alcohol" not ethanol, but its the same thing.
California apparently banned denatured alcohol because of the VOC content.
I accidentally found a gray market source before discovering it is banned. Makes me wonder why they still bother denaturing it.
I accidentally found a gray market source before discovering it is banned. Makes me wonder why they still bother denaturing it.
The ethanol with methanol additive ("Denatured Alcohol") is a tax issue as well. Government wants to tax consumed ethanol.
Rubbing alcohol where I am is isopropyl alcohol (which is highly toxic -- your body metabolizes it into acetone), not ethanol. A kid in my high school class ended up getting his stomach pumped when drinking it to try to get drunk.
What makes you say the FDA is actively adding poison to other drugs, are there first hand sources from them?
"Not everyone thought it was a good idea to make alcohol deadly, when making it illegal hadn’t stopped drinkers, and New Jersey Senator Edward I. Edwards called it “legalized murder.” However, the Anti-Saloon League persisted, arguing that legal alcohol had killed many more in its day than denatured alcohol would kill during the transition to a teetotaling world. “The Government is under no obligation to furnish the people with alcohol that is drinkable when the Constitution prohibits it,” said advocate Wayne B. Wheeler. “The person who drinks this industrial alcohol is a deliberate suicide… To root out a bad habit costs many lives and long years of effort…”"
https://time.com/3665643/deadly-drinking/
"Not everyone thought it was a good idea to make alcohol deadly, when making it illegal hadn’t stopped drinkers, and New Jersey Senator Edward I. Edwards called it “legalized murder.” However, the Anti-Saloon League persisted, arguing that legal alcohol had killed many more in its day than denatured alcohol would kill during the transition to a teetotaling world. “The Government is under no obligation to furnish the people with alcohol that is drinkable when the Constitution prohibits it,” said advocate Wayne B. Wheeler. “The person who drinks this industrial alcohol is a deliberate suicide… To root out a bad habit costs many lives and long years of effort…”"
https://time.com/3665643/deadly-drinking/
This makes me wonder if it would have been possible to, instead of using something that causes significant harms to health, instead something which just causes a rather unpleasant experience.
But, I guess one important thing is whether such an additive is compatible with the altered substance still being usable for the purpose for which it is being made available.
Now, presumably something as simple as “dissolve large amounts of capsaicin in it” wouldn’t work (I’m not even sure if capsaicin can be dissolved in alcohol), but, what about something along those lines? Or something that just causes headaches, or vomiting?
But, I guess one important thing is whether such an additive is compatible with the altered substance still being usable for the purpose for which it is being made available.
Now, presumably something as simple as “dissolve large amounts of capsaicin in it” wouldn’t work (I’m not even sure if capsaicin can be dissolved in alcohol), but, what about something along those lines? Or something that just causes headaches, or vomiting?
During prohibition, the government tried things along those lines, as well as basically any poisonous or unpleasant chemical they could get their hands on. However, the problem was that anything not sufficiently alcohol-like could be pretty easily distilled out by bootleggers. What was much harder to distill out was large quantities of exceptionally-poisonous methanol.
Nowadays, of course, alcohol is cheap and plentiful enough that there's no incentive to re-nature it, and we can get away with much less extreme measures. In many cases, the alcohol won't contain any methanol at all, and may even be drinkable.
A good article on the government's arms race against bootlegging: https://slate.com/technology/2010/02/the-little-told-story-o... (also, the author's book "The Poisoner's Handbook")
Nowadays, of course, alcohol is cheap and plentiful enough that there's no incentive to re-nature it, and we can get away with much less extreme measures. In many cases, the alcohol won't contain any methanol at all, and may even be drinkable.
A good article on the government's arms race against bootlegging: https://slate.com/technology/2010/02/the-little-told-story-o... (also, the author's book "The Poisoner's Handbook")
They already add a bittering agent to ethanol when it's sold as a disinfectant. It's not toxic, just very unpleasant
Not true, they add a bitterant but if it's in the US they're still required to add acetone and methyl isobutyl ketone as well.
https://www.law.cornell.edu/cfr/text/27/21.49
That formula clearly spells out rubbing alcohol and disinfectants under the authorized uses. It's toxic and unpleasant.
https://www.law.cornell.edu/cfr/text/27/21.49
That formula clearly spells out rubbing alcohol and disinfectants under the authorized uses. It's toxic and unpleasant.
Woah! I think it's different here in canada then.
I think that's what they ended up doing, post-Prohibition. A bottle of rubbing alcohol from the drugstore is either isopropyl alcohol, which is toxic by itself but not intentionally so, or ethanol mixed with a denaturing agent that's more benign than methanol or whatever they were using back in the day.
Different denaturants for different purposes.
Choose your poison:
27 CFR § 21.151 - List of denaturants authorized for denatured spirits. https://www.law.cornell.edu/cfr/text/27/21.151
Choose your poison:
27 CFR § 21.151 - List of denaturants authorized for denatured spirits. https://www.law.cornell.edu/cfr/text/27/21.151
Look up DXM.
You will never find it without either Gualfenisin or acetaminophen.
Does DXM need either of those to do what it does?
No.
Would it simplify dosing to be sold alone so that laymen didn't have to worry about potentially overdosing on three drugs at once instead of just one?
Yes.
However, from the war on drugs perspective, that makes it "easier to abuse" to achieve it's hallucinogenic side effect. Bundled with acetaminophen or gualfenisin however, you'd have to be a chemist intimately familiar with how to seperate the other two components to distill DXM in any amount with abuse potential, and the naive non-chemist trying to get high will either end up puking their guts out (Gualfenisin OD) or burning out their liver (Tylenol OD, which is exacerbated by alcohol consumption as well).
The Tylenol one is particularly problematic, because acetaminophen is also commonly prescribed with other common multi-drug formulations that people may not realize are additive.
When you take the route of adding a substance that does harm to discourage a pattern of behavior, you are poisoning. Poisoning being the act of artificially and with intent increasing the toxicity of an imbibed substance to disincent some pattern of behavior.
This is actually based on a natural pattern of behavior by the way. There is a mushroom that is generally completely harmless... Until you drink alcohol. Metabolizing the mushroom depletes the supply of the same enzymes that detoxify alcohol (and Tylenol).
https://en.m.wikipedia.org/wiki/Coprinopsis_atramentaria
So to be clear... If you call this mushroom poisonous, and it targets the same enzyme that alcohol does, then adding something like tylenol to something that doesn't need it to do it's job, you are poisoning.
It just happens to be handwaved because in the establishment's mind, those damn druggies aren't worth caring about anyway.
Not a partaker of DXM, but very concerned with the ethical implications, and the adverse contribution to trust in public health measures that this practice entails.
You will never find it without either Gualfenisin or acetaminophen.
Does DXM need either of those to do what it does?
No.
Would it simplify dosing to be sold alone so that laymen didn't have to worry about potentially overdosing on three drugs at once instead of just one?
Yes.
However, from the war on drugs perspective, that makes it "easier to abuse" to achieve it's hallucinogenic side effect. Bundled with acetaminophen or gualfenisin however, you'd have to be a chemist intimately familiar with how to seperate the other two components to distill DXM in any amount with abuse potential, and the naive non-chemist trying to get high will either end up puking their guts out (Gualfenisin OD) or burning out their liver (Tylenol OD, which is exacerbated by alcohol consumption as well).
The Tylenol one is particularly problematic, because acetaminophen is also commonly prescribed with other common multi-drug formulations that people may not realize are additive.
When you take the route of adding a substance that does harm to discourage a pattern of behavior, you are poisoning. Poisoning being the act of artificially and with intent increasing the toxicity of an imbibed substance to disincent some pattern of behavior.
This is actually based on a natural pattern of behavior by the way. There is a mushroom that is generally completely harmless... Until you drink alcohol. Metabolizing the mushroom depletes the supply of the same enzymes that detoxify alcohol (and Tylenol).
https://en.m.wikipedia.org/wiki/Coprinopsis_atramentaria
So to be clear... If you call this mushroom poisonous, and it targets the same enzyme that alcohol does, then adding something like tylenol to something that doesn't need it to do it's job, you are poisoning.
It just happens to be handwaved because in the establishment's mind, those damn druggies aren't worth caring about anyway.
Not a partaker of DXM, but very concerned with the ethical implications, and the adverse contribution to trust in public health measures that this practice entails.
Interesting.
First off: Amazon is NOT my first choice for a source of pharmaceutical. Period.
Second, spin through the comments. Quoted below is an example of exactly what I'm talking about:
>Active ingredient is dextromethorphan. This blocks cough receptors in the brain. Got a cough? Get this!
>2. No extra ingredients. It’s so hard to find pure medicines just for cough. Store shelves are littered with bundled products for all sorts of symptoms. I don’t like taking a bunch of unnecessary meds, so I buy single symptom products like this.
8<---
>Finally, these gels are only sold in some stores. Shelf space is limited, so they rather carry heavily advertised, bundled meds that pay bigger margins. But they are here at Amazon for a great price!
8<---
Point there being, you've got a system where being able to acquire unadulterated formulations of a substance is the exception rather than the norm.
If you look through drug applications or filings with FDA, you will find that many pharmaceutical companies favor highlighting "abuse-resistant" formulations of combo drugs, while downplaying potential harms and that marketshare of the pure drug decreases after an approval of a combo drug is achieved.
I have started to pay more attention to this sort of thing since they started toying with doing the same thing on stuff I take. I can see a blatant flex of incentive shaping when I see it, and frankly, I disagree with it.
Very vocally.
First off: Amazon is NOT my first choice for a source of pharmaceutical. Period.
Second, spin through the comments. Quoted below is an example of exactly what I'm talking about:
>Active ingredient is dextromethorphan. This blocks cough receptors in the brain. Got a cough? Get this!
>2. No extra ingredients. It’s so hard to find pure medicines just for cough. Store shelves are littered with bundled products for all sorts of symptoms. I don’t like taking a bunch of unnecessary meds, so I buy single symptom products like this.
8<---
>Finally, these gels are only sold in some stores. Shelf space is limited, so they rather carry heavily advertised, bundled meds that pay bigger margins. But they are here at Amazon for a great price!
8<---
Point there being, you've got a system where being able to acquire unadulterated formulations of a substance is the exception rather than the norm.
If you look through drug applications or filings with FDA, you will find that many pharmaceutical companies favor highlighting "abuse-resistant" formulations of combo drugs, while downplaying potential harms and that marketshare of the pure drug decreases after an approval of a combo drug is achieved.
I have started to pay more attention to this sort of thing since they started toying with doing the same thing on stuff I take. I can see a blatant flex of incentive shaping when I see it, and frankly, I disagree with it.
Very vocally.
You can also pick it up at your local Walgreens (https://www.walgreens.com/store/c/walgreens-wal-tussin-cough...) or CVS (https://www.cvs.com/shop/cvs-health-tussin-cough-liquid-gels...) if you prefer. Maybe your area has some regulations restricting access, but it's not a nationwide thing. It's just sitting on the shelf next to all the other cough medicines in mine.
I agree with you Amazon is not the best place to get pharmaceutical products and "abuse-resistant" formulations are effectively murder targeted at the most vulnerable. They are practically eugenicist in nature.
When I was much younger I had a bit of an adventurous spirit and never had problems finding pure DXM on the shelf. The issue I ran into most often was it was a frequent target for shoplifters so the name brand gel caps would often be out of stock. Usually you could find the generic store brand version though. Delsym was almost always available. The extended release may or may not be desirable depending on how long you want to trip, but IIRC you could just mix it with something acidic like orange juice to dissolve it and make it instant release. Just anecdotal I know, but that was my experience.
When I was much younger I had a bit of an adventurous spirit and never had problems finding pure DXM on the shelf. The issue I ran into most often was it was a frequent target for shoplifters so the name brand gel caps would often be out of stock. Usually you could find the generic store brand version though. Delsym was almost always available. The extended release may or may not be desirable depending on how long you want to trip, but IIRC you could just mix it with something acidic like orange juice to dissolve it and make it instant release. Just anecdotal I know, but that was my experience.
Dextromethorphan HBr? It's definitely sold on its own in the US.
I also wonder where the idea that the FDA 'denatures' hydrocodone with acetaminophen comes from. AFAICT, if you overdose on vicodin it's more likely the hydrocodone will kill you before the acetaminophen.
This is entirely false.
You can overdose from ~4 grams of APAP which you can ingest by taking 6 7.5/750 hydrocodone/APAP tablets
That's not nearly enough hydrocodone to kill you
You can overdose from ~4 grams of APAP which you can ingest by taking 6 7.5/750 hydrocodone/APAP tablets
That's not nearly enough hydrocodone to kill you
That seems low -- 4 grams is the max daily dose for OTC acetaminophen.
According to this [1] the minimum single dose toxicity for APAP is more like 7.5 to 12 grams. Finding a value for a lethal hydrocodone dose is more difficult, but I did see 90 mg mentioned.
For the dose of Vicodin you specified, 90mg of hydrocodone would correspond to 9 grams of APAP. So it's a race that it looks like either one could win.
[1] https://www.uspharmacist.com/article/acetaminophen-intoxicat...
According to this [1] the minimum single dose toxicity for APAP is more like 7.5 to 12 grams. Finding a value for a lethal hydrocodone dose is more difficult, but I did see 90 mg mentioned.
For the dose of Vicodin you specified, 90mg of hydrocodone would correspond to 9 grams of APAP. So it's a race that it looks like either one could win.
[1] https://www.uspharmacist.com/article/acetaminophen-intoxicat...
>The United States FDA clearly states “severe liver damage may occur if you take more than 4000 mg of acetaminophen in 24 hours.”
>There is no question that the upper threshold on the maximum daily allowed dose of APAP has been the subject of controversy.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4913076/
>There is no question that the upper threshold on the maximum daily allowed dose of APAP has been the subject of controversy.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4913076/
The difference is you can build a tolerance to opioids, so the LD of hydrocodone in an addict (or even just someone using for an extended period medically) will be FAR higher than in an opiod-naive person.
Opioids kill via respiratory depression, not by destroying your organs.
Opioids kill via respiratory depression, not by destroying your organs.
[deleted]
Not sure I understand what you're saying about blister packaging? Are there drugs that don't come in blister packaging in the US?
Here all I can think about are the paracetamol/acetaminophen effervescent tablets that come in tubes of 8 x 1g (or 16 x 500mg).
Here all I can think about are the paracetamol/acetaminophen effervescent tablets that come in tubes of 8 x 1g (or 16 x 500mg).
There are drugs that come just in bottles: the typical OTC pain relievers (acetaminophen/paracetamol, ibuprofen, etc.) are all offered this way and you can easily buy bottles containing hundreds of pills. And of course there are others.
Prescription drugs are pretty routinely dispensed in just pill bottles also, though I'm sure there are some for which this isn't allowed.
Prescription drugs are pretty routinely dispensed in just pill bottles also, though I'm sure there are some for which this isn't allowed.
I'm pretty sure there are also "degrees" of blister packaging too. You've got the ones that are just foil, you've got ones with a paper backing, and then you've got ones where I'm pretty sure the paper is glued to the foil so it's basically impossible to get it to separate and you have to cut it out with a knife.
The first doesn't really bother me. The last one is absolutely obnoxious. I'm guessing the FDA is pushing the last type for "drugs of concern" like sudafed or imodium.
The first doesn't really bother me. The last one is absolutely obnoxious. I'm guessing the FDA is pushing the last type for "drugs of concern" like sudafed or imodium.
oxy doesn't even come in blister packs here. at least not as of a few years ago, when i got it for spraining my ankle
You keep mentioning blister packs: I wish they were on all OTC drugs and many prescription drugs. On OTC drugs, I also support package size limits. These keep folks safer, lowering both accidental and intentional overdoses. I suspect that it taking longer to open and having a handy way to estimate what youve taken helps.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC31616/
There is plenty of cough syrup without acetaminophen sold in the US, by the way. People like all-in-one products, though, hence there being many with it in it. I'm gonna need some evidence for the "FDA actively uses it as a poison", though. I'm not so convinced a lot of folks think about side effects of tylenol but instead, see it as rather safe.
And it really doesn't matter if a few folks will find ways around an intervention. An improvement doesn't need to be perfect to be implemented nonetheless - because, it is an improvement and as such, better than before.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC31616/
There is plenty of cough syrup without acetaminophen sold in the US, by the way. People like all-in-one products, though, hence there being many with it in it. I'm gonna need some evidence for the "FDA actively uses it as a poison", though. I'm not so convinced a lot of folks think about side effects of tylenol but instead, see it as rather safe.
And it really doesn't matter if a few folks will find ways around an intervention. An improvement doesn't need to be perfect to be implemented nonetheless - because, it is an improvement and as such, better than before.
Umm... As you get older, you'll simultaneously need more pills and lose your ability to easily open blister packs.
A much better solution would be to have a robot pill dispenser that's hooked to the doctor's office, a pharmacy, and an alarm clock.
A much better solution would be to have a robot pill dispenser that's hooked to the doctor's office, a pharmacy, and an alarm clock.
"Umm... As you get older, you'll simultaneously need more pills and lose your ability to easily open blister packs."
That isn't really a feature of old age. Some folks have some issues, sure, and sure - it is more likely when you are older, but by no means is it a given nor is it necessarily tied to old age. There are simple solutions for that, like ordering easy-to-open packaging from the pharmacist (here, they would literally put it in plastic bags). Some pharmacies already help folks organize medicines and I don't see where this would be a real issue.
I'll also state that most folks shouldn't need to buy a robot to take simple medicines plus it is going to add an expense that a lot of folks couldn't afford. It doesn't seem to be a huge issue in countries with blister packs that are fairly standard - again, pharmacies are generally helpful.
That isn't really a feature of old age. Some folks have some issues, sure, and sure - it is more likely when you are older, but by no means is it a given nor is it necessarily tied to old age. There are simple solutions for that, like ordering easy-to-open packaging from the pharmacist (here, they would literally put it in plastic bags). Some pharmacies already help folks organize medicines and I don't see where this would be a real issue.
I'll also state that most folks shouldn't need to buy a robot to take simple medicines plus it is going to add an expense that a lot of folks couldn't afford. It doesn't seem to be a huge issue in countries with blister packs that are fairly standard - again, pharmacies are generally helpful.
How is this "dangerously close to toxic"? Extra strength is 500mg. Adults should not take more than 3000mg in a day. Taking 7000 more more can lead to liver problems.
https://medlineplus.gov/ency/article/002598.htm
Common dosage forms and strengths:
Suppository: 120 mg, 125 mg, 325 mg, 650 mg Chewable tablets: 80 mg Junior tablets: 160 mg Regular strength: 325 mg Extra strength: 500 mg Liquid: 160 mg/teaspoon (5 milliliters) Drops: 100 mg/mL, 120 mg/2.5 mL Adults should not take more than 3,000 mg of single-ingredient acetaminophen a day. You should take less if you are over 65 years old. Taking more, especially 7,000 mg or more, can lead to a severe overdose problems. If you have liver or kidney disease, you should discuss the use of this drug with your health care provider.
https://medlineplus.gov/ency/article/002598.htm
Common dosage forms and strengths:
Suppository: 120 mg, 125 mg, 325 mg, 650 mg Chewable tablets: 80 mg Junior tablets: 160 mg Regular strength: 325 mg Extra strength: 500 mg Liquid: 160 mg/teaspoon (5 milliliters) Drops: 100 mg/mL, 120 mg/2.5 mL Adults should not take more than 3,000 mg of single-ingredient acetaminophen a day. You should take less if you are over 65 years old. Taking more, especially 7,000 mg or more, can lead to a severe overdose problems. If you have liver or kidney disease, you should discuss the use of this drug with your health care provider.
Note that metabolism of drugs is roughly proportional to bodyweight. A petite 100 lb person may only need 200mg for an effective dose. An obese 400 lb person may require ~4x that dosage for the equivalent effect.
The one-size-fits-all drug dosing we do in this country seems crazy to me.
"Research Chemical" drug users have developed techniques to calibrate doses of substances with unknown potency - start with ~100th of what you expect to be an active dose and then gradually double it until proper effects are achieved.
I'd imagine it would be more expensive for pharmacies to distribute drugs in this way, but allowing patients to titrate their doses could significantly reduce/avoid negative side effects from just throwing the same standardized dose at every person with a prescription regardless of bodyweight.
The one-size-fits-all drug dosing we do in this country seems crazy to me.
"Research Chemical" drug users have developed techniques to calibrate doses of substances with unknown potency - start with ~100th of what you expect to be an active dose and then gradually double it until proper effects are achieved.
I'd imagine it would be more expensive for pharmacies to distribute drugs in this way, but allowing patients to titrate their doses could significantly reduce/avoid negative side effects from just throwing the same standardized dose at every person with a prescription regardless of bodyweight.
This is especially important when it comes to children. This is because kids vary in weight in relation to age more than adults do, but the vast majority of drugs are dosed by age. This is just insanity at it's finest.
Yep, and that's only using the rough metric of bodyweight. There are a number of other major factors like size and health of liver, whether the patient has any under/over expression of metabolic enzymes, etc that can further complicate the determination of proper dosage.
Would be super cool if we had an objective measure of proper dosage - such as blood concentration or excreted metabolites - to give us more insight into how the drug is being metabolized by the individual.
Would be super cool if we had an objective measure of proper dosage - such as blood concentration or excreted metabolites - to give us more insight into how the drug is being metabolized by the individual.
Is there any evidence that harm is being caused from age-based dosing?
My understanding is that acetaminophen toxicity has been a problem particularly for children, because 1) the toxic dose is lower, 2) many common OTC products for children include some amount of acetaminophen among their active ingredients and 3) parents may give their children multiple such products (one for runny nose, one for fever reduction, one for nighttime relief, etc.) over the course of a day and end up exceeding the safe dose, leading to liver toxicity. That was the situation a few years ago at least.
acetaminophen is often put in medications because it's toxic. It's there to dissuade people from *gasp* taking too much and possibly experiencing some positive feelings or enjoyment that offends the sensibilities of decision makers. Better that we destroy a few people's livers than that those people get a buzz. (to be clear, this last sentence is not my view. I'm mocking that view)
This is the one and only reason that Vicodin and Percocet exist. They don't want people getting high, so they're punishing them by trying to kill them. It's barbaric. Literally evil.
Edit: just to be clear, there are times when it might make sense to take oxycodone or hydrocodone alongside acetaminophen, but they should be prescribed separately and with caution. The reason they're combination drugs is because the toxicity is a "desirable" side-effect meant to discourage abuse. It's that reasoning that is evil.
Edit: just to be clear, there are times when it might make sense to take oxycodone or hydrocodone alongside acetaminophen, but they should be prescribed separately and with caution. The reason they're combination drugs is because the toxicity is a "desirable" side-effect meant to discourage abuse. It's that reasoning that is evil.
This also is silly, illegal drug users constantly take their dosages mixed with much worse things than Tylenol with no noticeable dissuasion effect that I am aware of. Acetaminophen is mixed with oxycodone etc bc it increases the pain relieving effect of the opiate drug (which for many people (e.g. me), are of limited effectiveness relative to the side effects/"buzz"), and because, unlike NSAIDs, it doesn't thin your blood so it can be taken after surgeries.
Having chronic pain sucks, having something that you can take for it, especially something boring like Tylenol that can't be snatched away from you by doctors/police/etc, is a huge quality of life issue.
Having chronic pain sucks, having something that you can take for it, especially something boring like Tylenol that can't be snatched away from you by doctors/police/etc, is a huge quality of life issue.
I don’t think anyone reasonable is actively arguing to delist Tylenol as OTC, rather we shouldn’t be so restrictive on these medications that can actually really help people. In addition we should be giving people resources for discontinuing use when they no longer need it.
Also, we need to really research the NSAIDS after surgery thing, afaik, there has been nothing super rigorous on it and is only going off of the common knowledge that they do thin blood. I do not like Tylenol and my partner is allergic, we’ve both broken the rule about nsaids post surgery.
Also, we need to really research the NSAIDS after surgery thing, afaik, there has been nothing super rigorous on it and is only going off of the common knowledge that they do thin blood. I do not like Tylenol and my partner is allergic, we’ve both broken the rule about nsaids post surgery.
Yes absolutely. I don't want to see Tylenol go away. I want more options, not less. I think as long as companies are being honest about the product they are selling, even if it's ineffective I think it should be available.
Well I was in the ER 2 days ago and my liver enzymes were bad. I don’t drink, he said it was the acetaminophen I’ve been taking. I had been taking significantly less than the recommended amount for less than a week.
(to be clear: not a doctor)
the "daily" recommended doses are for a single day. If you are taking it daily you need to at least halve the recommended dose. I wouldn't have said a week was a problem but... yeah. Tylenol is dangerous.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4913076/
Specifically this study referenced: https://jamanetwork.com/journals/jama/fullarticle/211014
> One study reported that ingestion of the recommended maximum amount of 4000 mg of APAP for 2 weeks resulted in the asymptomatic elevation of alanine transaminase, up to three times normal, in 40% of patients.19 These transaminase elevations did not amount to any clinical significance, and after the APAP was discontinued the transaminase levels returned to normal.19 Yet, while asymptomatic, chronically elevated aminotransferases may be of concern to healthcare providers, leading to further costly diagnostic studies or changes/restrictions in necessary medications
If anything the summary in that review is underselling it. Average was 2.78x baseline (3x is considered clinically significant) and 20% of the population was over 5x the peak (so, 20% had clinically significant elevations from the study). By peak levels, around 27% of the population saw peak levels of 8x baseline. So basically, even the "average" participant was almost to the threshold of clinical significance just from this study (at the recommended daily dose) and a cohort of around 20-25% will see clinically-significant warning signs at the recommended dosage, even among healthy patients. And risk factors significantly increase that.
That's basically a "liver stressor" enzyme, even if it's not killing the patients over the course of the study, it's not a good thing. That's your body's warning signal that it's stressed. And generally that's an uncontroversial finding I think, everyone agrees tylenol is a liver stressor, but they just have various thresholds of the acceptable risk. Would I do it daily? No.
And in med-speak, that's what they're saying here too. Use with caution, don't go above the recommended dosage in acute situations and use caution with chronic dosing. https://pubmed.ncbi.nlm.nih.gov/11847957/
Anyway, the rule of thumb I always heard is that half of the "daily" dose appears to be more appropriate for chronic daily usage. I am not a doctor and you can do whatever you want, but that is personally what I would hold to. Going less, or picking a different FDA-approved alternative like ibuprofen or aspirin, is always a perfectly acceptable choice.
That number appears to be reasonably supportable too. Instead of "half of our patients were over triple their baseline ALT level" this study found that 50% of the daily doage, chronically over 12 weeks, gets you to a 20% average increase in ALT levels. It's never not going to be a liver stressor and if you have other risk factors then you should probably stay away entirely (I think that's just good advice in general) but 20% increase in ALT after 12 weeks is a hell of a lot better than tripling your ALT in 2 weeks. But even then, during a 12-week study of 94 healthy adult patients, at half the recommended dose, they still had to withdraw one participant due to hepatotoxicity. https://pubmed.ncbi.nlm.nih.gov/25899926/
(as far as risk factors, see the first link above for a good review, aggravating factors for hepatoxicity can include things like non-alcoholic fatty liver or nutritional deficiency. Which basically describes an overweight computer-toucher with a poor diet to a tee.)
the "daily" recommended doses are for a single day. If you are taking it daily you need to at least halve the recommended dose. I wouldn't have said a week was a problem but... yeah. Tylenol is dangerous.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4913076/
Specifically this study referenced: https://jamanetwork.com/journals/jama/fullarticle/211014
> One study reported that ingestion of the recommended maximum amount of 4000 mg of APAP for 2 weeks resulted in the asymptomatic elevation of alanine transaminase, up to three times normal, in 40% of patients.19 These transaminase elevations did not amount to any clinical significance, and after the APAP was discontinued the transaminase levels returned to normal.19 Yet, while asymptomatic, chronically elevated aminotransferases may be of concern to healthcare providers, leading to further costly diagnostic studies or changes/restrictions in necessary medications
If anything the summary in that review is underselling it. Average was 2.78x baseline (3x is considered clinically significant) and 20% of the population was over 5x the peak (so, 20% had clinically significant elevations from the study). By peak levels, around 27% of the population saw peak levels of 8x baseline. So basically, even the "average" participant was almost to the threshold of clinical significance just from this study (at the recommended daily dose) and a cohort of around 20-25% will see clinically-significant warning signs at the recommended dosage, even among healthy patients. And risk factors significantly increase that.
That's basically a "liver stressor" enzyme, even if it's not killing the patients over the course of the study, it's not a good thing. That's your body's warning signal that it's stressed. And generally that's an uncontroversial finding I think, everyone agrees tylenol is a liver stressor, but they just have various thresholds of the acceptable risk. Would I do it daily? No.
And in med-speak, that's what they're saying here too. Use with caution, don't go above the recommended dosage in acute situations and use caution with chronic dosing. https://pubmed.ncbi.nlm.nih.gov/11847957/
Anyway, the rule of thumb I always heard is that half of the "daily" dose appears to be more appropriate for chronic daily usage. I am not a doctor and you can do whatever you want, but that is personally what I would hold to. Going less, or picking a different FDA-approved alternative like ibuprofen or aspirin, is always a perfectly acceptable choice.
That number appears to be reasonably supportable too. Instead of "half of our patients were over triple their baseline ALT level" this study found that 50% of the daily doage, chronically over 12 weeks, gets you to a 20% average increase in ALT levels. It's never not going to be a liver stressor and if you have other risk factors then you should probably stay away entirely (I think that's just good advice in general) but 20% increase in ALT after 12 weeks is a hell of a lot better than tripling your ALT in 2 weeks. But even then, during a 12-week study of 94 healthy adult patients, at half the recommended dose, they still had to withdraw one participant due to hepatotoxicity. https://pubmed.ncbi.nlm.nih.gov/25899926/
(as far as risk factors, see the first link above for a good review, aggravating factors for hepatoxicity can include things like non-alcoholic fatty liver or nutritional deficiency. Which basically describes an overweight computer-toucher with a poor diet to a tee.)
> the "daily" recommended doses are for a single day.
No. We've got thousands of people living more or less permanently on the maximum daily dose, including some children and vulnerable populations. Yes, some of those people have elevated liver enzymes. Yes, Tylenol is dangerous, but certainly not more than the alternatives. NSAIDs are certainly not any less dangerous, especially in populations with high prevalence of diabetes and kidney failure.
Tylenol overdose is one of the most frequent suicide plans in teens, with lethal doses usually starting from 8g. This is one of the reasons Tylenol has such a bad reputation.
No. We've got thousands of people living more or less permanently on the maximum daily dose, including some children and vulnerable populations. Yes, some of those people have elevated liver enzymes. Yes, Tylenol is dangerous, but certainly not more than the alternatives. NSAIDs are certainly not any less dangerous, especially in populations with high prevalence of diabetes and kidney failure.
Tylenol overdose is one of the most frequent suicide plans in teens, with lethal doses usually starting from 8g. This is one of the reasons Tylenol has such a bad reputation.
The intervention-based study (giving patients a controlled dose and measuring the enzyme response) found that over half of study participants will have clinically-significant elevation of ALT at the recommended dose, and 20-30% will have numbers as bad as 5x sustained. Short study aside, that's not what I would personally choose.
Remember, there were never Phase trials showing 4g is the right maximum either. It’s just grandfathered in Uber the “well I guess if it were dangerous we’d have noticed by now” standard. But did a statistically large enough segment take exactly 4g over a course of years such that we can definitively say that’s safe? Most people are taking lower doses and shorter doses. At least on paper.
It's "there's no double-blind study that shows masks can prevent the spread of covid!" redux. And actually it's worse because there already is a standard for what clinically-significant elevated levels of that enzyme are, and healthy study participants are blasting right by it. That's not relevant .... because?
It's not just a random number going up from some un-related mechanism, it's liver stress, they even think they know what the mechanism is. It’s a reaction that is well-known for this drug, as a warning sign for this problem. Claiming that it suddenly doesn’t mean the same thing it’d mean if you took 0.001mg more is just pedantic. It was never formally studied and approved, it would be completely unsurprising if they got the number a little wrong.
And again - that's study participants who are chosen to be healthy. If you're fat, or aren't getting your macronutrients, your risk is much higher.
Using a lower dose or using something else is always a valid option. "The dose makes the poison" and using the lowest effective dose is absolutely standard practice and any doctor is going to tell you that's a baseline they always operate under.
Anyway, do whatever you want personally, but I would personally think strongly about staying at half the recommended dose or less for chronic usage, or looking for an alternative option. 20% of the healthy population, plus the unhealthy population, is a decent chunk of people.
Remember, there were never Phase trials showing 4g is the right maximum either. It’s just grandfathered in Uber the “well I guess if it were dangerous we’d have noticed by now” standard. But did a statistically large enough segment take exactly 4g over a course of years such that we can definitively say that’s safe? Most people are taking lower doses and shorter doses. At least on paper.
It's "there's no double-blind study that shows masks can prevent the spread of covid!" redux. And actually it's worse because there already is a standard for what clinically-significant elevated levels of that enzyme are, and healthy study participants are blasting right by it. That's not relevant .... because?
It's not just a random number going up from some un-related mechanism, it's liver stress, they even think they know what the mechanism is. It’s a reaction that is well-known for this drug, as a warning sign for this problem. Claiming that it suddenly doesn’t mean the same thing it’d mean if you took 0.001mg more is just pedantic. It was never formally studied and approved, it would be completely unsurprising if they got the number a little wrong.
And again - that's study participants who are chosen to be healthy. If you're fat, or aren't getting your macronutrients, your risk is much higher.
Using a lower dose or using something else is always a valid option. "The dose makes the poison" and using the lowest effective dose is absolutely standard practice and any doctor is going to tell you that's a baseline they always operate under.
Anyway, do whatever you want personally, but I would personally think strongly about staying at half the recommended dose or less for chronic usage, or looking for an alternative option. 20% of the healthy population, plus the unhealthy population, is a decent chunk of people.
I personally prescribe loads of painkillers, including the whole range of the WHO ladder, and many of those patients have liver tests. It rarely happens that we have to discontinue Tylenol due to hepatitis. I see people on NSAIDs with kidney failure every week. So again yes, Tylenol is toxic. But from personal experience, it's rarely a clinically relevant problem.
Frankly, I'm not sure why NSAIDs are considered the safer option. There was a period of time when I was young, where I had tried various painkillers for treatment of headaches. Every time I had tried an NSAID, my chest felt like it was going to explode, and it became difficult to breathe. Later learned that they may increase the risk of heart attacks and strokes (of which I have a family history). For these reasons, I've sworn to never take them, and only take acetaminophen on rare occasions when pain is bad enough.
Most people don't read the label on medicines that they take. Take two extra strength acetaminophen tablets, combination liquid cold medicine, some of the sleep aids with diphenhydramine + acetaminophen, a glass of wine, repeat for 3 days, and you're easily into danger territory.
5:1 ratio (a dose is "take two 325mg") between therapeutic and danger doses is really low as far as modern drugs would be concerned. Most drugs are more in the 50:1 or 100:1 range, drugs with a 5:1 ratio typically would not be approved and certainly would require very close supervision. Tylenol being OTC is complete insanity (or rather, regulatory capture and general public comfort with it).
Also note that those dosages are only for single usages! Tylenol also has a fun thing where daily/chronic usage within the "safe" dose can still cause liver damage. Chronic usage, you need to halve those doses.
The causal mechanism is believed to be basically low-level liver damage. Drinking a sixpack of beer once every couple weeks is fine - it's still not healthy, it damages your body, but your liver will repair itself in the meantime - but do it every day and your body cumulatively cannot repair the damage, while drinking a ton could cause acute failure. Tylenol actually works the same way - every dose is damaging your liver a bit, but if you don't do it every day it's fine, your body will repair it. But if you do take it daily, your body doesn't get a chance to repair the liver damage that tylenol causes, and the actual "safe" dosage becomes lower.
That puts the actual "safe" dose at closer to 1500mg per day for an adult. Having a 2.5:1 theraputic ratio on an over-the-counter drug is absolute fucking insanity.
And worse, those numbers are for men - they're lower for women. Yes, so is the theraputic dose, but they don't make special pills for women. Taking a standard dose (two 325mg pills) twice a day can cause liver damage to women, that's above the safe threshold for daily/chronic use. And that's not something people really consider when they pop a couple tylenol.
And then you've got combination products. OK, so you get sick, you take a couple tylenol and a dose of cough syrup. The dose of cough syrup likely is another 500mg or so of tylenol. So you actually took a 1125mg dose. And then you do it again before you go to bed. That's edging into dangerous territory with tylenol.
Obviously "don't do that", read the label and don't double up on an active ingredient that's already there in combination, but combination products are implicitly dangerous, they are fishing for that to happen, encouraging it. But the FDA wants it because it "discourages abuse". That's literally more important than burning out your liver.
The rest of the world uses tylenol in very niche situations. Usually it's behind the counter at a minimum (not always, but usually) and you probably will be told to take some ibuprofen instead. Ibuprofen and Aspirin are not perfect but they are much, much, much safer than tylenol is.
Tylenol is absolutely, completely, absurdly dangerous and should not be anywhere near as common as it is in the US, but drug war + legacy product sales rule the day.
To echo another sibling commenter here, I don't allow acetaminophen in the house period. It is an accident waiting to happen. I certainly don't allow combination products, and I will actively go out of my way to buy anything that doesn't include it. This is overkill as a single childless person who is aware of the danger, but you never know when something could go wrong and the cat knocks the bottle off the counter and the dog gets it, etc. You just should not keep dangerous things around unless you absolutely need to. Some things you can't avoid, but it's not hard to just buy ibuprofen instead of tylenol.
Also note that those dosages are only for single usages! Tylenol also has a fun thing where daily/chronic usage within the "safe" dose can still cause liver damage. Chronic usage, you need to halve those doses.
The causal mechanism is believed to be basically low-level liver damage. Drinking a sixpack of beer once every couple weeks is fine - it's still not healthy, it damages your body, but your liver will repair itself in the meantime - but do it every day and your body cumulatively cannot repair the damage, while drinking a ton could cause acute failure. Tylenol actually works the same way - every dose is damaging your liver a bit, but if you don't do it every day it's fine, your body will repair it. But if you do take it daily, your body doesn't get a chance to repair the liver damage that tylenol causes, and the actual "safe" dosage becomes lower.
That puts the actual "safe" dose at closer to 1500mg per day for an adult. Having a 2.5:1 theraputic ratio on an over-the-counter drug is absolute fucking insanity.
And worse, those numbers are for men - they're lower for women. Yes, so is the theraputic dose, but they don't make special pills for women. Taking a standard dose (two 325mg pills) twice a day can cause liver damage to women, that's above the safe threshold for daily/chronic use. And that's not something people really consider when they pop a couple tylenol.
And then you've got combination products. OK, so you get sick, you take a couple tylenol and a dose of cough syrup. The dose of cough syrup likely is another 500mg or so of tylenol. So you actually took a 1125mg dose. And then you do it again before you go to bed. That's edging into dangerous territory with tylenol.
Obviously "don't do that", read the label and don't double up on an active ingredient that's already there in combination, but combination products are implicitly dangerous, they are fishing for that to happen, encouraging it. But the FDA wants it because it "discourages abuse". That's literally more important than burning out your liver.
The rest of the world uses tylenol in very niche situations. Usually it's behind the counter at a minimum (not always, but usually) and you probably will be told to take some ibuprofen instead. Ibuprofen and Aspirin are not perfect but they are much, much, much safer than tylenol is.
Tylenol is absolutely, completely, absurdly dangerous and should not be anywhere near as common as it is in the US, but drug war + legacy product sales rule the day.
To echo another sibling commenter here, I don't allow acetaminophen in the house period. It is an accident waiting to happen. I certainly don't allow combination products, and I will actively go out of my way to buy anything that doesn't include it. This is overkill as a single childless person who is aware of the danger, but you never know when something could go wrong and the cat knocks the bottle off the counter and the dog gets it, etc. You just should not keep dangerous things around unless you absolutely need to. Some things you can't avoid, but it's not hard to just buy ibuprofen instead of tylenol.
Actually every country is different in that regard. In many parts of Asia (e.g. Singapore, Hong Kong) good luck even finding ibuprofen or aspirin. It's usually behind the counter rather than in open display.
Instead there's dozens and dozens of GSK's Panadol paracetamol (acetaminophen), some of which even next to a cash register as a throw in.
Instead there's dozens and dozens of GSK's Panadol paracetamol (acetaminophen), some of which even next to a cash register as a throw in.
Are you actually an MD?
I actually only ever hear about acetaminophen/paracetamol being dangerous from Americans - in other Anglo countries everyone will happily suggest you take it all the time, it is available OTC, and it comes as something kids will mistake for lemonade.
https://www.amazon.co.uk/Lemsip-Cold-Blackcurrant-Flavour-Sa...
> Ibuprofen and Aspirin are not perfect but they are much, much, much safer than tylenol is.
Only short term. Ibuprofen is less safe taken chronically, it'll destroy your stomach lining.
I actually only ever hear about acetaminophen/paracetamol being dangerous from Americans - in other Anglo countries everyone will happily suggest you take it all the time, it is available OTC, and it comes as something kids will mistake for lemonade.
https://www.amazon.co.uk/Lemsip-Cold-Blackcurrant-Flavour-Sa...
> Ibuprofen and Aspirin are not perfect but they are much, much, much safer than tylenol is.
Only short term. Ibuprofen is less safe taken chronically, it'll destroy your stomach lining.
> For the average healthy adult, the generally recommended maximum daily dose is no more than 4,000 milligrams (mg) from all sources. But in some people, doses close to the 4,000 mg daily limit for adults could still be toxic to the liver.
https://www.health.harvard.edu/pain/acetaminophen-safety-be-...
4,000 mgs is easy to hit for people who don't realize that it can be dangerous. I know lots of people who would say "Well, my pain is bad, let me take double"... which for extra strength would be 4 x 500 MG, which is 2000 MGs in a single dose... which then if you do it twice in a day is right there at the 4000 MG mark. Most people are fine with that, but some people can get really sick.
If the person then does it 3 times a day, they are close to the danger zone for most people and over the danger zone for some people. Then multiply that by a few days....
You can easily say, "Well, they are taking more than they are supposed to!", but it is really common to take a bit extra if you feel really bad without realizing how dangerous it is, because Tylenol is `safe`
https://www.health.harvard.edu/pain/acetaminophen-safety-be-...
4,000 mgs is easy to hit for people who don't realize that it can be dangerous. I know lots of people who would say "Well, my pain is bad, let me take double"... which for extra strength would be 4 x 500 MG, which is 2000 MGs in a single dose... which then if you do it twice in a day is right there at the 4000 MG mark. Most people are fine with that, but some people can get really sick.
If the person then does it 3 times a day, they are close to the danger zone for most people and over the danger zone for some people. Then multiply that by a few days....
You can easily say, "Well, they are taking more than they are supposed to!", but it is really common to take a bit extra if you feel really bad without realizing how dangerous it is, because Tylenol is `safe`
No, I am not. It's a dune reference.
Ulcers ("destroying your stomach lining") is less bad than "destroying your liver", and typically you will have to screw up harder before other NSAIDs reach that level. Tylenol literally is dangerous following the directions on the bottle, because those directions aren't calibrated for chronic usage, when they say "daily max" they don't mean you take it daily, that dose is even lower.
Ulcers ("destroying your stomach lining") is less bad than "destroying your liver", and typically you will have to screw up harder before other NSAIDs reach that level. Tylenol literally is dangerous following the directions on the bottle, because those directions aren't calibrated for chronic usage, when they say "daily max" they don't mean you take it daily, that dose is even lower.
This is wrong. Kidney failure from NSAIDs is very common, and also very dangerous. And can develop at recommended dosage.
hey, thanks for the correction from a real doctor, I will be much more perceptive of that risk in the future.
again, I don't do analgesics daily but I will be sure to adhere to the doage schedule on that. Pain medication is such an unfortunate area of medicine.
again, I don't do analgesics daily but I will be sure to adhere to the doage schedule on that. Pain medication is such an unfortunate area of medicine.
I had a roommate who nearly died (his words) from taking a chronic regular dose of ibuprofen for a month or two when he was sofa-ridden after tearing his ACL.
Check your labels more carefully!
I just looked at a bottle of it here. Yes, 500mg. Adult dose: 2. That's 1,000mg. Every 6 hours to a maximum of 6 per day. That's 3,000mg/day. Danger at 7,000mg/day means a therapeutic ratio of less than three--nothing like that should be OTC and it's use should be carefully considered.
I just looked at a bottle of it here. Yes, 500mg. Adult dose: 2. That's 1,000mg. Every 6 hours to a maximum of 6 per day. That's 3,000mg/day. Danger at 7,000mg/day means a therapeutic ratio of less than three--nothing like that should be OTC and it's use should be carefully considered.
Ah, but two every 6 hours is 4000 mg/day, and my bottle claims that's safe. When I'm anywhere near that dose, I have a > 102F fever, which means I'm in peak form to compute dosages and timings.
Of course that's over the counter. Prescription strength also exists.
I'm a fan of switching between two pain killers / fever reducers (and only one liver killer), overlapping the effective time window by a few hours, but keeping both at ~50% the recommended max daily dose (a doctor recommended this to me a few years ago).
Of course, that makes the dose schedule more complicated, getting back to the problem it is trying to solve.
Of course that's over the counter. Prescription strength also exists.
I'm a fan of switching between two pain killers / fever reducers (and only one liver killer), overlapping the effective time window by a few hours, but keeping both at ~50% the recommended max daily dose (a doctor recommended this to me a few years ago).
Of course, that makes the dose schedule more complicated, getting back to the problem it is trying to solve.
This is very silly, acetaminophen is very effective against pain, and for many people (e.g. me) is tolerated much better, especially at higher doses, than ibuprofen etc. There is already way to much panic about drugs/medicines, especially pain meds, especially especially for chronic conditions, without further hysterics about the 'threat' of useful and well tolerated chemicals. (Not a doctor, not offering medical advice.)
>doesn't get you high
A huge point in its favor if you can't lay in bed opiated all day.
>doesn't get you high
A huge point in its favor if you can't lay in bed opiated all day.
I find acetaminophen almost completely useless for pain. Ibuprofen is better but still not very effective. Naproxen sodium is the only OTC pain medicine which is effective for me.
[deleted]
After going nearly a year without taking painkillers of any kind (not an aspirin, ibuprofen, or acetaminophen dose), I took some Tylenol for a bad headache, and it worked far better than it had ever worked for me before.
Granted, I've had to learn to put up with a lot more constant low-level pain in my day-to-day life. But I think that's a reasonable trade off for choosing between cooking my kidneys (aspirin, ibuprofen) or blowing out my liver (acetaminophen).
I had a really weird 1-in-ten-million side-effect with Naproxen sodium. It caused hard insomnia (confirmed under a doctor's care, this was before it was OTC).
Granted, I've had to learn to put up with a lot more constant low-level pain in my day-to-day life. But I think that's a reasonable trade off for choosing between cooking my kidneys (aspirin, ibuprofen) or blowing out my liver (acetaminophen).
I had a really weird 1-in-ten-million side-effect with Naproxen sodium. It caused hard insomnia (confirmed under a doctor's care, this was before it was OTC).
>After going nearly a year without taking painkillers
I find this pretty shocking. Is this how people normally take painkillers, would you say? Speaking for myself, I normally go for years without taking anything.
I find this pretty shocking. Is this how people normally take painkillers, would you say? Speaking for myself, I normally go for years without taking anything.
Throughout my life I've suffered from significant allergies, so I've taken antihistamines for many decades (by prescription in my youth to OTC now). The allergies frequently cause sinus infections, which can include anything from minor pain around the ears and jaw, to heavy duty headaches.
It used to be the doctors would have me bomb my system with antibiotics, decongestants, and, yes, painkillers. Forty years on, we know a bit more, or at least I do, and I avoid as many medications (and the side-effects which increase with aging) as I can. I also suffered from tendonitis in the knees, so all of this put together meant I was regularly taking Tylenol or Advil for one or the other.
Then I stopped. I stopped using Tylenol unless I had a fever, or a really bad headache. When I got a sinus headache the first thing I'd reach for was a netty pot or sinus rinse instead of decongestants and painkillers. Physical therapy helped rehabilitate the knees, and when it rains, I just suck it up and limp for a day or two.
Those things and a few other medical issues add up to a steady catalog of pain that I just ignore for most of the day. In some cases, I stretch or exercise. I consider myself doing OK if I'm taking Tylenol or Aspirin once a quarter.
I'm happy you need no painkillers whatsoever for years on end. I think that's how it's supposed to be. For some people, it doesn't work out that way.
It used to be the doctors would have me bomb my system with antibiotics, decongestants, and, yes, painkillers. Forty years on, we know a bit more, or at least I do, and I avoid as many medications (and the side-effects which increase with aging) as I can. I also suffered from tendonitis in the knees, so all of this put together meant I was regularly taking Tylenol or Advil for one or the other.
Then I stopped. I stopped using Tylenol unless I had a fever, or a really bad headache. When I got a sinus headache the first thing I'd reach for was a netty pot or sinus rinse instead of decongestants and painkillers. Physical therapy helped rehabilitate the knees, and when it rains, I just suck it up and limp for a day or two.
Those things and a few other medical issues add up to a steady catalog of pain that I just ignore for most of the day. In some cases, I stretch or exercise. I consider myself doing OK if I'm taking Tylenol or Aspirin once a quarter.
I'm happy you need no painkillers whatsoever for years on end. I think that's how it's supposed to be. For some people, it doesn't work out that way.
You probably don't have a chronic pain condition, but a fair number of people do, especially as they get older.
Many migraine sufferers will take pain killers multiple times in a month
People with chronic pain do what they have to do to get through the day.
accordind to the American Dental Association, 500mg of acetaminophen in combination with 200mg of ibuprofen is more effective than naproxen for pain relief.
https://jada.ada.org/article/S0002-8177(18)30117-X/fulltext (the result are in table 1)
https://jada.ada.org/article/S0002-8177(18)30117-X/fulltext (the result are in table 1)
Don't really care what the ADA has to say. I have conducted my own study on myself, my comment was regarding which is most effective for me, and naproxen sodium is by far more effective for my pain relief than other OTC pain relievers including combinations which I have in fact tried.
I'm not saying it'd be good if acetaminophen got you high, just that one of the reasons it's still OTC is that it doesn't get you high, so there's no one champing at the bit to crack down on it, the way they robbed us of the highly-effective and fairly-harmless pseudoephedrine for the one and only reason that it can be illicitly turned into a street drug.
That's reasonable. My concern is that during my lifetime I have had my access to useful medicines with zero abuse potential restricted because of (imo) panics that it could be turned into street drugs (pseudoephedrine), and also because of panics (imo) that it is too hard on my body (Torodol), and of course because of panics (imo) that they will turn me into a drug addict (opiates). The last class is admittedly worth being cautious about, especially with the more potent forms, but all of these drugs have legitimate medicinal uses and people suffer when they are taken away.
(Also, for drugs that you have to take to get through the day, the lack of a buzz is a definite benefit, and not just because it closes off one argument for restricting them.)
(Also, for drugs that you have to take to get through the day, the lack of a buzz is a definite benefit, and not just because it closes off one argument for restricting them.)
I doubt it.
Ibuprofen and other NSAISDs were approved not that long ago, cause plenty of GI bleeds, have nephrotoxicity when used chronically and increase the risk of cardiovascular events.
And they’re OTC.
Acetaminophen is actually very safe considering the number of serious events and the facts it’s in hundreds of different OTC combinations.
Ibuprofen and other NSAISDs were approved not that long ago, cause plenty of GI bleeds, have nephrotoxicity when used chronically and increase the risk of cardiovascular events.
And they’re OTC.
Acetaminophen is actually very safe considering the number of serious events and the facts it’s in hundreds of different OTC combinations.
Any sources on that bit about chronic ibuprofen usage? I'm aware of the GI issues (stomach lining actually), and not the others. I'm a long chronic user (daily for years now), and appear to have a reliable mitigation for the GI problems, so I'd love to know more about the other stuff you mentioned.
I think Google would help with the nephrotoxicity topic, but with regards to cardiovascular risk, the FDA has been doing a ton of work on it since the early 2000's when Vioxx and Bextra were pulled off the market. The other NSAIDs like ibuprofen, naproxen were kept on the market due to a lower, but not non-existent, risk.
I take NSAID for pain, but personally I'm not too concerned as it's only a ~10-50% increase in relative risk. If I was at a higher risk for stroke or heart attack, or took them very frequently (say daily for arthritis) I'd probably look for alternatives, but there are lots of others things to worry about.
This is the latest FDA update I could find, there may be more information out there:
https://www.fda.gov/drugs/drug-safety-and-availability/fda-d...
I take NSAID for pain, but personally I'm not too concerned as it's only a ~10-50% increase in relative risk. If I was at a higher risk for stroke or heart attack, or took them very frequently (say daily for arthritis) I'd probably look for alternatives, but there are lots of others things to worry about.
This is the latest FDA update I could find, there may be more information out there:
https://www.fda.gov/drugs/drug-safety-and-availability/fda-d...
Here are some interesting related HN posts regarding Acetaminophen:
https://hn.algolia.com/?dateEnd=1648670057&dateRange=custom&...
https://hn.algolia.com/?dateEnd=1648670057&dateRange=custom&...
Although perhaps true about FDA clearance, I wouldn't be alarmist and characterize the effective dose as "dangerously" close to the LD50.
The highest dose that therapeutically is used is about 1000mg per dose. The fatal dose is about 15 times that amount.
To put it into perspective, a patient would have to be willfully taking 45 tylenol (325mg/pill) all at once to cause lethal liver damage. Doses like that are usually not accidental.
The highest dose that therapeutically is used is about 1000mg per dose. The fatal dose is about 15 times that amount.
To put it into perspective, a patient would have to be willfully taking 45 tylenol (325mg/pill) all at once to cause lethal liver damage. Doses like that are usually not accidental.
Not accidental, but very tragic. It's the #1 cause for calls to poison control, and accounts for 26,000 hospitalizations every year, and 500 deaths. Dying from an acetaminophen overdose is not a good way to go out, you spend a couple days in the hospital suffering as your organs fail and your loved ones watch.
Other OTC drugs are much safer. I don't allow acetaminophen in the house. Pseoudoephedrine? Yes.
Acetaminophen also should not be taken as a hangover cure, due to interactions with alcohol (alcohol and acetaminophen compete for the same metabolic pathways in the liver, and this exacerbates the toxic effects of acetaminophen). The problem is that someone who's drinking and has a hangover is probably going to reach for one of the two most common OTC pain relievers in their medicine cabinet, and not consider that one of those two pain relievers should not be combined with alcohol.
Other OTC drugs are much safer. I don't allow acetaminophen in the house. Pseoudoephedrine? Yes.
Acetaminophen also should not be taken as a hangover cure, due to interactions with alcohol (alcohol and acetaminophen compete for the same metabolic pathways in the liver, and this exacerbates the toxic effects of acetaminophen). The problem is that someone who's drinking and has a hangover is probably going to reach for one of the two most common OTC pain relievers in their medicine cabinet, and not consider that one of those two pain relievers should not be combined with alcohol.
500 deaths (many intentional attempts at suicide) in a country of 350M where arguably every household has acetaminophen present is incredibly low.
By comparison, the number of accidental firearm deaths is around 430 per year, and somewhere around 40% of US households have a firearm. So we can say that having acetaminophen in the house is roughly as dangerous as having a firearm in the house. Obviously this is not some kind of direct comparison between firearms and acetaminophen.
I included the statistic in the first place because I thought it didn’t make sense to cherry pick the scariest statistics. I’m not fearmongering here, just trying to illustrate that acetaminophen should be treated with more care than we currently do. I think we could be making better health policy decisions about which medications are OTC and which aren’t, although this topic is incredibly complicated and doesn’t just come down to simple facts like toxicity.
I included the statistic in the first place because I thought it didn’t make sense to cherry pick the scariest statistics. I’m not fearmongering here, just trying to illustrate that acetaminophen should be treated with more care than we currently do. I think we could be making better health policy decisions about which medications are OTC and which aren’t, although this topic is incredibly complicated and doesn’t just come down to simple facts like toxicity.
I wouldn’t use accidental gun deaths when acetaminophen is often used in suicides. There are 25,000 of those with guns each year in the US.
But yes, acetaminophen is a drug, can be dangerous and shouldn’t be treated as benign.
But yes, acetaminophen is a drug, can be dangerous and shouldn’t be treated as benign.
Do you have numbers for how often acetaminophen are used in suicides?
[deleted]
Yes, agree with everything factual you said. I guess the problem isn't the compound itself but rather not enough information regarding its use.
I personally keep tylenol in the house because it's probably the best non-narcotic non-NSAID pain medicine.
We use it all the time in patients who are elderly with decreased renal function because they don't do well with opiates or NSAIDs (ibuprofen)
I personally keep tylenol in the house because it's probably the best non-narcotic non-NSAID pain medicine.
We use it all the time in patients who are elderly with decreased renal function because they don't do well with opiates or NSAIDs (ibuprofen)
Nowhere is this more evident than in the treatment of endometriosis.
It seems like even gynaecologists are woefully ignorant & untrained in this disease, leading to so much unnecessary suffering by women (my wife included).
Guys & gals, if you or your partner suffer from endometriosis, listen up!
* Find the best gynaecologist you can that specialises in endo & can perform excision surgery.
* Burning off the lesions (ablation) is not an effective treatment. Excision surgery is by far the most effective current treatment. Unfortunately, it seems like many gynaecologists do not have the training to perform this surgery, and therefore don't even mention it (lest they lose your valuable business).
* There is absolutely zero evidence that pregnancy "cures" endometriosis, despite doctors continually repeating this myth. My wife's awesome gyno told us - and you can research yourself - that this is absolute rubbish.
https://theconversation.com/pregnancy-doesnt-cure-endometrio...
It causes me to wonder when I go see a doctor, what else are they ignorant about? I like to think I can defer to their expertise, and set my mind to other things. Maybe not.
It seems like even gynaecologists are woefully ignorant & untrained in this disease, leading to so much unnecessary suffering by women (my wife included).
Guys & gals, if you or your partner suffer from endometriosis, listen up!
* Find the best gynaecologist you can that specialises in endo & can perform excision surgery.
* Burning off the lesions (ablation) is not an effective treatment. Excision surgery is by far the most effective current treatment. Unfortunately, it seems like many gynaecologists do not have the training to perform this surgery, and therefore don't even mention it (lest they lose your valuable business).
* There is absolutely zero evidence that pregnancy "cures" endometriosis, despite doctors continually repeating this myth. My wife's awesome gyno told us - and you can research yourself - that this is absolute rubbish.
https://theconversation.com/pregnancy-doesnt-cure-endometrio...
It causes me to wonder when I go see a doctor, what else are they ignorant about? I like to think I can defer to their expertise, and set my mind to other things. Maybe not.
It seems that every case of endometriosis comes with a horror story of years, if not decades, of being ignored or not being taken seriously
"lack of consensus about how to treat some of the most common conditions in the human population (e.g. back pain)"
That one is obvious: question too broad ... does not compute ... out of cheese error.
Back pain is a massive, massive thing - it sometimes doesn't actually involve the back. Here's an anecdote:
I (50ish y/o male) used to have episodes of quite crippling to very crippling "back pain". To cut a long story short, I found at least two causes (can't remember the medical term - indicator?) and sorted them. One was putting my wallet in my back pocket - sounds innocuous but it puts pressure on the buttock involved and skews your posture slightly. The other was seemingly ridiculous: When turning over in bed, I used to flick myself over by performing a sort of torsion twist about my spine. That's fine when you are 10 but not 30, 40, 50 etc.
Nowadays I simply avoid silly lifting postures and all is generally good. It took about four or five years to recover from past habits.
That one is obvious: question too broad ... does not compute ... out of cheese error.
Back pain is a massive, massive thing - it sometimes doesn't actually involve the back. Here's an anecdote:
I (50ish y/o male) used to have episodes of quite crippling to very crippling "back pain". To cut a long story short, I found at least two causes (can't remember the medical term - indicator?) and sorted them. One was putting my wallet in my back pocket - sounds innocuous but it puts pressure on the buttock involved and skews your posture slightly. The other was seemingly ridiculous: When turning over in bed, I used to flick myself over by performing a sort of torsion twist about my spine. That's fine when you are 10 but not 30, 40, 50 etc.
Nowadays I simply avoid silly lifting postures and all is generally good. It took about four or five years to recover from past habits.
I wouldn't call the latter a "fix". More like avoiding the problem. Let's pretend for as second the actual problem was some sort of muscular tightness you've developed, wouldn't the preferable fix be to identify the tightness, do some exercises regularly that alleviate it, and conserve the original function of your body? Otherwise seems like you're just slowly abandoning capabilities that your body used to have.
I'm a bloke what is going from 0 to n years old where n is hopefully undefined and roughly "later". I'm currently 51.
When I was a child/teen/young adult I had a habit of basically twisting myself in such a way that I stored energy and then released it to turn over - perhaps a bit like a rubber band being twisted. That's fine in a young body but not in an older one. Bear in mind that the same person (mind) is within both the young and old body and it took quite a lot of time to realise that I'm not as agile as I was.
I'm a lot more cunning these days and for example can actually ski far better than I used to as a child but if I fall, it bloody hurts!
Funnily enough the wallet thing is way more important to my wellbeing.
When I was a child/teen/young adult I had a habit of basically twisting myself in such a way that I stored energy and then released it to turn over - perhaps a bit like a rubber band being twisted. That's fine in a young body but not in an older one. Bear in mind that the same person (mind) is within both the young and old body and it took quite a lot of time to realise that I'm not as agile as I was.
I'm a lot more cunning these days and for example can actually ski far better than I used to as a child but if I fall, it bloody hurts!
Funnily enough the wallet thing is way more important to my wellbeing.
"Slowly abandoning capabilities that your body used to have" is inevitable. Everyone will do this at a different rate and on a different time profile, but everyone will do it, and everyone will eventually reach capability = zero.
> official sounding diagnoses that on inspection are actually defined as "we have no idea"
I suffer from IBS, and it's basically a diagnosis of exclusion of everything else.
> lack of consensus about how to treat some of the most common conditions in the human population (e.g. back pain)
Back pain isn't a condition, it's a symptom. And with the amount of conditions and diseases that have this symptom in their list, it's not surprising there isn't a "one-size-fits-all" remedy or cure to it.
I suffer from IBS, and it's basically a diagnosis of exclusion of everything else.
> lack of consensus about how to treat some of the most common conditions in the human population (e.g. back pain)
Back pain isn't a condition, it's a symptom. And with the amount of conditions and diseases that have this symptom in their list, it's not surprising there isn't a "one-size-fits-all" remedy or cure to it.
Before my gout became more obviously gout (I had elevated uric acid, but there was often little to no crystallization), one of my diagnoses was "seronegative arthritis" - "It looks like you have arthritis, but you have neither RF or CCP in your blood, so... huh."
Hopefully you never get something unrecognized by current medical knowledge. You visit progressively more esteemed experts: local, regional, national, global. Then you get to the top, and (in my experience) that’s it.
I thought for sure there was a “ok now we hand this off to the labs so we can learn” step… but, no. It was just a shrug and literally “come back in 8 months if you’re still having problems.”
I became my own lab and fixed my problem. I reported my findings to the doctors, and never heard back.
Pretty disappointing.
I thought for sure there was a “ok now we hand this off to the labs so we can learn” step… but, no. It was just a shrug and literally “come back in 8 months if you’re still having problems.”
I became my own lab and fixed my problem. I reported my findings to the doctors, and never heard back.
Pretty disappointing.
Well..yeah?
I mean it’s human biology we’re dealing with. Most medicine is “we think is the best approach” with varying levels of data from “best guess” to “a few anecdotes” to “suggestive data” to “robust, well designed clinical trials”.
If we only ever treated people with data from the last bucket most of the time your doctor would recommend “just wait and hope it gets better”
I mean it’s human biology we’re dealing with. Most medicine is “we think is the best approach” with varying levels of data from “best guess” to “a few anecdotes” to “suggestive data” to “robust, well designed clinical trials”.
If we only ever treated people with data from the last bucket most of the time your doctor would recommend “just wait and hope it gets better”
>the complete lack of enforcement of what goes in supplements
I agree with everything you said except for this. If resources are finite to approve and regulate drugs, 3rd-party supplements are the first thing I want tossed before any other more critical medication.
I agree with everything you said except for this. If resources are finite to approve and regulate drugs, 3rd-party supplements are the first thing I want tossed before any other more critical medication.
Mislabeled supplements can be very dangerous and some people require supplements due to diet choice or health issues such as pernicious anemia.
It's not just the US, it's pretty much the same everywhere.
Ex-doc here.
Ex-doc here.
> I've recently had to deal with the medical profession a lot more than in the past and I'm finding this sort of thing everywhere. OTC medicines that by current standards would not be made OTC
This comment reflects a common, but mistaken, believe that OTC = "essentially medicine, but safe enough to not need a prescription". In most cases, nothing could be further from the truth .
OTCs of course do include useful medications such as acetaminophen (eg Tylenol), ibuprofen (eg Advil), Aspirin, and so on. However, OTCs also include miscellaneous and assorted nonsense, such as the heroic quantities of vitamin C that many companies like to sell as somehow beneficial, and the assorted concoctions that fall under the banner of "natural health products".
In the United States, a product can pass as an OTC "medication" if it passes under the generally regarded as safe (GRAS) exemption. This basically involves sending documents to the FDA that suggest the product should be safe in humans, without necessarily having to prove it's an effective treatment for anything. Couple that with the fact that manufacturers do lie about how well they tested the safety of their products (many are fly-by-night operations with little to lose), and you end up with the situation described in the article.
You can probably blame the pharmaceutical companies for some of this confusion, as it is their wont to mix actual medications with miscellaneous nonsense in the pursuit of profit.
This comment reflects a common, but mistaken, believe that OTC = "essentially medicine, but safe enough to not need a prescription". In most cases, nothing could be further from the truth .
OTCs of course do include useful medications such as acetaminophen (eg Tylenol), ibuprofen (eg Advil), Aspirin, and so on. However, OTCs also include miscellaneous and assorted nonsense, such as the heroic quantities of vitamin C that many companies like to sell as somehow beneficial, and the assorted concoctions that fall under the banner of "natural health products".
In the United States, a product can pass as an OTC "medication" if it passes under the generally regarded as safe (GRAS) exemption. This basically involves sending documents to the FDA that suggest the product should be safe in humans, without necessarily having to prove it's an effective treatment for anything. Couple that with the fact that manufacturers do lie about how well they tested the safety of their products (many are fly-by-night operations with little to lose), and you end up with the situation described in the article.
You can probably blame the pharmaceutical companies for some of this confusion, as it is their wont to mix actual medications with miscellaneous nonsense in the pursuit of profit.
> grift
It's not grift, it's people with limited information and resources doing the best they can with their expertise. Should your doctor, lacking certain information, do nothing?
Every profession is the same: You rarely have the ideal of perfect information, enough time, enough resources. That's where human adaptability and expertise come into play: You find a way.
> I feel like my entire understanding of the medical system in the US was a lie.
How much is our responsibilities, especially as educated, informed persons?
It's not grift, it's people with limited information and resources doing the best they can with their expertise. Should your doctor, lacking certain information, do nothing?
Every profession is the same: You rarely have the ideal of perfect information, enough time, enough resources. That's where human adaptability and expertise come into play: You find a way.
> I feel like my entire understanding of the medical system in the US was a lie.
How much is our responsibilities, especially as educated, informed persons?
[deleted]
The fact that I am here is 100% due to the medical science of the 1970s. I was born with a hole in my heart. The fact that I lived past 19 is due to the medical science of the late 1990s. That same area of my heart had a short circuit that would sporadically cause 200bpm+ heart rates and cause me to nearly pass out. It’s called Wolf-Parkinson-White syndrome. I had a cardiac ablation which 100% cured me of that. The fact that I am here now is because of modern medicine. I just completed colon cancer treatment for which I lost a foot of colon and had chemotherapy. As I write this I can’t believe that I am not even listing everything that has happened to me and considered myself generally healthy. Anyway medicine in the US is definitely responsible for my still being alive. I’m sure other health care systems would have kept me alive too but it is pure speculation and luck I suppose. I could just as easily have gotten a bad doctor and not been so lucky.
> in the US was a lie. We're constantly touting that we have the most advanced technology but if you have a complex condition you are likely to fall prey to multiple kinds of grift.
I feel like so much of what goes on day to day is one grift or another.
I feel like so much of what goes on day to day is one grift or another.
And now I am reminded of https://dx.doi.org/10.1136%2Fbmj.327.7429.1459 and the fact that there is no randomised controlled trials that show the effectiveness of parachutes either.
Au contraire! https://www.bmj.com/content/363/bmj.k5094
Note that this is the study that prompted the study I linked to. But yes, worth a read too.
As of 2020 there wasn't an RCT for surgical masks being helpful in surgery.
I’m feeling this way too hard. I have a condition where any food I consistently eat I become sensitized to and begin developing severe reactions that are alike anaphylaxis in nearly every way but not quite as severe. I have been hospitalized several times now with starvation issues. Yeah immune suppressants sorta worked but you can’t exactly stop a full on immune response so it just bought a little bir of time.
(1) mast cell testing - negative (2) ige testing - mostly negative but i also avoid things i react to (3) endoscopy - mostly negative but some inflammation (4) psychological - medications didnt do anything
(5) Non-allopathic stool testing from Genova Diagnostcs? astronomically high secretory IgA levels, high zonulin levels, disturbed gut flora populations and altered stool enzyme levels. -> point this out to doctors “sorry cant help ya there. _that’s unvalidated_”
Me - well fucking figure out something to try then!!!!
Dead end. I am so sick of evidence based medicine.
(1) mast cell testing - negative (2) ige testing - mostly negative but i also avoid things i react to (3) endoscopy - mostly negative but some inflammation (4) psychological - medications didnt do anything
(5) Non-allopathic stool testing from Genova Diagnostcs? astronomically high secretory IgA levels, high zonulin levels, disturbed gut flora populations and altered stool enzyme levels. -> point this out to doctors “sorry cant help ya there. _that’s unvalidated_”
Me - well fucking figure out something to try then!!!!
Dead end. I am so sick of evidence based medicine.
At least I don't go down the anaphylaxis route. Unless the picture changes I won't have starvation issues, malnutrition is definitely an issue. I'm sure it's going to end up having to go with immune suppression (and I have every reason to suspect that's only going to be a temporary solution) but so far I've been able to avoid that.
Never tried the psych stuff. One doctor suggested it but it felt very much like they were pretending it had off-label relevance--but he ignored my saying capsules, not tablets. Sorry, you're not thinking about it and I'm not taking psych stuff without the doctors considering it carefully. And tablets that can't be cold-turkeied are a hard no for me. (I'm going to go sensitive to the tablet binder at some point. If I go sensitive to a capsule I can at least break it open.)
Nobody's suggested the stool testing, is that something new? I'm pretty sure gut flora play a role but I don't have details. (E-mail in my profile.)
Never tried the psych stuff. One doctor suggested it but it felt very much like they were pretending it had off-label relevance--but he ignored my saying capsules, not tablets. Sorry, you're not thinking about it and I'm not taking psych stuff without the doctors considering it carefully. And tablets that can't be cold-turkeied are a hard no for me. (I'm going to go sensitive to the tablet binder at some point. If I go sensitive to a capsule I can at least break it open.)
Nobody's suggested the stool testing, is that something new? I'm pretty sure gut flora play a role but I don't have details. (E-mail in my profile.)
GDX stool testing was something recommended by an integrative dual resident at ucsd for me.
I think if you disturb the flora and lining too badly the normal tolerance mechanism with Tregs breaks down. That’s my theory anyway.
I think if you disturb the flora and lining too badly the normal tolerance mechanism with Tregs breaks down. That’s my theory anyway.
I also had no issue starting and stopping low dose benzos
I had a condition recently, now resolved. During that time I had many consultations with specialists and did quite a bit of research myself.
It's astonishing. 80pc or more of shelf products in a pharmacy will do nothing and many will make things worse.
It's astonishing. 80pc or more of shelf products in a pharmacy will do nothing and many will make things worse.
The "substantially similar" thing for medical devices is a funny one. Especially when a company depends on that classification and then goes and tries to get a patent on part of their product.
Wait until you get to the bullshit around pain management.
In the US medicine is a business. Their job is not to make you better. Their job is to get as much money as possible out of you.
"the complete lack of enforcement of what goes in supplements"
This is because of the oddly libertarian 1994 DSHEA act:
https://ods.od.nih.gov/About/dshea_Wording.aspx
From 1904 to 1994 the FDA was fairly strict about banning most herbal remedies. Indeed, the FDA was created, in part, to limit the types of "snake oil" treatments that used to abound, and to limit the claims that could made for unproven treatments. But DSHEA opened the door to unproven treatments. In theory, the companies behind these treatments are not allowed to make medical claims, but we've all seen them walk right up to the line and make claims that sound somewhat medical.
This is because of the oddly libertarian 1994 DSHEA act:
https://ods.od.nih.gov/About/dshea_Wording.aspx
From 1904 to 1994 the FDA was fairly strict about banning most herbal remedies. Indeed, the FDA was created, in part, to limit the types of "snake oil" treatments that used to abound, and to limit the claims that could made for unproven treatments. But DSHEA opened the door to unproven treatments. In theory, the companies behind these treatments are not allowed to make medical claims, but we've all seen them walk right up to the line and make claims that sound somewhat medical.
The fear at the time was that all supplements would be by prescription only.
Then a 250 mg capsule of Vitamin C would be $14.00.
Then a 250 mg capsule of Vitamin C would be $14.00.
Welcome to medicine!
emergency medical care is almost unquestionable.
My drug of choice for colds is NyQuil. It's always been great for opening up my nasal passages enough to let me breathe easily and then knocking me the fuck out so I could sleep off most of the cold.
I remember several years ago when all of a sudden NyQuil stopped doing anything useful. I had no idea why but I directly observed that it was like it had been replaced with a non-functioning placebo.
Only a couple years later did I make the connection that this was right when they passed the law restricting pseudoephedrine. I got my hands on some NyQuil D and everything was back to normal and I had a functioning cold remedy again.
Phenylephrine is completely useless.
I remember several years ago when all of a sudden NyQuil stopped doing anything useful. I had no idea why but I directly observed that it was like it had been replaced with a non-functioning placebo.
Only a couple years later did I make the connection that this was right when they passed the law restricting pseudoephedrine. I got my hands on some NyQuil D and everything was back to normal and I had a functioning cold remedy again.
Phenylephrine is completely useless.
NyQuil is a combination medicine. The cough, cold and flu formula contains Tylenol (fever/pain reliever), DXM (stops cough) and an antihistamine (dries out your runny nose/postnasal drip).
NyQuil can be a great all-in-one product when it's what you need. It's useful to know what it is composed of and why. All of the medicines in it treat symptoms, not the underlying cause, which will be fought off by your immune system. If you have only one or two symptoms, you can always buy each drug separately - doing so allows you to more precisely control dosage and timing as well.
FYI, two other common symptoms not covered above are sinus congestion - which can be treated with Sudafed - and chest congestion (e.g. a phlegmy cough) - which can be treated with Mucinex.
NyQuil can be a great all-in-one product when it's what you need. It's useful to know what it is composed of and why. All of the medicines in it treat symptoms, not the underlying cause, which will be fought off by your immune system. If you have only one or two symptoms, you can always buy each drug separately - doing so allows you to more precisely control dosage and timing as well.
FYI, two other common symptoms not covered above are sinus congestion - which can be treated with Sudafed - and chest congestion (e.g. a phlegmy cough) - which can be treated with Mucinex.
Multiple clarifications -
Antihistamines do not directly dry up your runny nose/post nasal drip. Rather, they reduce the histamine response, which is helpful when something is caused by allergies. It's usually not that helpful with an actual cold (but allergic rhinitis is often mistaken for a cold).
Sudafed is what the parent was referring to with Pseudophedrine; a decongestant. This works by shrinking blood vessels, causing swollen passageways to open back up. It doesn't actually do anything to reduce the runny nose or post nasal drip, but by opening the passages more can help them drain more efficiently, preventing that feeling of congestion (hence the name).
Guaifenesin (Mucinex being the name brand) is an expectorant; it causes you to generate more mucus, and reduces the viscosity, allowing you to cough/sneeze/etc your mucus/phlegm based congestion out more easily.
Otherwise I totally agree; it is worth understanding what each of these do so you can pick and choose what you need. Nyquil includes DXM (dextromethorphan) to reduce cough severity, but the acetaminophen is not helpful unless you have a fever or headache, and the Doxylamine Succinate and Phenylephrine (both antihistamines; the Doxyl is added to Nyquil because it's also a sleep aid) aren't particularly helpful unless your cold symptoms are actually allergy related.
Better to buy DXM separately usually; fewer side effects, cheaper, and you can pair it with what else will help you (if you need something to help you sleep, you can add Doxyl or Diphenhydramine if you want; YMMV as to how effective they are)
Don't take Guaifenesin before bed (the increased mucus/phlegm production will make it harder to sleep), but it's good during daytime.
A common side effect of Sudafed is trouble sleeping; if you don't have this side effect it can be helpful in reducing congestion while you try and sleep, but if you do have this side effect, obviously, don't take it before bed.
Antihistamines do not directly dry up your runny nose/post nasal drip. Rather, they reduce the histamine response, which is helpful when something is caused by allergies. It's usually not that helpful with an actual cold (but allergic rhinitis is often mistaken for a cold).
Sudafed is what the parent was referring to with Pseudophedrine; a decongestant. This works by shrinking blood vessels, causing swollen passageways to open back up. It doesn't actually do anything to reduce the runny nose or post nasal drip, but by opening the passages more can help them drain more efficiently, preventing that feeling of congestion (hence the name).
Guaifenesin (Mucinex being the name brand) is an expectorant; it causes you to generate more mucus, and reduces the viscosity, allowing you to cough/sneeze/etc your mucus/phlegm based congestion out more easily.
Otherwise I totally agree; it is worth understanding what each of these do so you can pick and choose what you need. Nyquil includes DXM (dextromethorphan) to reduce cough severity, but the acetaminophen is not helpful unless you have a fever or headache, and the Doxylamine Succinate and Phenylephrine (both antihistamines; the Doxyl is added to Nyquil because it's also a sleep aid) aren't particularly helpful unless your cold symptoms are actually allergy related.
Better to buy DXM separately usually; fewer side effects, cheaper, and you can pair it with what else will help you (if you need something to help you sleep, you can add Doxyl or Diphenhydramine if you want; YMMV as to how effective they are)
Don't take Guaifenesin before bed (the increased mucus/phlegm production will make it harder to sleep), but it's good during daytime.
A common side effect of Sudafed is trouble sleeping; if you don't have this side effect it can be helpful in reducing congestion while you try and sleep, but if you do have this side effect, obviously, don't take it before bed.
Do any of these compounds actually do what they say? I have always found all cold medicines to be entirely worthless. Supposedly a study found guaifenesin to be no better than a placebo:
http://rc.rcjournal.com/content/59/5/788
http://rc.rcjournal.com/content/59/5/788
So the treatment of symptoms, in general, leads to some really inconsistent results, as it's really hard to measure them. Some studies have definitely found guaifenesin to not be helpful (others have), but the way all of them measure it is...questionable. Ultimately, what a user wants is a subjective experience of "I feel better", but what is being tested for is stuff like "what concentration of inhailed capsaicin leads to them coughing".
So generally my take is "hey, this is what it's been found effective for, and it's generally regarded as safe to take. Is it going to help here, for you, in this situation? Who knows! Give it a whirl if you got the money and want to try".
So generally my take is "hey, this is what it's been found effective for, and it's generally regarded as safe to take. Is it going to help here, for you, in this situation? Who knows! Give it a whirl if you got the money and want to try".
Guaifenesin is mostly useless and only approved so that they can stick it next to your dextromethorphan as an emetic to stop you from abusing it. I was vomiting from COVID and I was incredibly pissed off when I found out it was actually just because they poisoned my cough syrup on purpose.
[deleted]
Prior to the regulation of pseudoephedrine, NyQuil also contained pseudoephedrine and since the nasal congestion from a a virus can often be the most disruptive factor for sleep (at least, in my personal experience, that's the case) it's considered by some to the be most important component.
NyQuil with pseudoephedrine included is now marketed as "NyQuil D" and is available behind many pharmacy counters with the same restrictions as other pseudoephedrine products. However, it could also rightly be called "NyQuil Classic" (to borrow branding from Coca-Cola).
NyQuil with pseudoephedrine included is now marketed as "NyQuil D" and is available behind many pharmacy counters with the same restrictions as other pseudoephedrine products. However, it could also rightly be called "NyQuil Classic" (to borrow branding from Coca-Cola).
I feel like the true “Cocaine Cola Classic” would still have some of that, um, regulated stimulant in it. Cocaine. Might be good for decongestion?
Cocaine is indeed an excellent decongestant. To the point that it'll pierce a hole through your nasal septum through vasoconstriction.
afaik coca cola is the only entity in the US allowed to import actual coca leaves, so, technically?
While true, the cocaine is processed out of the leaves themselves and sold to pharmaceutical companies. The remaining leaf product is used in the flavoring.
I’m not sure if it is still legal, but importing “coca tea” - that is, tea bags filled with shredded coca leaves - was legal at some point and a few enterprising folks imported a few kilos of it and processed it into the drug.
It's still legal to buy decocanized coca leaves but I think the odds of getting anything worthwhile out of it would be slim and probably more expensive than a plane ticket to Peru.
We haven't been able to find NyQuil D for almost a year here in Illinois
NyQuil also contains alcohol and pseudo (in some formulations).
My pet theory is that NyQuil's biggest effect is simply to make you mildly "faded" so all your symptoms are more tolerable. DXM, the antihistamine, the pseudo, and the alcohol are all drugs that would definitely do that if taken in larger doses. While NyQuil doesn't have those larger doses, the combination of all of them may amplify the otherwise weaker effects into a general buzz/haze that helps you go about your day/night.
My pet theory is that NyQuil's biggest effect is simply to make you mildly "faded" so all your symptoms are more tolerable. DXM, the antihistamine, the pseudo, and the alcohol are all drugs that would definitely do that if taken in larger doses. While NyQuil doesn't have those larger doses, the combination of all of them may amplify the otherwise weaker effects into a general buzz/haze that helps you go about your day/night.
DXM doesn’t actually suppress cough either, right?
Sort of! There isn't consistent evidence that -any- antitussive is more effective than placebo. A majority of studies show a statistically significant result for DXM, but not all, and they aren't fully replicable which definitely calls it into question. But that's true of every purported cough suppressant, and there's understandable reasons for that; coughing is a voluntary response to irritation, so there's definitely a lot going to determine whether you cough or not on beyond a purely autonomous system response. Plus there's not really much clarity in how to measure improvement (reduction in frequency may not actually be a reduction in irritation; reduction in severity is hard to measure. Etc).
So, really, for a given incident, try it, see if it helps. If it does, great, if it doesn't, stop taking it.
So, really, for a given incident, try it, see if it helps. If it does, great, if it doesn't, stop taking it.
According to whom?
American law is so disjointed.
On one hand, we're decriminalizing drugs. Pot is widely legal now. Other states are allowing mushrooms and LSD. Cocaine and heroin are not legal, but have all but been decriminalized on the West Coast.
Meanwhile it's harder than ever to get pain killers from your doctor, even when you have a demonstrated need for them. Same with ephedrine -- a very useful drug -- it's very difficult to get even when in need. And if you mention enjoying tobacco products, you're treated as a leper.
I wish we had a self-consistent view of the issue.
On one hand, we're decriminalizing drugs. Pot is widely legal now. Other states are allowing mushrooms and LSD. Cocaine and heroin are not legal, but have all but been decriminalized on the West Coast.
Meanwhile it's harder than ever to get pain killers from your doctor, even when you have a demonstrated need for them. Same with ephedrine -- a very useful drug -- it's very difficult to get even when in need. And if you mention enjoying tobacco products, you're treated as a leper.
I wish we had a self-consistent view of the issue.
It's not inconsistent to treat different things differently and different drugs are radically different in their individual health and societal effects.
I live in Seattle where marijuana is legal. Alcohol and marijuana are widely consumed and I rarely see any large-scale problems from it. Obviously, there are many people who can't handle either of those, but their failure to handle it well seems to not impinge on others as much. And, compared to them, there are a huge number of people able to consume alcohol and marijuana in a safe, healthy, non-problematic way.
I also live next to a couple of homeless encampments. Many of the people living there are clearly addicted to opioids and/or meth. In just this month and within a mile of my house:
* I saw a woman, topless, brandishing an umbrella, wandering between the sidewalk and into the street screaming at no one.
* A man was shot in the stomach in front of a food bank.
* Another man was shot in the neck at an encampment.
* A drive-by shot up an RV and car. (The people inside fortunately weren't hit.)
There's more I'm sure but these are just the ones I know about in the last few weeks.
It's entirely consistent to say that we should treat drugs that lead to the latter behavior differently from drugs that don't. Opioids and meth are incredibly destructive. I'm not saying what specific policies I advocate for them, just that it is reasonable to have different policies for those drugs compared to others.
I live in Seattle where marijuana is legal. Alcohol and marijuana are widely consumed and I rarely see any large-scale problems from it. Obviously, there are many people who can't handle either of those, but their failure to handle it well seems to not impinge on others as much. And, compared to them, there are a huge number of people able to consume alcohol and marijuana in a safe, healthy, non-problematic way.
I also live next to a couple of homeless encampments. Many of the people living there are clearly addicted to opioids and/or meth. In just this month and within a mile of my house:
* I saw a woman, topless, brandishing an umbrella, wandering between the sidewalk and into the street screaming at no one.
* A man was shot in the stomach in front of a food bank.
* Another man was shot in the neck at an encampment.
* A drive-by shot up an RV and car. (The people inside fortunately weren't hit.)
There's more I'm sure but these are just the ones I know about in the last few weeks.
It's entirely consistent to say that we should treat drugs that lead to the latter behavior differently from drugs that don't. Opioids and meth are incredibly destructive. I'm not saying what specific policies I advocate for them, just that it is reasonable to have different policies for those drugs compared to others.
You don't see anyone who is using opioids in the privacy of their own home who aren't out on the streets, so your sampling is massively biased.
And the way we should look at drug addition with opiates isn't by looking at the homeless users, but consider the fact that we're all potentially one bad car accident away from getting hooked on pain killers, and asking what kind of support we would need to avoid winding up homeless due to that.
Punishment via the criminal justice system is what is likely to wind up with you losing your job and winding up out there in that camp with them. So how should you be treated if it happens to you?
And the glib answer of "put a bullet in my head" or whatever isn't an acceptable response. Treat the problem seriously and propose how society helps you help yourself to get clean without at trip through a homeless camp. And the people who refuse to deal with the reality that it could happen to them or engage with the problem are likely those most at risk of lacking the self-awareness to recognize when it starts happening to them.
And the way we should look at drug addition with opiates isn't by looking at the homeless users, but consider the fact that we're all potentially one bad car accident away from getting hooked on pain killers, and asking what kind of support we would need to avoid winding up homeless due to that.
Punishment via the criminal justice system is what is likely to wind up with you losing your job and winding up out there in that camp with them. So how should you be treated if it happens to you?
And the glib answer of "put a bullet in my head" or whatever isn't an acceptable response. Treat the problem seriously and propose how society helps you help yourself to get clean without at trip through a homeless camp. And the people who refuse to deal with the reality that it could happen to them or engage with the problem are likely those most at risk of lacking the self-awareness to recognize when it starts happening to them.
> You don't see anyone who is using opioids in the privacy of their own home who aren't out on the streets
I also don't see anyone who is using alcohol and marijuana in the privacy of their own home.
My sampling is biased in that it doesn't accurately reflect the percentage all people using those various drugs. But it is (I believe) relatively unbiased in that it shows that of the people whose drug use concurrent with homelessness a much higher fraction of them are using opioids or meth compared to booze and pot.
I think there is a reasonable inference there that using opioids or method is much more likely to result in homelessness than using booze or pot.
Again, I'm not making any claims about what our policies should be for opioids and method. All I claim is that it's entirely reasonable to have different policies for them versus booze, pot—hell, caffeine—because while, sure, they are all technically drugs, they are radically different in how they affect individuals and society at large.
I'll also point out that I didn't suggest criminalizing hard drug use. Also, of the four epidodes I described, only one is about drug use itself. The other three were violent crimes whose victims were homeless people.
I also don't see anyone who is using alcohol and marijuana in the privacy of their own home.
My sampling is biased in that it doesn't accurately reflect the percentage all people using those various drugs. But it is (I believe) relatively unbiased in that it shows that of the people whose drug use concurrent with homelessness a much higher fraction of them are using opioids or meth compared to booze and pot.
I think there is a reasonable inference there that using opioids or method is much more likely to result in homelessness than using booze or pot.
Again, I'm not making any claims about what our policies should be for opioids and method. All I claim is that it's entirely reasonable to have different policies for them versus booze, pot—hell, caffeine—because while, sure, they are all technically drugs, they are radically different in how they affect individuals and society at large.
I'll also point out that I didn't suggest criminalizing hard drug use. Also, of the four epidodes I described, only one is about drug use itself. The other three were violent crimes whose victims were homeless people.
Alcohol, marijuana and caffeine aren't anywhere near as likely to lead to someone losing their job.
You've observed that the most highly criminalized drugs are used by the people who have probably been the most affected by trying to use the criminal justice system as our drug treatment program.
You need to disentangle the effects of the drug from the effects of how we treat the users of the drug. You can't look at the end product at attribute it entirely to the inherent properties of the substance. You're not observing it in a sociological vacuum.
You've observed that the most highly criminalized drugs are used by the people who have probably been the most affected by trying to use the criminal justice system as our drug treatment program.
You need to disentangle the effects of the drug from the effects of how we treat the users of the drug. You can't look at the end product at attribute it entirely to the inherent properties of the substance. You're not observing it in a sociological vacuum.
The fallout from the over-criminalization of opioids, meth, etc is a big reason that you're observing these behaviors. Stigmatizing drug use perpetuates the punitive approach to this problem. If the law treated addiction and the abuse of hard drugs with compassion rather than the draconian approach that we have in place currently you'd be seeing a lot less of this stuff.
This post could have easily been written about alcohol in the prohibition era. We've since learned that criminalizing alcohol makes its impact on society worse rather than better. We can't strip drug users of their autonomy and their ability to lead any sort of normal life and then act surprised when they turn to crime or turn back to drugs when they have nothing left.
This post could have easily been written about alcohol in the prohibition era. We've since learned that criminalizing alcohol makes its impact on society worse rather than better. We can't strip drug users of their autonomy and their ability to lead any sort of normal life and then act surprised when they turn to crime or turn back to drugs when they have nothing left.
> This post could have easily been written about alcohol in the prohibition era. We've since learned that criminalizing alcohol makes its impact on society worse rather than better.
It's worth remembering that Prohibition was, in fact, quite successful: https://www.vox.com/the-highlight/2019/6/5/18518005/prohibit...
To quote that article:
> Across the Hudson River, in Manhattan, the number of patients treated in Bellevue Hospital’s alcohol wards dropped from fifteen thousand a year before Prohibition to under six thousand in 1924. Nationally, cirrhosis deaths fell by more than a third between 1916 and 1929. In Detroit, arrests for drunkenness declined 90 percent during Prohibition’s first year. Domestic violence complaints fell by half.
Of course, one can still find Prohibition objectionable, or think that the costs outweighed the benefits. But there is strong evidence that Prohibition succeeded in reducing some of the negative impacts of alcohol use.
It's worth remembering that Prohibition was, in fact, quite successful: https://www.vox.com/the-highlight/2019/6/5/18518005/prohibit...
To quote that article:
> Across the Hudson River, in Manhattan, the number of patients treated in Bellevue Hospital’s alcohol wards dropped from fifteen thousand a year before Prohibition to under six thousand in 1924. Nationally, cirrhosis deaths fell by more than a third between 1916 and 1929. In Detroit, arrests for drunkenness declined 90 percent during Prohibition’s first year. Domestic violence complaints fell by half.
Of course, one can still find Prohibition objectionable, or think that the costs outweighed the benefits. But there is strong evidence that Prohibition succeeded in reducing some of the negative impacts of alcohol use.
Interesting, thanks! I think I mostly took issue with the idea that throwing drug users in jail is the best course of action, and the condescending/judgemental tone of the original comment. I think we can dissuade substance use and abuse through other means (better drug education and rehabilitation, taxation, non-felony level criminalization) that will be a good middle ground between no drug laws and the draconian life-ruining ones that we have in place right now.
> The fallout from the over-criminalization of opioids, meth, etc is a big reason that you're observing these behaviors.
Didn't the massive opiod epidemic occur before they were criminalized?
Didn't the massive opiod epidemic occur before they were criminalized?
Opioid possession without a prescription is a class C felony
I believe the parent is referring to policies about how addiction is defined; a good article on the matter is
https://slatestarcodex.com/2019/09/16/against-against-pseudo...
Essentially by rules a patient asking for higher dosage of an addictive drug is automatically seen as a sign of addiction, even if sometime it might just be that the current dosage is too low.
https://slatestarcodex.com/2019/09/16/against-against-pseudo...
Essentially by rules a patient asking for higher dosage of an addictive drug is automatically seen as a sign of addiction, even if sometime it might just be that the current dosage is too low.
I just finished reading The Urge: Our history of Addiction. If you're interested in some background on how we got here, the author does a great job of laying out the historical, legal, and social constructs that have resulted in the inconsistent mess.
https://www.harvard.com/book/the_urge/
https://www.harvard.com/book/the_urge/
>all but been decriminalized on the West Coast.
There's talk that WA is going to introduce a bill in the next session to completely decriminalize.
There's talk that WA is going to introduce a bill in the next session to completely decriminalize.
There is probably some truth to this but it is worth noting the opiod epidemic is largely why it's hard to get pain killers now. A few of the pharma companies have settled that they sort of knew people were taking them from pharmacies and selling them on the black market.
“Cocaine and heroin are not legal, but have all but been decriminalized on the West Coast.”
Citation needed. Never heard this before now. Or is this just some California thing?
Citation needed. Never heard this before now. Or is this just some California thing?
In several cities they are now citations. You may get a fine for possession but you will not be arrested. In Portland for example the ticket is around $150, which is about the same as the fee for an expired vehicle registration. This change in policies has basically stopped enforcement. As you can imagine it is not a profitable practice to ticket the unhoused.
In Canada you can find cough & cold medications in both the Phenylephrine and Pseudoephedrine formulation, often under near-identical labels (IIRC one can buy "Tylenol Cough and Cold" with either active ingredient, for example - carefully checking the label is the only way to tell). I didn't realize there was a difference until one day after running out of Phenylephrine-based medication I bought the Pseudoephedrine-based one - it was a night and day difference! Now I tell everybody with a cold to check the labels and buy the good stuff.
Interesting case study in being able to sell a low-quality product (one of the most important active ingredients doesn't work!) side-by-side with a much better product and most people won't ever notice that one is better.
Interesting case study in being able to sell a low-quality product (one of the most important active ingredients doesn't work!) side-by-side with a much better product and most people won't ever notice that one is better.
In US, same deal, but you have to show your ID at the counter to obtain the pseudophedrine version. Phenylephrine is so useless. Nothing worse than getting to a store after pharmacy hours and being forced to only get the useless garbage.
From what I've read, d-amphetamine[0] was the decongestant of choice for much of the 20th century. It's just that the counterculture weirdos were abusing it and that led to its restriction. Compared to pseudoephedrine its way more useful with minimal side effects like drinking a cup of coffee.
[0]https://www.theatlantic.com/health/archive/2012/04/the-lost-...
[0]https://www.theatlantic.com/health/archive/2012/04/the-lost-...
I mentioned in my last comment that Sudafed had effects in treating my ADHD.
Ultimately I couldn't use it this way more than a few days a week or I'd get lower back pain. I've also tried steeping ephedra tea but did not notice any effects on concentration.
Later on when I was formally diagnosed and prescribed proper meds I was placed on Adderall first and had similar unwanted side effects after a time. Ultimately, I settled on Dexedrine and no more side effects (other than insomnia if I take it too late) and haven't felt a need to up the dose for years now. It does still have decongestant effects like the other two.
Considering I'm caffeine dependent and can't cycle off daily intake without crippling headaches, where I cycle Dexedrine off on the weekends/holidays without any withdrawal effects, I'd have to agree: So long as it's a therapeutic dose it's on-par or safer than coffee.
Ultimately I couldn't use it this way more than a few days a week or I'd get lower back pain. I've also tried steeping ephedra tea but did not notice any effects on concentration.
Later on when I was formally diagnosed and prescribed proper meds I was placed on Adderall first and had similar unwanted side effects after a time. Ultimately, I settled on Dexedrine and no more side effects (other than insomnia if I take it too late) and haven't felt a need to up the dose for years now. It does still have decongestant effects like the other two.
Considering I'm caffeine dependent and can't cycle off daily intake without crippling headaches, where I cycle Dexedrine off on the weekends/holidays without any withdrawal effects, I'd have to agree: So long as it's a therapeutic dose it's on-par or safer than coffee.
That's dangerous to think it's the same as coffee. You can have a daily coffee when pregnant but we don't know about a daily dl-amphetamine. Not even close to the same side-effect profile. Coffee doesn't dilate your eyes, for starters. It's just not the same as a dopaminergic
Dexedrine is a normal ADHD medicine so this has been studied and it seems fine.
eg https://journals.sagepub.com/doi/10.1177/1087054719896857
eg https://journals.sagepub.com/doi/10.1177/1087054719896857
This is really good news but hardly a comprehensive meta analysis over thousands of infants.
Well, it's not the only study, it's just an example. I think it was already generally considered safe but doctors were worried it might be passed on through breastfeeding.
Sure but I would not equate with coffee which empirically we know can be well-tolerated by most of the population basically from birth to death.
Adderall (dl mixture) is just not the same. We know Adderall tends to exacerbate acne and some forms of dermatitis but we don't know how much. We don't know if the pupil effects contribute to driving incidents. We don't know if dry mouth from Adderall is worse for dental health than the dry mouth that some people get after heavy espresso or other stimulating substances, like pseudoephedrine. We don't think the risk of paranoid behavior is high but it is higher than coffee, of course.
And of course some not insignificant portion of the population can tolerate coffee or pseudoephedrine, but we're not too sure about Adderall. Schizophrenic, bipolar, OCD individuals, those with tics, tachycardia, etc, need to tread carefully with stimulants, even maybe sudafed.
Adderall (dl mixture) is just not the same. We know Adderall tends to exacerbate acne and some forms of dermatitis but we don't know how much. We don't know if the pupil effects contribute to driving incidents. We don't know if dry mouth from Adderall is worse for dental health than the dry mouth that some people get after heavy espresso or other stimulating substances, like pseudoephedrine. We don't think the risk of paranoid behavior is high but it is higher than coffee, of course.
And of course some not insignificant portion of the population can tolerate coffee or pseudoephedrine, but we're not too sure about Adderall. Schizophrenic, bipolar, OCD individuals, those with tics, tachycardia, etc, need to tread carefully with stimulants, even maybe sudafed.
Counterculture weirdos and Paul Erdos
Original NyQuil also had a healthy shot of ethyl alcohol in it. Exactly the thing you weren't supposed to mix with pseudoephedrine.
I believe you're just not supposed to drink alcohol on Pseudoephedrine because you'd be combining an upper with a downer, and it's very easy to go overboard with the downers when you're on an upper (tolerance to alcohol increases dramatically and increases overdose risk along with all the other side effects and risks.)
So a small amount of alcohol won't really have much of an effect, I'd claim.
So a small amount of alcohol won't really have much of an effect, I'd claim.
In my experiences with old NyQuil it was enough to make you drowsier. And getting to sleep was the primary objective of NyQuil.
Back in my college days you could replicate it with one 30mg Sudafed and a shot of Jagermeister. =)
Back in my college days you could replicate it with one 30mg Sudafed and a shot of Jagermeister. =)
> NyQuil
I don't know about this medication in particular (since I don't live in the US), but I see it contains DXM (dextromethorphan), which is a dissociative (such as ex. ketamine), which probably causes the effects you described. I'm seeing it also contains acetaminophen, which probably makes it hard on your kidneys, if you take too much, so that is probably why people don't abuse it more (I guess or hope).
I don't know about this medication in particular (since I don't live in the US), but I see it contains DXM (dextromethorphan), which is a dissociative (such as ex. ketamine), which probably causes the effects you described. I'm seeing it also contains acetaminophen, which probably makes it hard on your kidneys, if you take too much, so that is probably why people don't abuse it more (I guess or hope).
in the US Robitussin DM is the one you get if you aim for disassociation(?) - NyQuil is explicitly a sleep aid with some other stuff mixed in, I'd have to go dig a bottle out but i think the active ingredient is an anti-histamine (diphenylhydramine i think) - as a sleep aid, mind you. It is true that NyQuil used to have alcohol, and didn't have DXM or acetaminophen. If the liquid you are looking at is Orange, that's the "daytime" stuff, and that's overpriced garbage.
One could buy generic "tussin DM" (or pill form of dextro), mucinex (for guafenasin), and benadryl (or generic diphenylhydramine) to get the same usefulness that a bottle of liquid NyQuil has.
One could buy generic "tussin DM" (or pill form of dextro), mucinex (for guafenasin), and benadryl (or generic diphenylhydramine) to get the same usefulness that a bottle of liquid NyQuil has.
It still does have alcohol[1]:
> Q: How much alcohol is in NyQuil?
> A: NyQuil Liquid contains 10 percent alcohol. NyQuil LiquiCaps does not contain alcohol. Alcohol-Free NyQuil Cold & Flu Nighttime Relief Liquid does not contain alcohol.
https://vicks.com/en-us/safety-and-faqs/faqs/vicks-nyquil-fa...
> Q: How much alcohol is in NyQuil?
> A: NyQuil Liquid contains 10 percent alcohol. NyQuil LiquiCaps does not contain alcohol. Alcohol-Free NyQuil Cold & Flu Nighttime Relief Liquid does not contain alcohol.
https://vicks.com/en-us/safety-and-faqs/faqs/vicks-nyquil-fa...
Didn’t they also drop the alcohol percentage? It’s 10% now (I know this because post Covid I seem to be catching EVERYTHING), I could have sworn it was 14% or higher growing up.
This may be regional, but it's been 10% here for as long as I can recall - although the alcohol free version is much more prevalent than it used to be.
InCityDreams(1)
This works for one or two nights with me, and then it feels like I've built up a tolerance to it and I think that it actually keeps me awake. I'll use it if I have a cough which keeps me awake, and, if I time it right, I'm pretty good at recovering within a day or two.
Yes, I have the exact same response. If I take it more than a few days, I'll get a rebound effect.
My strategy is to take it full strength for a day or two and then taper it off gradually for the next few days after that.
My strategy is to take it full strength for a day or two and then taper it off gradually for the next few days after that.
Probably would be better to take two shots of whisky, a teaspoon of honey and a shot of Afrin in each nostril[0]. NyQuil isn't what it used to be.
[0] Careful, you can easily form an "addiction" to this med.
[0] Careful, you can easily form an "addiction" to this med.
The lack of availability of proper pseudoephedrine in USA led to situation where there are papers describing how to turn methamphetamine into pseudoephedrine, not the other way around.
With explanation in abstract that its easier to buy meth than pseudoephedrine.
With explanation in abstract that its easier to buy meth than pseudoephedrine.
> With explanation in abstract that its easier to buy meth than pseudoephedrine.
People may laugh at this, as they should since it is an absurd situation, but this isn't entirely wrong.
Neither my wife or I drive and during the pandemic she gave up her license after getting an appointment at the DOL was difficult. Both of us carry US passport cards as our ID.
This has resulted in several situations where we've been turned down for purchasing restricted items like alcohol or drugs containing pseudoephedrine, particularly the latter, because a passport card can't be scanned by the usual point of sale systems. There are a couple of places in Seattle that are happy to accept a passport card but even at them it's sometimes been dependent on who is working the counter that day.
People may laugh at this, as they should since it is an absurd situation, but this isn't entirely wrong.
Neither my wife or I drive and during the pandemic she gave up her license after getting an appointment at the DOL was difficult. Both of us carry US passport cards as our ID.
This has resulted in several situations where we've been turned down for purchasing restricted items like alcohol or drugs containing pseudoephedrine, particularly the latter, because a passport card can't be scanned by the usual point of sale systems. There are a couple of places in Seattle that are happy to accept a passport card but even at them it's sometimes been dependent on who is working the counter that day.
Gotta chime in on this.
Seattle (in general a great place) has some pretty horrible things re: purchasing alcohol. Idiot/mis-placed store/bar-workers who only want a state ID. My U.S. passport=NO. My U.N. passport=NO.
Freakin' weird.
Edit: I worked at Boeing for eight years, very often in a sec/reserved area. My passport was good there. Buying booze down the street from [Boeing] plant 2, no.
Freakin' weird.
Edit: I worked at Boeing for eight years, very often in a sec/reserved area. My passport was good there. Buying booze down the street from [Boeing] plant 2, no.
> My U.N. passport=NO.
I wouldn't blame a regular store clerk for not knowing what a UN Lassiez-Passier is, especially since it doesn't have the word "passport" in the name. But a passport, especially one from their own country, definitely ought to be recognized.
I wouldn't blame a regular store clerk for not knowing what a UN Lassiez-Passier is, especially since it doesn't have the word "passport" in the name. But a passport, especially one from their own country, definitely ought to be recognized.
Not entirely unique to Seattle, in my experience.
Seared into my head is my experience of trying to buy alcohol in Boston back in 2009, when I was in town for a wedding. I had just turned 21 so buying alcohol was still novel and exciting. I had multiple bars and liquor stores refuse my valid Illinois license, forcing me to hand alcohol to my father to purchase, and find shady bars that wouldn’t card me. It was extremely frustrating to have to rely on such tactics despite being legally allowed to purchase alcohol.
Seared into my head is my experience of trying to buy alcohol in Boston back in 2009, when I was in town for a wedding. I had just turned 21 so buying alcohol was still novel and exciting. I had multiple bars and liquor stores refuse my valid Illinois license, forcing me to hand alcohol to my father to purchase, and find shady bars that wouldn’t card me. It was extremely frustrating to have to rely on such tactics despite being legally allowed to purchase alcohol.
When I lived in downtown Seattle in 2010 I had no problems using a passport to buy alcohol. (Unfortunately, routinely carrying around my passport resulted in me losing it, and replacing a lost passport is a giant pain in the ass)
Weird. Even during covid when I was wearing a mask, I never got ID checked at a store in WA. It seems much laxer here than in other states I've lived in.
Why not get a non-motorist ID card? Every US state has these; here's Washington's: https://www.dol.wa.gov/driverslicense/gettingidcard.html
We are aware of these. The reason is: Because unless you get the "enhanced" version, due to the ridiculous REAL ID situation you have to have another card anyway. For me in particular, where I work operates a medical clinic in a facility owned by the federal government so a non-enhanced card doesn't get me in the door, but a passport card does.
For my wife, it's because she has even less tolerance for paperwork than I do and it's easier to just go to the pharmacies we know have their heads bolted on straight than it is to gather up all of the stuff and go to the overworked and harried DOL.
For my wife, it's because she has even less tolerance for paperwork than I do and it's easier to just go to the pharmacies we know have their heads bolted on straight than it is to gather up all of the stuff and go to the overworked and harried DOL.
[deleted]
Many Americans have difficulty obtaining ID, because they cannot afford or cannot obtain the underlying documents that are a prerequisite to obtaining government-issued photo ID card.
Underlying documents required to obtain ID cost money, a significant expense for lower-income Americans. The combined cost of document fees, travel expenses and waiting time are estimated to range from $75 to $175.
The travel required is often a major burden on people with disabilities, the elderly, or those in rural areas without access to a car or public transportation. In Texas, some people in rural areas must travel approximately 170 miles to reach the nearest ID office.
Underlying documents required to obtain ID cost money, a significant expense for lower-income Americans. The combined cost of document fees, travel expenses and waiting time are estimated to range from $75 to $175.
The travel required is often a major burden on people with disabilities, the elderly, or those in rural areas without access to a car or public transportation. In Texas, some people in rural areas must travel approximately 170 miles to reach the nearest ID office.
That's true and all, but the person I was replying to already has a federal passport, which suffices for all levels of state ID.
Do you have any specific citations on that?
I find it a credible claim. There was a story a few years back which made the rounds that ... turned out to be a case of fraud.
http://www.miamiherald.com/news/nation-world/national/articl...
https://www.inquirer.com/news/mark-damico-johnny-bobbitt-kat...
That said, given frictions of obtaining ID and necessity of having same, I could well believe that this is an issue.
I find it a credible claim. There was a story a few years back which made the rounds that ... turned out to be a case of fraud.
http://www.miamiherald.com/news/nation-world/national/articl...
https://www.inquirer.com/news/mark-damico-johnny-bobbitt-kat...
That said, given frictions of obtaining ID and necessity of having same, I could well believe that this is an issue.
It can be quite a headache.
I ran into a guy online that couldn't obtain an ID, period. The only form of ID he had was a driver's license. His doctor pulled it (legitimately, but needlessly--there was no question he was incapable of driving) leaving him with nothing. Where he lives that left one option--get a birth certificate. The application must be signed--something he's no longer capable of doing. The only other route would be to show up in person at the right office--multiple states away, a trip that would be medically ill-advised.
Note that he's educated and not poor, this is purely a problem of the system not handling the oddball cases. That state needs to be clobbered with a clue-by-4, if you pull a driver's license you should issue the person a non-driver's ID!
We have also run into a problem. When my wife was naturalized a hyphen got inserted in her name on her naturalization certificate, it wasn't noticed at the time. Almost everything is in her name as intended but social security saw the hyphen and would not relent. Even after we legally changed her name to rid it of the hyphen they were digging in their heels on changing the records. At this point we *think* the Real ID stuff is going to work, but the virus interfered. For the occasional place that won't accept her expired ID we use her passport card. (She doesn't drive, there's no issue of driving on an expired license.)
I ran into a guy online that couldn't obtain an ID, period. The only form of ID he had was a driver's license. His doctor pulled it (legitimately, but needlessly--there was no question he was incapable of driving) leaving him with nothing. Where he lives that left one option--get a birth certificate. The application must be signed--something he's no longer capable of doing. The only other route would be to show up in person at the right office--multiple states away, a trip that would be medically ill-advised.
Note that he's educated and not poor, this is purely a problem of the system not handling the oddball cases. That state needs to be clobbered with a clue-by-4, if you pull a driver's license you should issue the person a non-driver's ID!
We have also run into a problem. When my wife was naturalized a hyphen got inserted in her name on her naturalization certificate, it wasn't noticed at the time. Almost everything is in her name as intended but social security saw the hyphen and would not relent. Even after we legally changed her name to rid it of the hyphen they were digging in their heels on changing the records. At this point we *think* the Real ID stuff is going to work, but the virus interfered. For the occasional place that won't accept her expired ID we use her passport card. (She doesn't drive, there's no issue of driving on an expired license.)
All you had to do is ask for a free state ID card.
- It’s Federal law.
I don’t know why people keep forking over money for state ID. It’s a state government scam.
- It’s Federal law.
I don’t know why people keep forking over money for state ID. It’s a state government scam.
> Underlying documents required to obtain ID cost money
Err, no they don't. At least not with any of the IDs I've gotten in California for the past several years....
Err, no they don't. At least not with any of the IDs I've gotten in California for the past several years....
The county in California where I was born charges $32 for a birth certificate. Most (all?) of the proof of address documents also require you to spend money. If you already have multiple utility bills in your name it's NBD, but if you live with someone it could be a pain in the ass.
Then a DL itself is another $40. A non-driving ID is like $30, although there's discounts depending on age and income.
Then a DL itself is another $40. A non-driving ID is like $30, although there's discounts depending on age and income.
Where can you get a certified birth certificate for free?
Yes, but you live in the People's Republic of California.
I'm next door in Nevada.
Scraping together the required documentation for proving her address was problematic. I set up the utilities, I'm the one that deals with them, they're just in my name. She doesn't like dealing with that sort of stuff and at the time most of it was done her English (she learned her first word of English at 43) would have added needless complexity.
Even the property records are problematic on that--we put our house into an estate-planning trust. The correct titling of the property has the trust and then both of our names--but the system only *displays* two lines. Thus it shows the trust and then my name, hers gets omitted.
Scraping together the required documentation for proving her address was problematic. I set up the utilities, I'm the one that deals with them, they're just in my name. She doesn't like dealing with that sort of stuff and at the time most of it was done her English (she learned her first word of English at 43) would have added needless complexity.
Even the property records are problematic on that--we put our house into an estate-planning trust. The correct titling of the property has the trust and then both of our names--but the system only *displays* two lines. Thus it shows the trust and then my name, hers gets omitted.
I believe this is the key element:
> she gave up her license after getting an appointment at the DOL was difficult.
I'm not sure what DOL is a reference to; however I now many individuals struggled to get appointments at the Secretary of State (SoS) and that is also where one (at least where I live) would need to get a non-motorist ID. Same amount of frustration / time spent to get a non-motorist ID as it would be to renew your driver license.
> she gave up her license after getting an appointment at the DOL was difficult.
I'm not sure what DOL is a reference to; however I now many individuals struggled to get appointments at the Secretary of State (SoS) and that is also where one (at least where I live) would need to get a non-motorist ID. Same amount of frustration / time spent to get a non-motorist ID as it would be to renew your driver license.
DOL = Washington Department of Licensing: https://www.dol.wa.gov/
DOL ~= DMV = RMV
In Illinois, it's the Secretary of State's Driver Services office. In Texas, it's the Department of Public Safety, and your plates may be in one building/location and your driver's license/state ID in another part of town.
Maybe the most honest state is Missouri, where plates, stickers for them, and your driver's license are all handled by the state's Department of Revenue.
Maybe the most honest state is Missouri, where plates, stickers for them, and your driver's license are all handled by the state's Department of Revenue.
Would that not still require an in-person visit that they've already stated was not possible? I'd assume the state would require a new photo for a new ID at the least to make an in-person visit required. Probably need new fingerpritns as well (if that's something WA does).
Society wouldn't function if people weren't willing to bend the rules.
Not really sure what you're on about here. There's a time and place where bending the rules is possible. Attempting to get a government issued ID and not following the basic rules of showing up in person is not really one of them in my book.
But why get one? A passport/passport card is a _better_ ID document in almost every way. State non-motorist IDs should really cease to exist and we should increase access to passport cards
Except for the way of not being scannable at point of purchase machines that was clearly stated. So if the one point qualifying for "almost every way" is hitting right out of the gate, then it doesn't seem to be that viable of an option.
>State non-motorist IDs should really cease to exist
State non-motorist IDs are some of the only IDs available to non-citizens who live in the US and don't drive
State non-motorist IDs are some of the only IDs available to non-citizens who live in the US and don't drive
Don't they presumably have a US alien ID (Green Card or otherwise) and/or a foreign passport? What other documents could they use to establish identity to be able to get a State ID?
>Don't they presumably have a US alien ID (Green Card or otherwise) and/or a foreign passport
There are millions of visa-holders who live in the US but don't have green cards. Carrying around a foreign passport for everyday identification is an absolutely terrible idea because of the risk of theft or loss. Losing a visa-containing foreign passport can necessitate getting an emergency travel document from your foreign-country consulate, traveling back to your home country, getting a new passport, getting an appointment at the US embassy in your home country, getting a new visa issued in your new passport, then finally traveling back to the US. The whole process could take weeks or months and cost thousands of dollars.
There are millions of visa-holders who live in the US but don't have green cards. Carrying around a foreign passport for everyday identification is an absolutely terrible idea because of the risk of theft or loss. Losing a visa-containing foreign passport can necessitate getting an emergency travel document from your foreign-country consulate, traveling back to your home country, getting a new passport, getting an appointment at the US embassy in your home country, getting a new visa issued in your new passport, then finally traveling back to the US. The whole process could take weeks or months and cost thousands of dollars.
My wife is foreign-born, but was in the US as a non-resident when our hearts turned proximity into much more. Since she was already here the whole application process took place in the US. It was just under two years from when we married until she had a green card. (And note that there is also a delay from being granted a green card to actually having one in one's possession.)
Foreign passport and non-driver's ID were her only options--and passports are a nuisance to carry around and a PITA if lost/stolen.
(And, yes, I think that just under two years bit was not by chance. They were definitely looking for signs of fraud and I'm sure they finally approved it just before the point where they would have had to issue a permanent one rather than a conditional one.)
Foreign passport and non-driver's ID were her only options--and passports are a nuisance to carry around and a PITA if lost/stolen.
(And, yes, I think that just under two years bit was not by chance. They were definitely looking for signs of fraud and I'm sure they finally approved it just before the point where they would have had to issue a permanent one rather than a conditional one.)
And, a government photo ID is required to get a passport. A state ID is very useful for non-driving citizens, as well as non-citizens.
[deleted]
As someone who moved to Seattle during the pandemic, I knew when you mentioned getting an appointment with the DOL that it was probably WA. I had to go out to Wenatchee (2 hour drive each way) to get my license because everywhere else was booked.
Yeah, many years ago my wife had a fair problem at a bank because the teller didn't like being presented with a passport. "Just bring your driver's license!" Hey, you've already seen and rejected her non-driver's ID (at the time the non-driver IDs didn't have expiration dates and the bank wouldn't take any ID without an expiration date) and here you can't have both a driver's license and a non-driver's ID. It took getting a manager involved.
Now, had this happened a few years earlier before she was naturalized.... While her passport did have the standard English labels it was mostly written in bird tracks.
Now, had this happened a few years earlier before she was naturalized.... While her passport did have the standard English labels it was mostly written in bird tracks.
> People may laugh at this
Not to spoil the joke, but the paper by "O. Hai" and "I. B. Hakkenshit" is satire--I would be absolutely gobsmacked if anyone is actually doing this.
Not to spoil the joke, but the paper by "O. Hai" and "I. B. Hakkenshit" is satire--I would be absolutely gobsmacked if anyone is actually doing this.
Right.
Here's a copy of the paper, if anyone is interested:
https://maggiemcneill.files.wordpress.com/2012/03/synthesizi...
Here's a copy of the paper, if anyone is interested:
https://maggiemcneill.files.wordpress.com/2012/03/synthesizi...
The process described is true, but the authors are anonymous - and rightly snarky
My favorite REAL ID compliant ID to use is my Global Entry card.
A divers license or state issue ID (much easier to get if you get it before you surrender/expire you DL) is just a defacto standard in the US.
The people who check IDs for medications and alcohol are trained to check DL cards, not passports. It's not surprising that using an ID different from 99.9% of other people causes issues. Although my friend who was a student from Germany never had any issues...
The people who check IDs for medications and alcohol are trained to check DL cards, not passports. It's not surprising that using an ID different from 99.9% of other people causes issues. Although my friend who was a student from Germany never had any issues...
"While N-methylamphetamine itself is a powerful
decongestant, it is less desirable in a medical setting because
of its severe side effects and addictive properties... Other side
effects may include violent urges or, similarly, the urge to be
successful in business or finance."
Authored by O. Hai, and I. B. Hakkenshit
[deleted]
Thank you for making my day.
It would be interesting to see if there were any reliable stats on how many, if any, people were caught by the ID check laws trying to manufacture from pseudoephedrine, because even at the height of the meth panic that engendered the laws something like 95% of pseudoephedrine outside of a handful of high-risk areas was very obviously not being used for any illegal purposes.
I doubt it caught people. That wasn't the purpose. Rather, it deterred them from buying up a bunch of it and thus got rid of the meth labs. And I think that's a good thing--while I am solidly on the side of drug legalization I don't want amateurs making hazmat sites all over the place.
Pseudoephedrine is still available -behind the counter-. You literally just have to ask the pharmacist for it.
Let’s not turn grad students having a laugh into an actual statement on public policy.
Let’s not turn grad students having a laugh into an actual statement on public policy.
Which means it's not available outside of the pharmacist counter's more-limited hours. And there's often an additional line to wait in before acquiring. And, as another thread points out, extra ID requirements.
So how exactly do the costs/benefits on this "public policy" sum out?
Benefits:
• some grandstanding politicians enjoy the superficial appearance of being "tough on meth"
Costs:
• Americans waste $billions on an ineffective placebo decongestant
• Legitimate manufacturers of a working medicine, pseudoephedrine hcl, lose sales due to extra cost/effort/stigma associated with the purchase. They shift real productive resources – inputs & worker hours – to making & marketing placebos instead.
• Larger cross-border criminal organizations – of the kind that regularly murder politicians south-of-the-border – grow in market-share, sophistication, & power.
• Meth continues to be available at high volume, & low costs, unaffected by the pseudoephedrine limits.
• Recent meth formulations – likely prompted by the limits on the pseudoephedrine-process – seem to create a stronger & more-destructive addiction among abusers: https://www.theatlantic.com/magazine/archive/2021/11/the-new...
If we don't listen to 'grad students having a laugh' who are pointing out the wasteful absurdities of 'public policy', we'll keep such nonsense destructive rules indefinitely.
The 'serious folks' among politicians & suited 'public-policy' types are derelict in their duties.
So how exactly do the costs/benefits on this "public policy" sum out?
Benefits:
• some grandstanding politicians enjoy the superficial appearance of being "tough on meth"
Costs:
• Americans waste $billions on an ineffective placebo decongestant
• Legitimate manufacturers of a working medicine, pseudoephedrine hcl, lose sales due to extra cost/effort/stigma associated with the purchase. They shift real productive resources – inputs & worker hours – to making & marketing placebos instead.
• Larger cross-border criminal organizations – of the kind that regularly murder politicians south-of-the-border – grow in market-share, sophistication, & power.
• Meth continues to be available at high volume, & low costs, unaffected by the pseudoephedrine limits.
• Recent meth formulations – likely prompted by the limits on the pseudoephedrine-process – seem to create a stronger & more-destructive addiction among abusers: https://www.theatlantic.com/magazine/archive/2021/11/the-new...
If we don't listen to 'grad students having a laugh' who are pointing out the wasteful absurdities of 'public policy', we'll keep such nonsense destructive rules indefinitely.
The 'serious folks' among politicians & suited 'public-policy' types are derelict in their duties.
> Larger cross-border criminal organizations – of the kind that regularly murder politicians south-of-the-border – grow in market-share, sophistication, & power.
Are you suggesting my neighborhood friendly drug dealer could hook me up with some real sudafed? Might be nicer than trying to get it from the pharmacy when I need it.
Are you suggesting my neighborhood friendly drug dealer could hook me up with some real sudafed? Might be nicer than trying to get it from the pharmacy when I need it.
Not sure if you're joking, but he's suggesting that if bulk pseudoephedrine were still available, cartel meth wouldn't have 99% of the market like it does today.
Because yeah, your neighborhood dealer would make his own meth and would probably have lots of Sudafed.
Because yeah, your neighborhood dealer would make his own meth and would probably have lots of Sudafed.
Around here, you pick up a card from the shelf with a picture of the product you want, then wait in line for the pharmacist. Then they say "Sorry, we're out of that one, what else do you want", "I don't know, what do you have", "sigh... here's what we have left...".
Then you show your drivers license and the pharmacist records it and you pay and finally walk out with your sudafed. If you want to buy several boxes because it's allergy season, well too bad, you can't buy 2 boxes today, you have to come back tomorrow for the second one.
It's actually easier to buy as a prescription, then the Dr can write you a prescription for any amount you need/want.
Then you show your drivers license and the pharmacist records it and you pay and finally walk out with your sudafed. If you want to buy several boxes because it's allergy season, well too bad, you can't buy 2 boxes today, you have to come back tomorrow for the second one.
It's actually easier to buy as a prescription, then the Dr can write you a prescription for any amount you need/want.
My state attempted to make pseudoephedrine require a prescription. One of the state lawmakers that was opposed was a doctor and he cited studies where phenylephrine was less effective than placebo. I wrote to my representative, who called me after voting for the bill to tell me that some sheriff told him phenylephrine is equally effective.
Every time you buy the stuff from the pharmacist, they're logging the purchase in a national DB and you're signing an acknowledgement that it's a huge felony to go beyond the limit. But they never tell you where you are vs the limit, and the limits aren't clearly stated. End result: chilling effect.
My mom timed her purchases incorrectly (family of 5 with mom shopping for all at the time) and went past the limit. After that she was flagged and had to have an actual doctor's prescription in order to purchase pseudoephedrine for 6-12 months. That is a HUGE hurdle for most people, and doctors don't want to see people who have cold symptoms. Heck, I was turned away from a CVS Minute Clinic recently because I had COVID like symptoms in the last 7 days. As in refused to see me, even though I had recently tested negative for COVID and had a fever + persistent cough.
Every time you buy the stuff from the pharmacist, they're logging the purchase in a national DB and you're signing an acknowledgement that it's a huge felony to go beyond the limit. But they never tell you where you are vs the limit, and the limits aren't clearly stated. End result: chilling effect.
My mom timed her purchases incorrectly (family of 5 with mom shopping for all at the time) and went past the limit. After that she was flagged and had to have an actual doctor's prescription in order to purchase pseudoephedrine for 6-12 months. That is a HUGE hurdle for most people, and doctors don't want to see people who have cold symptoms. Heck, I was turned away from a CVS Minute Clinic recently because I had COVID like symptoms in the last 7 days. As in refused to see me, even though I had recently tested negative for COVID and had a fever + persistent cough.
Good to see your representative was getting his information on the effectiveness of medicine from a cop and ignoring the doctor. Emblematic of modern America.
“I asked a cop about how effective an OTC medicine is” is an absolutely insane thing for anyone to say, let alone a legislator. Sadly it does not seem like such behavior receives the social opprobrium it deserves.
You don't just ask the pharmacist for it. You have to produce an acceptable form of identification that can be used to record the transaction in the universal database. It's unavailable to anyone who doesn't have one of those.
If you don't have any form of identification, getting pseudoephedrine from a pharmacy is probably not too high on your to-do list.
I suspect you're wrong. How many people do you think would prefer not having medication to having medication?
He’s definitely wrong. Sometime last year I had a cold and I know pseudoephedrine helps me.
I ran out and wanted to buy some at the local cvs. Now, I’m not a US citizen but I’ve been here a few years already and am a permanent resident. I do not have a US state ID or a US driving license, and in my many years it has _never_ been a problem. Everyone was always happy with my green card as my ID - bars, domestic flights, international flights back to USA, bank account openings etc. But not for purchasing pseudoephedrine at CVS…
I literally stood there with my green card and my European passport and was begging the cvs clerk to sell it to me, but the told me it’s impossible, system doesn’t accept those IDs (and they tried, even showed me their computer screen). And so I had to leave empty handed and with a runny nose, and came back later with an American friend to buy it…
I ran out and wanted to buy some at the local cvs. Now, I’m not a US citizen but I’ve been here a few years already and am a permanent resident. I do not have a US state ID or a US driving license, and in my many years it has _never_ been a problem. Everyone was always happy with my green card as my ID - bars, domestic flights, international flights back to USA, bank account openings etc. But not for purchasing pseudoephedrine at CVS…
I literally stood there with my green card and my European passport and was begging the cvs clerk to sell it to me, but the told me it’s impossible, system doesn’t accept those IDs (and they tried, even showed me their computer screen). And so I had to leave empty handed and with a runny nose, and came back later with an American friend to buy it…
Makes sense. I stand corrected. I was under the assumption you could use a passport.
> Let's not turn grad students having a laugh into an actual statement on public policy.
Not to put too fine a point on it, but... at least this you can't stop me from doing.
Not to put too fine a point on it, but... at least this you can't stop me from doing.
In my state, I'm able to walk down the road to a 24/7 chain pharmacy and buy pseudoephedrine whenever I want. The pharmacy, in combination with the state, uses ID to regulate how much an individual may purchase over some time frame(s).
Most doctors will just write you a prescription and you can get it delivered to your home. Super easy.
Most doctors will just write you a prescription and you can get it delivered to your home. Super easy.
Same here. But I think the edge cases are worth listening to as well. Green card residents, for instance. Sudafed is kind of a lifesaver for me at times and I feel fortunate to be able to buy it relatively easily.
The US would elect a baby-eating space alien from Tau Ceti VI as president if Zbleqq'takkx's primary platform plank was "make it so you can buy real Sudafed without a lot of hassle and faff."
Yeah, US voters do seem to like electing presidents for things only Congress has the power to do. Of course, presidents also like proposing things they can't do.
Presidents' main differences are on foreign policy which is the one thing nobody asks them about.
Presidents' main differences are on foreign policy which is the one thing nobody asks them about.
I don't about anywhere else but the only thing you have to do is walk up to the pharmacist and show an ID. I couldn't care less. I'm buying like a couple of weeks worth. I've had the same process in two different states, and not sure why it's a big deal? We can't have nice things because meth cooks were coming with shopping bags and stealing it all.
The cartels end up selling $200 bottles of cough medicine and making more money that way. Then they lobby to keep it illegal.
Is it also possible to buy meth and turn it into ephedrine? That would be phenomenal
Are chemistry papers describing the synthesis of methamphetamine illegal?
[deleted]
I wonder how difficult it would be to get the restrictions on pseudoephedrine rolled back now that it appears unlikely they're accomplishing their original goal of limiting the methamphetamine supply. Concern (legitimate and otherwise) over ability to breathe is a popular topic in politics lately.
Difficult. Dianne Feinstein was the figure behind the changes, as part of her war on drugs. She wanted pseudoephedrine made prescription only too.
https://www.drugcaucus.senate.gov/press-releases/feinstein-g...
ironically, OR and MS, the states listed in that report, are so far the only 2 that are starting to roll back the restrictions.
Our elected officials seem adverse to admitting something doesn't work well and rolling it back, unfortunately.
https://www.drugcaucus.senate.gov/press-releases/feinstein-g...
ironically, OR and MS, the states listed in that report, are so far the only 2 that are starting to roll back the restrictions.
Our elected officials seem adverse to admitting something doesn't work well and rolling it back, unfortunately.
Every time she's mentioned, there's something to make me dislike Feinstein more than I already did. It does seem likely her strong opposition would be a high bar to clear, though as the oldest current senator, she may not be a factor for a long time.
It really is amazing how someone manages to be on the wrong side of seemingly everything, and yet is locked into office past the point of senility.
[deleted]
Yeah once in a while she does something and I think "ok, that makes sense." But she's generally a broken clock.
Another arrow in my quiver for why the US is honestly not a country to bet on for the next 20 years.
The only countries with better demographic trends than the US are in Africa.
India?
This means that either your calibration mechanism for 'wrong side' is flawed, or the system is rigged in a way that it consistently produces bad outcomes.
Speaking for myself, am shocked and outraged that red senators and other congresscritters are consistently on the wrong side of seemingly everything, yet they keep getting elected. Of course, my political calibration mechanisms are quite in tune.
Speaking for myself, am shocked and outraged that red senators and other congresscritters are consistently on the wrong side of seemingly everything, yet they keep getting elected. Of course, my political calibration mechanisms are quite in tune.
Feinstein's hard authoritarian and surveillance state preferences haven't endeared her to many people who are also shocked and outraged by the usual collection of utterly repugnant red senators, so option B there.
> the system is rigged in a way that it consistently produces bad outcomes.
The system doesn't have to be rigged to produce bad outcomes. Most outcomes are bad, so only a system which is nearly perfect has any hope of producing good outcomes.
The system doesn't have to be rigged to produce bad outcomes. Most outcomes are bad, so only a system which is nearly perfect has any hope of producing good outcomes.
Feinstein is weirdly not aligned with the left or the tech industry given where she's from. Her strong anti-drug and anti-encryption stances are easy examples.
If I had to pick a single organizing principle to describe her positions it would be a bureaucratic sort of authoritarianism (as distinguished from the strongman authoritarianism of someone like Donald Trump).
I do believe the system is rigged in a way that consistently produces bad outcomes. The US Senate is structured to reward voters for keeping incumbents in office, and plurality voting virtually guarantees two dominant parties.
If I had to pick a single organizing principle to describe her positions it would be a bureaucratic sort of authoritarianism (as distinguished from the strongman authoritarianism of someone like Donald Trump).
I do believe the system is rigged in a way that consistently produces bad outcomes. The US Senate is structured to reward voters for keeping incumbents in office, and plurality voting virtually guarantees two dominant parties.
> the system is rigged in a way that it consistently produces bad outcomes.
Yes. That one.
"Real" change (ie, still a useless liberal democracy, but at least a bit more in service to the people) would start with voter reform and getting rid of FPTP entirely.
Yes. That one.
"Real" change (ie, still a useless liberal democracy, but at least a bit more in service to the people) would start with voter reform and getting rid of FPTP entirely.
You wouldn't like the results of either of those if you like "extreme" positions.
- The most popular replacement for FPTP (which is biased away from centrism) is RCV (which is biased towards it).
- FPTP does turn it into a two-party system, but US parties are weak. They don't control who joins them, who gets elected, or how anyone votes. In the UK you can actually get fired from the party for voting wrong.
- The most popular replacement for FPTP (which is biased away from centrism) is RCV (which is biased towards it).
- FPTP does turn it into a two-party system, but US parties are weak. They don't control who joins them, who gets elected, or how anyone votes. In the UK you can actually get fired from the party for voting wrong.
I don't care about "extreme" positions in the context of liberal democracies. I can confidently say that there are great improvements we can make within them while also supporting abolishing them entirely. I like to be at least somewhat pragmatic.
RCV/STV is absolutely an improvement on FPTP in almost every way.
As far as strong vs weak parties, that seems to be an issue with the UK. FPTP and weak-parties are separate sets. You could have FPTP with closed party membership, or RCV/STV with weak parties.
RCV/STV is absolutely an improvement on FPTP in almost every way.
As far as strong vs weak parties, that seems to be an issue with the UK. FPTP and weak-parties are separate sets. You could have FPTP with closed party membership, or RCV/STV with weak parties.
Hate to do this but hopefully she will step down at some point, willingly or not due to her age.
Wow, I did not know Oregon had repealed that already. Apparently, this past June: https://www.chpa.org/news/2021/06/oregon-repeal-unnecessary-...
IIRC, early attempts to repeal failed stalled. (I presumed due to some pharm lobby)
I wonder if Covid and focus on flu like symptoms led to it getting “fast tracked.”
Looks like pseudoephedrine OTC products became available for sale January 1st 2022. https://www.statesmanjournal.com/story/news/politics/2022/01...
I made the drive from Portland to Vancouver, WA multiple times over the years (usually while sick) to resupply with something that worked.
Glad that is done with.
IIRC, early attempts to repeal failed stalled. (I presumed due to some pharm lobby)
I wonder if Covid and focus on flu like symptoms led to it getting “fast tracked.”
Looks like pseudoephedrine OTC products became available for sale January 1st 2022. https://www.statesmanjournal.com/story/news/politics/2022/01...
I made the drive from Portland to Vancouver, WA multiple times over the years (usually while sick) to resupply with something that worked.
Glad that is done with.
Pessimistic me says not likely. Once these regulations are put in place, it is nearly impossible to get them removed. It takes a literal act of Congress. Now you have to spend useless energy against attacks of "soft on crime/drug abuse/etc" types of nonsense for suggesting removing an item from the list. Don't bother resorting to facts. Those are useless in the emotional knee jerk reactions that will ensue.
It's happening slowly. Oregon had pushed it all the way to requiring a prescription to get pseudoephedrine. It does still require a visit to the store pharmacy and showing your ID to prove you are an adult, but at least you can buy it without a prescription now. I think only a couple states ever went that far. But at least it is a step back in the right direction.
The ID check isn't for age verification. Federal law requires IDs to be recorded* to enforce restrictions on the maximum quantity that an individual is permitted to purchase per month.
* Edit: Where the word "recorded" appears, this comment previously said "scanned and submitted to a central database". While most states use a central database, the comment reply below pointed out that this goes beyond the minimum that federal law requires.
* Edit: Where the word "recorded" appears, this comment previously said "scanned and submitted to a central database". While most states use a central database, the comment reply below pointed out that this goes beyond the minimum that federal law requires.
I am not aware of a centralized federal database. My understanding is that federal regulations stipulate that the pharmacy must see photo ID and take note of who bought the pseudoephedrine, when, how much, and keep that information logged either on paper or electronically. To be available to law enforcement on request.
The Oregon law does have a central database requirement, however I believe this is in all cases a decision made by each state individually.
The Oregon law does have a central database requirement, however I believe this is in all cases a decision made by each state individually.
You are correct, I was conflating two separate steps of the process. Federal law only requires keeping records and these could technically be done on paper. In practice, more than two thirds of the states participate in a central electronic database called the National Precursor Log Exchange.
> how difficult it would be to get the restrictions on pseudoephedrine rolled back
Likely a non-starter until the FDA revokes phenylephrine's designation as a decongestant.
Likely a non-starter until the FDA revokes phenylephrine's designation as a decongestant.
WHY DO YOU WANT CHILDREN TO GET METH?--Opponents of rolling back restrictions on pseudoephedrine
But more seriously, the FDA ends up regulating something like 30% of the economy and getting them to deregulate something is near impossible
But more seriously, the FDA ends up regulating something like 30% of the economy and getting them to deregulate something is near impossible
Pseudoephedrine restrictions were recently was rolled back in Oregon, where you had to have a prescription to get it. Now we're able to buy it over the counter with ID. So it can happen!
The restrictions the state places on us largely function as a one way ratchet, alas. There is a lot about American drug policy that is wildly unpopular, and yet here we are.
A huge portion of the issue is that we’re largely ruled by people who don’t need to deal with any of the inconveniences they cause; if any senator or rep has a runny nose I’m sure they can get an aide to sort it out for them. The rest of us are not so lucky.
A huge portion of the issue is that we’re largely ruled by people who don’t need to deal with any of the inconveniences they cause; if any senator or rep has a runny nose I’m sure they can get an aide to sort it out for them. The rest of us are not so lucky.
It probably still makes it a lot more difficult to make meth in a "homelab", as alternative synthesis paths are probably a lot harder. So they're leaving it to the "clandestine pros", ironically ;).
Also, in legislation, it seems like making things illegal passes several orders of magnitudes more easily, than anything that gives normal citizens more rights.
Also, in legislation, it seems like making things illegal passes several orders of magnitudes more easily, than anything that gives normal citizens more rights.
Very difficult. Regulations live on regardless of their negative effects because there's very little incentive to get rid of them.
For a long time, I've had the idea in the back of my mind that all laws should have expiration dates, and the maximum duration shouldn't be very long (12 or 18 years would be two or three senate terms in the US). Ideally, it would be combined with something to keep the scope of each bill narrow.
Sunset provisions are popular actually. Jimmy Carter put that idea on his platform in '76, and it was carried out to some extent, and his own state was the example that sold people on it. I sense that they have waned since.
I believe there are restrictions on the breadth of laws but they are not honored very effectively.
I believe there are restrictions on the breadth of laws but they are not honored very effectively.
It wouldn't work because what would happen would be a mass reapproval of all regulations.
What I'd like to see is a constitutional amendment that the total body of federal laws and regulations can't be any longer or more complicated than a person of average intelligence can be taught in a week.
What I'd like to see is a constitutional amendment that the total body of federal laws and regulations can't be any longer or more complicated than a person of average intelligence can be taught in a week.
I used to think a limit on the total size of the law like that would be a good idea, but some areas of regulation are inherently complex. I still hold a related position: an adult of reasonable intelligence should be able to easily learn all the laws that they're likely to encounter, and learn which fields are subject to detailed regulation.
To give an example, the regulations governing design of commercial aircraft can almost certainly be simplified from their current state without killing people, but probably cannot be simplified to the point that someone who isn't already an expert on aircraft design can learn them in a week without killing people. Knowing that field is subject to special rules is enough to avoid accidentally violating the regulations.
To give an example, the regulations governing design of commercial aircraft can almost certainly be simplified from their current state without killing people, but probably cannot be simplified to the point that someone who isn't already an expert on aircraft design can learn them in a week without killing people. Knowing that field is subject to special rules is enough to avoid accidentally violating the regulations.
Currently there's no limit to the complexity that governments can inflict on us. Since there's no garbage collection process for laws/regulations, we wind up with an enormous body of legislation and regulation which almost nobody understands or adheres to. It's terrible for the rule of law.
Or simply require that they be read in the house / senate before a vote. Not "read" but actually read, word for word out loud, by the sponsor.
> It wouldn't work because what would happen would be a mass reapproval of all regulations.
Sunset provisions are an idea I tentatively like until I consider what happens with the fucking stupid, pointless "debt ceiling" crap Congress has decided to make themselves do. I imagine how fun it'd be watching months of idiotic brinksmanship over keeping murder illegal, because one group of legislators wants to grand-stand about abortion. Then repeat for practically everything else.
No thanks.
Sunset provisions are an idea I tentatively like until I consider what happens with the fucking stupid, pointless "debt ceiling" crap Congress has decided to make themselves do. I imagine how fun it'd be watching months of idiotic brinksmanship over keeping murder illegal, because one group of legislators wants to grand-stand about abortion. Then repeat for practically everything else.
No thanks.
Worse, there is an incentive to keep them going as there are entire industries and associated careers built around them.
That's actually evidence they're good, since nobody's built a country with so many successful industries and no regulation. They wouldn't be able to solve the coordination problems.
Phenylephrine does have one use that the author missed: It's used in ophthalmology to dilate the pupils before eye exams.
On the topic of other use case medications, I used to take Sudafed (the real pseudoephedrine kind) during allergy season for a few weeks each year and noticed my productivity skyrocketed during that time, when I normally had issues context switching. Eventually I narrowed it down to taking Sudafed and saw this post: https://accidentalscientist.com/2005/08/the-sudafed-test-for...
This lead to an ADHD diagnosis and proper meds and my life and work productivity improved pretty dramatically.
On the topic of other use case medications, I used to take Sudafed (the real pseudoephedrine kind) during allergy season for a few weeks each year and noticed my productivity skyrocketed during that time, when I normally had issues context switching. Eventually I narrowed it down to taking Sudafed and saw this post: https://accidentalscientist.com/2005/08/the-sudafed-test-for...
This lead to an ADHD diagnosis and proper meds and my life and work productivity improved pretty dramatically.
I ran into the opposite situation a few weeks ago. I was wondering why my allergies were so much worse on the weekends, and eventually narrowed it down to me only taking my ADHD meds on weekdays.
Bit disappointing that everyone starts commenting about amphetamines on a post about Sudafed working the same way as Strattera, which isn't a stimulant.
Though him telling people Strattera has no side effects hopefully didn't surprise anyone when they went on it, it feels (literally) like being kicked in the stomach and can make you quite nauseous.
Though him telling people Strattera has no side effects hopefully didn't surprise anyone when they went on it, it feels (literally) like being kicked in the stomach and can make you quite nauseous.
>Sudafed working the same way as Strattera
Well I have (currently) unmedicated ADHD and pseudoephedrine never did a thing for me besides clear my sinuses, so it's good to know beforehand that trying Strattera will be useless. My problem must be more dopamine and less so norepinepherine.
Well I have (currently) unmedicated ADHD and pseudoephedrine never did a thing for me besides clear my sinuses, so it's good to know beforehand that trying Strattera will be useless. My problem must be more dopamine and less so norepinepherine.
I didn't like the safety profile on Strattera nor the inability to take it 'as needed'. Rare, but there were reports of liver injuries on it. My doctor seemed to be unimpressed in it when I asked about options on and said in her experience amphetamines almost always had the best efficacy in adult ADHD patients.
The safety profile of amphetamines are not anywhere near as good as Strattera, so if that's why you are avoiding it, you should reconsider. Vyvanse can cause heart issues, liver issues, and kidney issues (and rarely lung issues). If amphetamines didn't have serious side effects, we'd let everyone use them :)
I took amphetamines for 10 years, and Strattera for 15 years. Straterra was much more consistent in efficacy, and it never stopped working for me - almost all amphetamines stopped working after a few years, and i would have to change them.
I took amphetamines for 10 years, and Strattera for 15 years. Straterra was much more consistent in efficacy, and it never stopped working for me - almost all amphetamines stopped working after a few years, and i would have to change them.
It works well for me. Just Vyvanse wasn't 24/7 (unless you enjoy never sleeping) and the comedown is really bad for me. I did have to suggest it myself because my doctor preferred guanfacine for a secondary medicine, but it has a lot of side effects itself - and whenever anyone else asked my medicines they thought I said "guaifenesin".
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I'm a physician- although I don't disagree with the spirit of the article the headline is exceptionally misleading.
Phenylephrine is useless as an oral decongestant. It is still quite useful for other indications, including as a vasopressor (given IV to increase blood pressure such as in hypotensive shock). I believe it is actually the only commonly available vasopressor in the US that is a pure alpha-1 agonist which in certain scenarios is desirable.
It is also indicated for treatment of priapism.
The real kicker is that phenylephrine actually does work as a nasal decongestant when it is used as an intranasal spray, which has the added benefit of fewer systemic side effects compared with oral decongestants.
Phenylephrine is useless as an oral decongestant. It is still quite useful for other indications, including as a vasopressor (given IV to increase blood pressure such as in hypotensive shock). I believe it is actually the only commonly available vasopressor in the US that is a pure alpha-1 agonist which in certain scenarios is desirable.
It is also indicated for treatment of priapism.
The real kicker is that phenylephrine actually does work as a nasal decongestant when it is used as an intranasal spray, which has the added benefit of fewer systemic side effects compared with oral decongestants.
> The real kicker is that phenylephrine actually does work as a nasal decongestant when it is used as an intranasal spray
humm, so, crush and and snort it?
humm, so, crush and and snort it?
You can buy it in nasal spray form already. I would skip it and use oxymetazoline, though. (Do be aware of "rebound congestion" with any of these decongestant sprays. If you're always stopped up, ask your doctor about the steroid sprays. They're over the counter as well, but I feel bad recommending steroids to random people on the Internet.)
What about when it does work for people as an oral decongestant though? Are you suggesting that's just randomness? Or perhaps the placebo effect? I guess I'm not entirely convinced it's really useless for that purpose, but I'm just a layman.
Here's my theory: you know that pseudoephedrine works, so taking this thing that's supposed to be a replacement for it, and sounds pretty similar, will convince your brain that phenylephrine will also work. So yes, placebo, but with foreknowledge of the effectiveness of pseudoephedrine. I'm curious if there have been placebo-controlled studies on phenylephrine where the participants were told they were receiving pseudoephedrine
The original article doesn't just suggest it, it claims it outright, and links a study to back up that claim: https://www.annallergy.org/article/S1081-1206(10)60240-2/ful...
He did mention it's usefulness for raising blood pressure and it's use in anesthesia.
It's also the active ingredient in Preparation H as a vasopressor
I've certainly found it useless, and when I need a decongestant I make certain I'm getting actual pseudoephedrine. The 12 and 24 hour slow-release versions are fantastic. I've never done a proper blind trial on myself, but I feel quite certain that I could tell the difference.
I suppose people must be buying it, and given how strong placebo effects are in general I guess it's doing something for them.
I suppose people must be buying it, and given how strong placebo effects are in general I guess it's doing something for them.
Same here. Actual Sudafed works for me and anything else I think generally only tends to work with whatever NSAID they bundle with it.
Same, Sudafed is a silver bullet for me. The 12 hour release absolutely works to clear my sinuses and relieves the sinus pressure headache (almost completely when combined with ibuprofen).
My wife insists Phenylephrine works for her and thats all she will take. She has offered it to me a couple times when we didn’t have any Sudafed and Phenylephrine had 0 noticeable effects for me.
Edit: I forgot to add that Alavert-D 12 also has Pseudoephedrine and works for me too and is what I take when my congestion is allergy related.
My wife insists Phenylephrine works for her and thats all she will take. She has offered it to me a couple times when we didn’t have any Sudafed and Phenylephrine had 0 noticeable effects for me.
Edit: I forgot to add that Alavert-D 12 also has Pseudoephedrine and works for me too and is what I take when my congestion is allergy related.
One of many such studies: https://pubmed.ncbi.nlm.nih.gov/19230461/
Keep in mind this doesn't say that it's not effective. It's just not more so than the placebo effect, which is quite real even on physiological matters.
Keep in mind this doesn't say that it's not effective. It's just not more so than the placebo effect, which is quite real even on physiological matters.
The article suggests the uptake is widely variable person to person so perhaps she’s just a lucky one.
The article comes so close to explaining a way to make it work, likely due to his hesitancy to recommend exceeding the recommended dose:
> Why is oral phenylephrine so useless? It is extensively metabolized, starting in the gut wall. You can find a bioavailability figure of 38% in the literature, but that appears to be the most optimistic number possible, and you can also find studies that show 1% or less. Overall, the Cmax is highly variable patient-to-patient, and the lack of cardiovascular effects at low doses argues for very low systemic effects (and expected low efficacy as a decongestant). The bioavailability increases at higher doses as you apparently saturate out some of the metabolic pathways, but at the 10mg dose typically used for decongestants, you can forget it.
Phenylephrine has variable Bioavailability. The bioavailability doubles if you take it with Tylenol, which is actually common in the context of colds. (Source: https://pubmed.ncbi.nlm.nih.gov/25475358/ ) The maximum dose was probably chosen based on worst-case scenarios, whereas the average person who complains it doesn't work is probably absorbing much less.
Always consult with your doctor, but I've found that taking a second dose of phenylephrine if the first one hasn't worked within about 30 minutes usually does the trick. Or just take it with Tylenol. It's worth checking your blood pressure to make sure you haven't started entering the realm of side significant side effects, though.
Also I should point out that pseudoephedrine isn't available behind the counter everywhere. It's prescription-only in some places.
> Why is oral phenylephrine so useless? It is extensively metabolized, starting in the gut wall. You can find a bioavailability figure of 38% in the literature, but that appears to be the most optimistic number possible, and you can also find studies that show 1% or less. Overall, the Cmax is highly variable patient-to-patient, and the lack of cardiovascular effects at low doses argues for very low systemic effects (and expected low efficacy as a decongestant). The bioavailability increases at higher doses as you apparently saturate out some of the metabolic pathways, but at the 10mg dose typically used for decongestants, you can forget it.
Phenylephrine has variable Bioavailability. The bioavailability doubles if you take it with Tylenol, which is actually common in the context of colds. (Source: https://pubmed.ncbi.nlm.nih.gov/25475358/ ) The maximum dose was probably chosen based on worst-case scenarios, whereas the average person who complains it doesn't work is probably absorbing much less.
Always consult with your doctor, but I've found that taking a second dose of phenylephrine if the first one hasn't worked within about 30 minutes usually does the trick. Or just take it with Tylenol. It's worth checking your blood pressure to make sure you haven't started entering the realm of side significant side effects, though.
Also I should point out that pseudoephedrine isn't available behind the counter everywhere. It's prescription-only in some places.
Do we have a study showing these (second dose within 30 minutes or paracetamol + phenylephrine) performing better than placebo?
We actually have a lot of studies where even standard 10mg phenylephrine taken alone outperforms placebo: https://pubmed.ncbi.nlm.nih.gov/17692721/
Note that Figure 3 also mentions the Tylenol combination effect and even shows how 10mg Phenylephrine + Tylenol performs somewhere between 10mg and 45mg of phenylephrine.
The article author just cherry-picked the one study where phenylephrine performed the worst. Cherry-picking a single study to support a conclusion and ignoring meta-analyses would normally get someone torn apart in the HN comments but apparently everyone loves pseudoephedrine so it gets a pass.
Note that Figure 3 also mentions the Tylenol combination effect and even shows how 10mg Phenylephrine + Tylenol performs somewhere between 10mg and 45mg of phenylephrine.
The article author just cherry-picked the one study where phenylephrine performed the worst. Cherry-picking a single study to support a conclusion and ignoring meta-analyses would normally get someone torn apart in the HN comments but apparently everyone loves pseudoephedrine so it gets a pass.
"Data from 7 crossover studies involving a total of 113 subjects were reanalyzed and then pooled for meta-analysis"
This is a huge red flag - I've read too many of Derek Lowe's blog posts to take that kind of study very seriously as medical advice. Much more promising leads than this have utterly bombed in clinical trials, it happens all the time.
This is a huge red flag - I've read too many of Derek Lowe's blog posts to take that kind of study very seriously as medical advice. Much more promising leads than this have utterly bombed in clinical trials, it happens all the time.
Read the whole abstract. They showed which studies reached statistical significance on their own.
You could just read those studies and ignore the meta-analyses if you want.
I honestly don't understand this current trend of assuming meta-analyses are inherently incorrect and cherry-picking the worst study as the source of the truth.
You could just read those studies and ignore the meta-analyses if you want.
I honestly don't understand this current trend of assuming meta-analyses are inherently incorrect and cherry-picking the worst study as the source of the truth.
It's not the meta-analysis part that's the biggest red flag, it's "a total of 113 subjects". That's the size of a Phase I trial, and the road to Phase III and clinical approval has a crazy high attrition rate.
My assumption has always been: people know pseudoephedrine works, so that's what they want to buy, but you can no longer sell pseudoephedrine over the counter. However, you can offer phenylephrine, which still lets you reasonably name the drug "Sudafed PE" or whatever. Customer browses the shelves, sees "PE" in the drug name, this triggers a vague impression that it contains pseudoephedrine and thus will actually work well.
or maybe like sudafed pe is an advertisement, a reminder to check behind the counter for the real thing
It is sad that society has gone into such a protectionist stance. In our great grandfathers day you could buy opiums and cocaine you name it. Now everything is so locked up heaven forbid someone abuses drugs. The problem with a useless drug like this is people won’t get the desired effect and start compounding more drugs into their system. Like what I had to do with an abscesses tooth. I don’t abuse drugs, I no longer drink and don’t smoke marijuana I don’t even drink coffee anymore. But when my tooth went bad all I was allowed was Acetaminophen and ibuprofen which didn’t even come close to touching the pain. So I took extra acetaminophen and ibuprofen anyways despite the risks out of desperation. Then I started using copious amounts of oral gel tooth numbing medicine which has benzocaine I believe which can also increase heart rate I believe. I was so desperate for any form of relief while I waited to get to the dentist that I was forced to abuse anything I could get for relief that one narcotic medication would have easily treated. I have often wished I could return unused narcotics I have been given to show the doctors “look I’m returning drugs I don’t have an abuse problem I only use them for pain control please continue being generous with them in the future”.
It's interesting how many younger people in the US aren't even aware that the only useful decongestants are behind the counter. I assume they just think there isn't a useful treatment for the symptoms.
I remember when the over the counter stuff just seemed to stop working. I just assumed that something about my body changed. Took me a year or so to find that the ones behind the counter still worked very well.
I think I'm lucky, in that I don't really need too much help that often. I can only imagine if my sinuses were as bad as they were back in the day, though.
I think I'm lucky, in that I don't really need too much help that often. I can only imagine if my sinuses were as bad as they were back in the day, though.
The herb ephedra (Ma Huang/Mormon Tea) contains appreciable amounts of ephedrine and is prepared as a tea in Chinese medicine as a remedy for asthma and cold congestion.
It can easily be purchased online and the ephedrine ban does not apply to it.
https://melmagazine.com/en-us/story/mormon-tea-ephedra-plant...
It can easily be purchased online and the ephedrine ban does not apply to it.
https://melmagazine.com/en-us/story/mormon-tea-ephedra-plant...
Any idea how pure or clean these online sources are?
NB: ephedrine and pseudoephedrine are related (they're stereoisomers), but are different drugs with somewhat different pharmacokinetics.
This is true, but the plant actually contains both. The amount of each can vary widely based on which species you're talking about. The species linked here, commonly known as Mormon Tea, is one of the few species that doesn't contain any ephedrine and only contains pseudo
Pseudoephedrine is wonderfully effective, but beware of its side effects.
I used to take it regularly due to congestion related to seasonal allergies, but at a recent medical visit I discovered that my blood pressure had jumped from its usual 120/75 up to 150/105. (My doctor was also alarmed!) I no longer take pseudoephedrine.
I'm told that the effect on blood pressure is usually mild, but based on my experience I'd recommend blood pressure monitoring to anyone planning on using it, just in case (like me) they're one of the unlucky people who experiences a dramatic increase in blood pressure.
I used to take it regularly due to congestion related to seasonal allergies, but at a recent medical visit I discovered that my blood pressure had jumped from its usual 120/75 up to 150/105. (My doctor was also alarmed!) I no longer take pseudoephedrine.
I'm told that the effect on blood pressure is usually mild, but based on my experience I'd recommend blood pressure monitoring to anyone planning on using it, just in case (like me) they're one of the unlucky people who experiences a dramatic increase in blood pressure.
How did you control for the pseudoephedrine in this experiment?
I stopped taking pseudoephedrine and the following day my blood pressure was back to normal.
I'm not OP, but its elimination half life is about six hours, so you'd superficially expect OP's BP to drop in a curve with a half life of six hours after the last dose. It would be really easy to chart with one of those wrist BP monitors and an excel spreadsheet.
there was a study published february 2022 that showed that acetaminophen also increases blood pressure. I was pretty aware that both pseudoephedrine and ephedrine raised blood pressure slightly - but it's always good to see it mentioned online where other people may not have known.
In my case, I was taking ibuprofen+pseudoephedrine, so acetaminophen wasn't a confounding factor.
And yes, there's plenty of literature showing a slight average increase in bp -- but it seems that there's a wide variance, with some people having dramatically larger side effects.
And yes, there's plenty of literature showing a slight average increase in bp -- but it seems that there's a wide variance, with some people having dramatically larger side effects.
There's only one reason phenylephrine is used as a substitute in the OTC decongestant products: the general public can't pronounce or spell the word "pseudoephedrine" and they're intentionally being duped.
They walk into the grocery store, convenience store, or pharmacy after a sleepless night of breathing through their mouth, see the red package that says SUDAFED and a vaguely familiar-looking active ingredient, grab it, and plop their money on the counter.
PsEudoEPHedRINE
PhEnylEPHRINE
This is OTC medical fraud.
They walk into the grocery store, convenience store, or pharmacy after a sleepless night of breathing through their mouth, see the red package that says SUDAFED and a vaguely familiar-looking active ingredient, grab it, and plop their money on the counter.
PsEudoEPHedRINE
PhEnylEPHRINE
This is OTC medical fraud.
Not quite the same thing, but it's odd the way they attached 8-chlorotheophylline to diphenhydramine, renamed it "dimenhydrinate" and marketed as "non-drowsy nausea medication" (Dramamine). The added molecule is totally ineffective at combating the drowsiness. It's all-but-technically an identical product to diphenhydramine.
If you get the chance, go read all of his (Derek Lowe) blog posts about things he refuses to work with. Highly entertaining read.
The problem with this advice (which gets posted to all of his articles) is those posts aren't meant to all be read at once. They're basically all the same thing, which is why he hasn't written any new ones recently.
I still want to know what isocyanide smells like.
I still want to know what isocyanide smells like.
Thanks for pointing out the author, the headline is not news to me and I would have passed on reading it.
Strange that you were reading all the comments about the article you weren't interested in...
I didn't say I wasn't interested in the [headline] I said it wasn't news to me. It's a topic I find interesting, and as it turns out, by an author I already enjoy.
The article was not informative [to me], but it was fun reading. Since it was not informative to me (as I deduced correctly from the headline) I could have easily read the comments and not the article.
Hope that helps!
The article was not informative [to me], but it was fun reading. Since it was not informative to me (as I deduced correctly from the headline) I could have easily read the comments and not the article.
Hope that helps!
The article, for anyone interested: https://www.science.org/content/blog-post/things-i-won-t-wor...
FOOF (or FOOOOOOF)
I’m skeptical the regulations will ever get rolled back, because it’s just so trivially easy to get spooked by the idea of making meth, but as mentioned in this article, I don’t think pseudoephedrine would become a significant source of methamphetamine again if it was made easily available over the counter.
Because the cartels have gotten really, really good at making meth. Extremely pure and extremely cheap, and the proper psychoactive isomer. There’s a massive supply of cheap and “good” crank out there, so I doubt deregulation of Sudafed would really make a blip in the total supply.
Because the cartels have gotten really, really good at making meth. Extremely pure and extremely cheap, and the proper psychoactive isomer. There’s a massive supply of cheap and “good” crank out there, so I doubt deregulation of Sudafed would really make a blip in the total supply.
I wonder if there is something they can add to it that is harmless to humans but makes it impractical or too expensive to use as a precursor for making meth.
The DEA, FDA, and state regulators are destroying everything IMO. Many doctors don't want to even deal with drugs labeled as a 'controlled substance'.
I ended up going off an extremely effective medication due to none of the doctors (including psychiatrists, etc.) wanting to prescribe it anymore due to restrictions. I now suffer daily. There are a few doctors who will still prescribe it, but predictably, NONE of them take insurance (because they know they can corner the market by not doing so). ALL of them charge $400+ per visit.
I ended up going off an extremely effective medication due to none of the doctors (including psychiatrists, etc.) wanting to prescribe it anymore due to restrictions. I now suffer daily. There are a few doctors who will still prescribe it, but predictably, NONE of them take insurance (because they know they can corner the market by not doing so). ALL of them charge $400+ per visit.
Phenylepherine has excellent "not being easily convertible into meth" properties, if only it had actual decongestant properties to go along with them...
Sigh.
Sigh.
By the way, if you want something that works, that you can buy without a prescription, I cannot recommend “BronkAid” aka ephedrine sulfate 25mg highly enough.
It’s sold “behind the counter” in the US at major pharmacy chains, which means you have to ask for it by name, they won’t even have the cards in the aisles that you then bring up and redeem.
You have to show ID — not sure if that’s a Federal or a State thing, and you’re limited in the quantity you can buy at once, but the limits are not overly restrictive.
It’s sold mainly as an anti-asthmatic. I personally have borderline asthma, meaning I’ve never had an asthma attack but in a test chamber my total lung volume increases 20% after puffing albuterol.
It opens up my breathing tremendously, very useful as a pre-workout, has a nice nootropic effect, and for me personally does not cause any increased heart rate, although for many people that is an undesirable effect. Perhaps best not to stack with caffeine.
And when I have a cold, I like it better than suppressants, expectorants, or even pseudoephedrine because I get clearing without turning into a leaky faucet.
Just my anecdata…
It’s sold “behind the counter” in the US at major pharmacy chains, which means you have to ask for it by name, they won’t even have the cards in the aisles that you then bring up and redeem.
You have to show ID — not sure if that’s a Federal or a State thing, and you’re limited in the quantity you can buy at once, but the limits are not overly restrictive.
It’s sold mainly as an anti-asthmatic. I personally have borderline asthma, meaning I’ve never had an asthma attack but in a test chamber my total lung volume increases 20% after puffing albuterol.
It opens up my breathing tremendously, very useful as a pre-workout, has a nice nootropic effect, and for me personally does not cause any increased heart rate, although for many people that is an undesirable effect. Perhaps best not to stack with caffeine.
And when I have a cold, I like it better than suppressants, expectorants, or even pseudoephedrine because I get clearing without turning into a leaky faucet.
Just my anecdata…
My understanding, consistent with your impression, is that ephedrine has more of a full-system effect, including lungs & bronchial tubes, along with (in many people) more of a general full-system stimulation. In contrast, pseudoephedrine has a greater nasal/sinus effect with a bit less full-system spillover (but still noticeable in some people, or at higher doses, or in combo with caffeine).
So it's worth it for people to be aware of ephedrine options – like ephedrine sulfate or ephedrine hcl ('Primatene') – but many will still find pseudoephedrine better for their symptoms. It's worth trying both, separately, depending on personal chemistry & concerns.
So it's worth it for people to be aware of ephedrine options – like ephedrine sulfate or ephedrine hcl ('Primatene') – but many will still find pseudoephedrine better for their symptoms. It's worth trying both, separately, depending on personal chemistry & concerns.
Shh! Don't talk about the secret stuff! My pharmacies run out of it too often as it is...
A1 headline right there. Not clickbait, but right to the point
Sometimes the most helpful thing when I have a problem is being listened to and accepted. It is frustrating to see doctors that only pretend to listen, and I wonder to what degree such doctors are satisfied with their work. We finally have for our child a pediatrician who gives us what I hope will someday be normal care and attention.
First hand experience.
Totally useless as a decongestant for me.
Stick with pseudoephedrine.
Totally useless as a decongestant for me.
Stick with pseudoephedrine.
Derek Lowe makes a good point that we're wasting everyone's time and money with useless phenylephrine and the fact that pseudoephedrine is so much better as a decongestant.
The fact is that pseudoephedrine is not only banned in the US but it is also banned in many other counties for the same reason that it's a precursor for meth.
The trouble is that banning pseudoephedrine seems to have only made matters considerably worse as I learned from this HN story a few months back: https://news.ycombinator.com/item?id=29027284
Banning pseudoephedrine has led drug cartels to ramp up production of the precursor P2P, phenylacetone, which, it seems, is a better precursor anyway. It's worth reading this story in conjunction with this one. As Lowe hints, given the circumstances, we'd be better off going back to a decongestant that actually works.
Quote from the earlier HN story:
"Meth in the US shifted to P2P synthesis between 2009 and 2012.
In the before times, meth was made with ephedrine or pseudoephedrine. However, in 2006, the US banned over-the-counter sales of pseudoephedrine, and in 2008 Mexico banned almost all sales. In response to this, meth makers switched to a synthesis based on P2P, which can be made from many different, widely available, source chemicals."
The fact is that pseudoephedrine is not only banned in the US but it is also banned in many other counties for the same reason that it's a precursor for meth.
The trouble is that banning pseudoephedrine seems to have only made matters considerably worse as I learned from this HN story a few months back: https://news.ycombinator.com/item?id=29027284
Banning pseudoephedrine has led drug cartels to ramp up production of the precursor P2P, phenylacetone, which, it seems, is a better precursor anyway. It's worth reading this story in conjunction with this one. As Lowe hints, given the circumstances, we'd be better off going back to a decongestant that actually works.
Quote from the earlier HN story:
"Meth in the US shifted to P2P synthesis between 2009 and 2012.
In the before times, meth was made with ephedrine or pseudoephedrine. However, in 2006, the US banned over-the-counter sales of pseudoephedrine, and in 2008 Mexico banned almost all sales. In response to this, meth makers switched to a synthesis based on P2P, which can be made from many different, widely available, source chemicals."
Pseudoephedrine isn't banned, you just have to ask the pharmacist for it.
Right, 'banned' is a blut word here, I suppose I should have used 'restricted schedule' as per officialdom but the earlier HN article used 'banned'. Incidentally, many countries have banned it or made it only available on script (i.e.: where I live).
Never tried to get it myself since it went on script. Personally, I find it repulsive stuff - makes me feel sicker than the cold or flu alone so I no longer use it (makes me feel queasy on the stomach).
Never tried to get it myself since it went on script. Personally, I find it repulsive stuff - makes me feel sicker than the cold or flu alone so I no longer use it (makes me feel queasy on the stomach).
[deleted]
I just recently got scammed by this. I’m not sure why they even allow selling and marketing this.
There's only a couple drugs I know by name to look for on package labels and pseudoephedrine is one of them.
The other one is diphenhydramine (an antihistamine i.e. Benadryl) because its common side effect of drowsiness means that its also one of the most common sleep aids. It has been more than once that myself or someone near me was having an allergic reaction and the 7/11 down the block didn't have any Benadryl but did have some sleep aid.
The other one is diphenhydramine (an antihistamine i.e. Benadryl) because its common side effect of drowsiness means that its also one of the most common sleep aids. It has been more than once that myself or someone near me was having an allergic reaction and the 7/11 down the block didn't have any Benadryl but did have some sleep aid.
The Wikipedia article they link to [0] has a pretty long list of brandnames. Many of them are the "-D" version of whatever the thing is. Claritin-D, Zyrtec-D and so on. I think the version without the "-D" doesn't have Pseudoephedrine?
[0] https://en.wikipedia.org/wiki/Pseudoephedrine#Brand_names
[0] https://en.wikipedia.org/wiki/Pseudoephedrine#Brand_names
In those cases, Claritin and Zyrtec are allergy medicines. The -D indicates that this allergy medicine comes along with a decongestant. The version without the -D will just be the allergy medicine.
Specifically, drugs with -D indicate that they come with pseudoephedrine. In the US, they (like the non-PE version of Sudafed) are only available behind the pharmacy counter.
I am suffering with a bad/cold flu right now and this has made me mad as hell! What if someone is so sick they can't fathom to walk into a pharmacy?
Fuck senators.
Fuck senators.
Thank God I have about 100 different people I could call and ask to pick up medicine for me were I in that situation.
Lucky you.
Phenylephrine is utterly useless on me. Maybe it works for some people but it may as well be Pez for all the good it does me.
I make it a point buy a pack of actual pseudoephedrine from my pharmacist every 6 months or so, to ensure I have a stock when I need it. Fortunately, I don't need it too often, but there's no good substitute when I do.
I make it a point buy a pack of actual pseudoephedrine from my pharmacist every 6 months or so, to ensure I have a stock when I need it. Fortunately, I don't need it too often, but there's no good substitute when I do.
It is even easier to make
https://en.wikipedia.org/wiki/Methcathinone
from pseudoephedrine. You can just oxidize PE with potassium permanganate and purify the product... No need to risk blowing yourself up the way you would making methamphetamine.
https://en.wikipedia.org/wiki/Methcathinone
from pseudoephedrine. You can just oxidize PE with potassium permanganate and purify the product... No need to risk blowing yourself up the way you would making methamphetamine.
Reminds me of docusate, a very commonly prescribed “Laxative”. The problem? There’s seemingly barely any evidence that it actually works. And plenty to suggest it has no effect over that of a placebo. Yet there’s a culture of prescribing it, so on prescribed it goes.
Wow. I've purchased more than a few bottles of ducosate. But it looks like you're right:
Reevaluating the Use of Docusate in the Management of Constipation https://www.drugtopics.com/view/reevaluating-the-use-of-docu...
Reevaluating the Use of Docusate in the Management of Constipation https://www.drugtopics.com/view/reevaluating-the-use-of-docu...
Physician, anesthesiologist speaking. Intravenous phenylephrine widely used, effective. No good in stomach.
Doctors struggle to harness all the historic use and evidence for treatments, sometimes based on great evidence. Often evidence is the best that can be had given available resources.
Drug companies hiding data (derived from volunteers and patients) is wrong, and a problem. Selective publishing of only positive findings in medical journals is common. Careers depend on publications. But despite these pressures, most doctors think hard about these issues, and do their truthful best for the patient in front of them, given the imperfect knowledge available.
OTC labeling is deceptive at best. Placebo only works for a few things.
Doctors struggle to harness all the historic use and evidence for treatments, sometimes based on great evidence. Often evidence is the best that can be had given available resources.
Drug companies hiding data (derived from volunteers and patients) is wrong, and a problem. Selective publishing of only positive findings in medical journals is common. Careers depend on publications. But despite these pressures, most doctors think hard about these issues, and do their truthful best for the patient in front of them, given the imperfect knowledge available.
OTC labeling is deceptive at best. Placebo only works for a few things.
It might not do much if taken orally, but a phenylephrine nasal spray can be pretty powerful.
This. Derek has missed that spray is rather effective. Also other agents, such as oxymetazoline is used. They all have a rebound effect, so their use should be limited to 7 days at most.
Also, this is mostly for comfort. There is no really reason to go back to pseudo-effedrive and risk side-effect (high-blood pressure etc.). Also people value their comfort a lot, they are not so good with assessing risks. Apparently that is the reasoning to continue selling phenylephrine because people want to get something even if it is not distinguishable from placebo.
Also, this is mostly for comfort. There is no really reason to go back to pseudo-effedrive and risk side-effect (high-blood pressure etc.). Also people value their comfort a lot, they are not so good with assessing risks. Apparently that is the reasoning to continue selling phenylephrine because people want to get something even if it is not distinguishable from placebo.
> Also, this is mostly for comfort.
Spoken like someone who has never had severe nasal congestion. A week or two of not being able to sleep, taste, or speak with your normal voice would change your view of the importance of good decongestants.
Spoken like someone who has never had severe nasal congestion. A week or two of not being able to sleep, taste, or speak with your normal voice would change your view of the importance of good decongestants.
When i lived in california, this was a yearly ordeal. I also found out that when a bottle says "do not use for more than 4 days" they mean that. I very nearly choked on my tongue because i couldn't move it in my mouth due to the insane dryness, i didn't think it was even possible to accomplish that level of dry.
I discovered "neti pots" because in a bout of panicked rage i snorted nearly an entire can of saline nasal wash, had immediate relief, and went and bought my first plastic neti pot. I never use deionized or whatever water, the chances of toxins in my water is extremely low, and i usually just do it in the shower anyhow, where there's hot water right there. Sodium Bicarb + NaCl just works.
More recently for the sort of dry allergy nasal stuff i started putting mentholated petrolatum jelly directly in and around my nose. I'm sure in 10 years i'll find out that i'll get nostril cancer or something, but whatever, i can breathe, thank you very much.
I discovered "neti pots" because in a bout of panicked rage i snorted nearly an entire can of saline nasal wash, had immediate relief, and went and bought my first plastic neti pot. I never use deionized or whatever water, the chances of toxins in my water is extremely low, and i usually just do it in the shower anyhow, where there's hot water right there. Sodium Bicarb + NaCl just works.
More recently for the sort of dry allergy nasal stuff i started putting mentholated petrolatum jelly directly in and around my nose. I'm sure in 10 years i'll find out that i'll get nostril cancer or something, but whatever, i can breathe, thank you very much.
Please use boiled water at least(and definitely not just hot shower water) due to the possibility of Legionnaires' Disease: https://en.wikipedia.org/wiki/Legionnaires%27_disease
I totally understand. That is two weeks of discomfort but not medically dangerous to your life. Whereas high blood pressure especially for people who already have elevated blood pressure and don't know it, can damaged your heart with long-term effects on your heart and possibly shorten your life by some non-trivial amount.
True, but they have a significant rebound effect.
Only relevant if you ever let it wear off. (/s)
So perhaps they should sell the sprays, for their topical effectiveness, but stop the wasteful sales/promotion of pills.
I haven't really been able to take pseudoephedrine for a number of years now due to getting heart palpitations with even a small dose. Luckily fluticasone is available without a prescription and I've had success with that.
I have the impression that many cold drugs are similarly useless. Dextromethorphan comes to mind[0]. I think its the nature of colds, they are not particularly severe and symptoms are easily influenced by placebo effects. Many of them are really just relying on caffeine for daytime meds and antihistamines for nighttime formulations. That whole market feels like a borderline scam.
0. https://pubmed.ncbi.nlm.nih.gov/11045895/
0. https://pubmed.ncbi.nlm.nih.gov/11045895/
I had a friend who would keep pseudoephedrine in his glovebox to be used for alertness in case he became drowsy driving. He was a chem nerd, so was not particularly remarkable to me.
I have to wonder if the restrictions on pseudoephedrine have driven anyone to purchase meth. The safety profile of pseudoephedrine is pretty good - I think it could be argued its a good legal stimulant to offer to the public.
Could increasing it's availability be a legitimate harm reduction measure that would displace/prevent meth use among some populations?
I have to wonder if the restrictions on pseudoephedrine have driven anyone to purchase meth. The safety profile of pseudoephedrine is pretty good - I think it could be argued its a good legal stimulant to offer to the public.
Could increasing it's availability be a legitimate harm reduction measure that would displace/prevent meth use among some populations?
Doubtful. Caffeine is already a legal recreational stimulant. What distinguishes methamphetamine/cocaine is that they are, for want of a better word, prosocial. People don't just do meth, they seek out other people who are also doing meth. Pseudo will not fill that niche.
There may be other "safe(r)" substitutes, such as HDMP-28 or amfonelic acid or something, but they have to reproduce the social function of recreational stimulants to culturally substitute.
There may be other "safe(r)" substitutes, such as HDMP-28 or amfonelic acid or something, but they have to reproduce the social function of recreational stimulants to culturally substitute.
Ah, yeah the social aspect probably can't be replaced by pseudoephedrine.
However, meth can be functional enough that I would guess it's used for wakefulness/focus among a significant proportion of users (especially in early stages of addiction): truckers using it to drive longer, students using it to study, graveyard shift workers using it to stay alert while operating dangerous equipment, etc. These use cases seem like they could potentially substitute pseudoephedrine, and in doing so, could function as an "anti-gateway-drug": users who solve their use case without the euphoria are less likely to get addicted or transition into social usage.
However, meth can be functional enough that I would guess it's used for wakefulness/focus among a significant proportion of users (especially in early stages of addiction): truckers using it to drive longer, students using it to study, graveyard shift workers using it to stay alert while operating dangerous equipment, etc. These use cases seem like they could potentially substitute pseudoephedrine, and in doing so, could function as an "anti-gateway-drug": users who solve their use case without the euphoria are less likely to get addicted or transition into social usage.
The only silver lining of the pandemic is that I haven't had a cold or flu in years and haven't needed to ask for behind the counter pseudoephedrine.
Pseudoephedrine is a stimulant and not a particularly pleasant one at that. Here in Canada there's still cold medicines with it in them, and to be honest, when I see it, I avoid it.
It may not be as good of a decongestant but phenylephrine won't keep me up at night. And when I'm sick with a cold what I really need is a good sleep.
It may not be as good of a decongestant but phenylephrine won't keep me up at night. And when I'm sick with a cold what I really need is a good sleep.
I have the same feeling. I’m very sensitive to pseudoephedrine jitters and do my best to avoid it. It may be placebo, but phenylephrine “works” for me and can “tell” days that I forget to take one in the morning when I have post nasal drip. Knowing it should have no clinical effect, I’d be interested in blinding myself to a placebo to convince myself it really has no effect.
Different people are different. It doesn't mess with sleep at all for me. My wife has to use it with care, continued taking of it gives her overdose symptoms. (Obviously, it's not being eliminated as fast as they expect.)
I've found dosage is critical with pseudoephedrine. I can only take one of the small 30mg red buttons (half the recommended dosage) in a 24 hour period and get the benefits without side effects.
Over here in Germany, when you ask for a decongestant, you usually get Xylometazolin as a spray. As I understand, that's both more effective and has fewer side effects (due to being local). You can also get pseudoephedrine, but I don't think it's as commonly used as these nasal sprays.
Is that not an option in the US?
Is that not an option in the US?
> As of 2021, no consumer products containing xylometazoline are marketed in the United States, however imported products containing xylometazoline are available online.
From the wikipedia article. Fascinating, it's the most common drug I use and it's not even available in US stores!
From the wikipedia article. Fascinating, it's the most common drug I use and it's not even available in US stores!
Have you ever tried taking twice the recommended daily dose of xylometazolin in one go?
Quite stimulating!
Quite stimulating!
I used the, I believe, dayquil version one time (active ingredient pseudoephedrine) in the US and my ability to focus that day was on a completely different level even being sick. I almost wanted to keep using it for productivity purposes.
Also love that I had to go to a controlled substance area of the pharmacy to get it.
Also love that I had to go to a controlled substance area of the pharmacy to get it.
My college buddy stayed with me about 22 years ago while he went to med school, and then when he graduated he moved out. I found after he left a box of phenylephine with "PLACEBO" scribbled over it.
That is to say, this has been known for at least 20 years. And yet this big, ok, medium-big, lie persists.
That is to say, this has been known for at least 20 years. And yet this big, ok, medium-big, lie persists.
I'm also irked by the fact that OTC cough suppressants like dextromethorphan are equally useless.
Citation? Dextromethorphan works very well for me. (Also DXM is a recreational drug which is why it's always sold OTC with either Tylenol in it or as an extended-release formula)
Chris Rock has a few brilliant, hyperbolic, minutes on how in some neighborhoods "tussin" is a cure-all.
Back then I'm pretty sure robitussin had codeine not DXM.
In the vast majority of cases for my family, Dextromethorphan is a miracle drug. We're in the middle of cold and allergy season here, and my kids (and I) stop coughing within 5-10 minutes of taking an appropriate dose.
Once every 3-4 years I'll get a cough so bad that DXM won't fix, and when that happens my doc gives me a prescription for a codeine based cough syrup that fixes it (and renders me useless as a human being).
Once every 3-4 years I'll get a cough so bad that DXM won't fix, and when that happens my doc gives me a prescription for a codeine based cough syrup that fixes it (and renders me useless as a human being).
I dunno, codeine makes me love my family even more, as an anecdote...
Mucinex (Guaifenesin) fixed all my illness cough problems. It makes your mucus thinner and produces more of it to make your coughs "more productive" which means you finally get that junk out of your throat. Eliminates tickly throat coughs and also is useful in pretty much all situations that involve coughing. It's a genuine magic bullet for me, where no cough suppressant has ever worked, through my entire 30ish year existence.
The title is misleading as written in the article. It should be "The Uselessness of Phenylephrine as a Decongestant". Phenylephrine is a lifesaving medicine in emergency medicine to increase the blood pressure of people with hypotension.
Are there any good decongestants?
Seems like all of them have potentially serious side effects. Pseudoephedrine works but drives up my blood pressure. There are any number of sprays like oxymetazoline but they all create addiction issues if you use them too much.
Seems like all of them have potentially serious side effects. Pseudoephedrine works but drives up my blood pressure. There are any number of sprays like oxymetazoline but they all create addiction issues if you use them too much.
Nothing works as well for allergies for me as zyrtec-d. I get the 12 hour variety and just use benadryl at night. Luckily I only need it a month or two out of the year. Don't know about taking that stuff year round :) (pseudoephedrine)
Now do cough medicine. The last time I looked at the literature, experts were asking why 95% of cough medicine was allowed to be sold when none of it was known to work. The list of OTC medical products that don’t work is very large.
[deleted]
Phenylephrine is 100% fake and it's frustrating it's allowed to be sold
For all phenylephrine oral is useless, FYI phenylephrine nasal spray seems to work well as a gentle decongestant, anecdotally much better than saline spray, and not as strong (or addictive) as oxymetazoline.
At least in the US and UK, you can actually still get pseudoephedrine-containing products from a pharmacist. In some countries (New Zealand!), it is prescription-only. Same with anything containing codeine.
I can buy "Wal-Phed D" at my Walgreens pharmacy. It's Pseudoephedrine HCl 100 mg and works very well. It's quite easy to get, they just look at my ID.
I remember somebody calculated the cost of making meth from over the counter pseudoephedrine tablets and it would be the single most expensive drug available.
Man I have congestion so often and I always took phenylephrine and always felt it was hit or miss. Now I know it wasn't just me!
funnily enough, phenylephrine is used daily in ophthalmology for dilated eye exams.
On that note, there's a bunch of esoteric drops that used to be used because of their useful pharmacokinetics, diagnostic/therapeutic abilities (cocaine, hydroxyamphetamine, pilocarpine 0.125%, homatropine), but are no longer being manufactured due to cost.
Levo-methamphetamine is a legal decongestant BTW
Where does one obtain that? From the waste stream of the methamphetamine producers?
It is sold over the counter in most US pharmacies under the Vicks inhaler brand. The active ingredient label conveniently uses a spelling that most people will not recognize which is probably effective in preventing alarm from customers who aren't familiar with the dramatic difference in the effects of the two enantiomers.
TIL!
Used to get Vicks inhalers with it. I don't know if its still available.
btw racemic meth is legally prescribed for ADHD under the brand desoxyn, although it's probably hard to find doctors prescribing it over regular amph
I won't rule out a placebo effect, but phenylephrine works just fine for me. Pseudoephedrine just makes me jumpy.
Sometimes I wonder if NSAIDs are the same deal, or if there's just a subset of people they don't work well on.
Tylenol (acetaminophen) does nothing for me. Advil (ibuprofen) does usually work. I used to get more headaches when I was younger, but I rarely get them now. Two things that have changed that might be related: I no longer use CRT screens, and I no longer drink diet soda (used to drink 4-6 cans a day, most days).
Aside from headaches, Advil does better on other aches and pains than Tylenol, which does almost nothing. And it's better for the liver.
Aside from headaches, Advil does better on other aches and pains than Tylenol, which does almost nothing. And it's better for the liver.
better for the liver, worse for the stomach. It's a sliding scale, you have to decide how much you care about whatever hurts not hurting anymore versus damage to organs you can't even see.
Also i used to get wicked headaches from diet soda when i was younger, too. Is it possible to be "slightly" Phenylketonuric? I had to google the spelling, and it's interesting that "hyperactivity and behavioral issues" is listed as one of the symptoms. I doubt "slightly" is possible, that was tongue-in-cheek.
Also as an aside, for pain that the standard dose of ibuprofen doesn't seem to help, emergency medicine studies have found that an additional standard dose of acetaminophen alongside the ibuprofen has greater pain reduction efficacy than vicodin.
Also i used to get wicked headaches from diet soda when i was younger, too. Is it possible to be "slightly" Phenylketonuric? I had to google the spelling, and it's interesting that "hyperactivity and behavioral issues" is listed as one of the symptoms. I doubt "slightly" is possible, that was tongue-in-cheek.
Also as an aside, for pain that the standard dose of ibuprofen doesn't seem to help, emergency medicine studies have found that an additional standard dose of acetaminophen alongside the ibuprofen has greater pain reduction efficacy than vicodin.
NSAIDs and Tylenol definitely work differently on different people and on different types of pain ime. The stronger ones, like Torodol, can be very effective on even quite serious pain, but you can't even get it _with_ a prescription anymore in the USA.
There is a significant amount of evidence supporting the efficacy of NSAIDs. Note that they are more effective for some types of pain than others, due to the mechanism by which they work.
Wait until people find out about the effectiveness of wearing masks on preventing covid infection and spread...
I noticed Phenylephrine didn't work at all for me a handful of years ago after the pseudoephedrine swap occurred. Did a web search and turned up the same info here.
At the time it was amazing to me that these products were being sold.
This is a great article and I applaud the author for trying to get these products pulled or replaced with something effective.
I noticed Phenylephrine didn't work at all for me a handful of years ago after the pseudoephedrine swap occurred. Did a web search and turned up the same info here.
At the time it was amazing to me that these products were being sold.
This is a great article and I applaud the author for trying to get these products pulled or replaced with something effective.
It's so bad that I'd rather just scan my ID and get a product that contains pseudoephedrine.
It's weird to me you can buy steroid nasal sprays OTC (Nasacort, Rhinocort, Flonase, etc.)
but not pseudoephedrine
but not pseudoephedrine
Phenylephrine must be totally useless since pseudoephedrine barely does anything in my experience!
It's not super effective on me either, except for triggering crippling anxiety, but remember that we are outliers, and it's a very effective medication for most folks.
Same. The original Sudafed did dry up a runny nose somewhat, but also made me jittery like I'd taken a big hit of caffeine.
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For some, pseudoephedrine make scuba diving possible.
The difficulty of getting some is very annoying.
The difficulty of getting some is very annoying.
How does Naphazoline (usually administrated as nasal drops) compare to pseudoephedrine?
If there were a darknet way to buy medical grade Sudafed that would be fine by me.
This is one of the more benign bits of stupidity that is The War On Drugs™.
Then why does something like Sudafed seemingly work for me?
phenylephrine is a great drug in hospital for sepsis patients, but as a nasal decongestant, it really is useless.
the "war on drugs" push to restrict pseudoephedrine created more problems than it's worth. "the new meth" has been even worse.
https://crimeandjusticenews.asu.edu/news/chemically-differen...
There's a really good Atlantic article about it as well (google "the new meth" Atlantic) but it's behind a paywall.
the "war on drugs" push to restrict pseudoephedrine created more problems than it's worth. "the new meth" has been even worse.
https://crimeandjusticenews.asu.edu/news/chemically-differen...
There's a really good Atlantic article about it as well (google "the new meth" Atlantic) but it's behind a paywall.
I recommend simply getting a Yoga nose cleaning thingy, it will also help prevent getting sick in the first place.
When I get a cold I simply get plenty of rest and ride it out. Drugs are not necessary for minor ailments.
To quote the alt text from https://xkcd.com/971/
> Telling someone who trusts you that you're giving them medicine, when you know you’re not, because you want their money, isn’t just lying--it’s like an example you’d make up if you had to illustrate for a child why lying is wrong.
> Telling someone who trusts you that you're giving them medicine, when you know you’re not, because you want their money, isn’t just lying--it’s like an example you’d make up if you had to illustrate for a child why lying is wrong.
I need a tl;dr: what medicine should I take if I’m congested??
pseudoephedrine. The ingredient in Sudafed, Nyquil, etc that actually works. You'll usually need to go to the pharmacy counter to get it and show ID. They track how much each person gets because some folks were using it to make meth a while back. The replacement in the OTC Sudafed, etc out one the shelves, phenylephrine, doesn't work.
Thank you!
First, I find that Phenylephrine works well enough as a decongestant for me, without the jitters and heart palpitations. Of course, others' mileage may vary.
Second, how did this sentence:
"There are a number of synthetic procedures for doing this, some of them quite alarming, and several of which can indeed be performed in the barn, garage, basement, or trailer park of your choice..."
make it through editing. This reeks of insensitivity and classism.
Second, how did this sentence:
"There are a number of synthetic procedures for doing this, some of them quite alarming, and several of which can indeed be performed in the barn, garage, basement, or trailer park of your choice..."
make it through editing. This reeks of insensitivity and classism.
No, not really. Meth manufacturing is famously a scourge of trailer park communities, where the manufacture itself poses risk to residents that probably outstrip the risks of the drug. Trailers and barns just happen to be an efficient place to stand up makeshift meth labs.