Combining Pain, Cold, Cough, And Sleep Meds - Great For Drug Companies, But Unethical

If you've spent any amount of time in the cough and cold section of your pharmacy, you may soon end up in the headache aisle. This is because the over-the-counter cough, cold, and allergy aisle is a daunting place, even for those of us who are familiar with all of the common medicines that are used in these products. There are so many combinations of products for so many different sets of symptoms that if you don't need reading glasses when you enter the pharmacy, you probably will by the time you leave.

This is not only intentional but also harmful, and, in my opinion, unethical. It is little but a sleight-of-hand used by drug companies to sell more of the same old drugs, but in different combinations, to people who don't need the combinations and can actually be harmed by them.

If you are trying to figure out what to take for a cough (1) you may go stark raving mad. Why? Because companies are making slightly concoctions of old, commonly used drugs in different combinations and doses, supposedly to treat different sets of symptoms. So if you go to the store for a simple cough syrup it's difficult to do so without wanting to sit down in the aisle and weep. And it's all unnecessary. Just look at Robitussin. It's a cough syrup. Pretty simple.  At least it used to be.

Robitussin madness. Photo: Ramsey Pediatrics

Do we really need 11 different types of Robitussin? We sure don't, since the 11 are no more than different combinations (and doses) of the same four drugs:

• Guaifenesin - loosens mucus

• Dextromethorphan - cough suppressant

• Pseudoephedrine - relieves nasal congestion

• Chlorpheniramine - antihistamine

Couldn't this be done in, say, three or four bottles? Yes, it could. But this is about marketing, not medicine.

Aside from whatever emotional distress you may experience from having to decide which of these stupid cough syrups to buy there's not much harm here. On the other hand, this is not always the case:

Combination sleep aids plus analgesics. Should these be sold at all? 

While the downside of selling redundant combinations of drugs in cough syrups is minimal, this is not the case with pain medications. It is pharmacological insanity to combine analgesics with other types of drugs, yet I know many people who swear by them, especially Tylenol PM, as sleep aids. They have been suckered by the drug companies into buying something they don't need and probably shouldn't take. 

When I ask them "Do you have pain, insomnia, or both?" The answer is almost always "insomnia." Then, I ask "Then why are you taking the Tylenol?" No good answer. Because there is no good answer, other than both drugs are stuffed into the same pill. People have been using Benadryl (diphenhydramine) as a sleep aid for decades. Yet now, many people take this instead:

Tylenol, PM combines Benadryl with a full dose of acetaminophen. Why?

I believe that the practice of selling medicines that are a combination of analgesics and sleep aids is unethical and should be banned. These combination pills usually provide no benefit to consumers (2) but carry the possibility of real harm. If you merely want to go to sleep, down a couple of Benadryl. Why take 1,000 mg of acetaminophen along with the Benadryl if you don't need it? Acetaminophen is not harmless (3). Nor are ibuprofen (Advil) or naproxen (Aleve). None of these drugs should be taken when they are not needed. 

The FDA is fully aware that acetaminophen is not a benign drug. In 2011, the agency required that the maximum daily recommended dose of the drug be lowered from 4,000 mg to 3,000 mg. And around that time, the agency took a similar action with prescription drugs. Restrictions were placed on opioid pills, such as Vicodin and Percocet, which are combinations of hydrocodone and oxycodone, respectively and acetaminophen. Before 2011 you could buy Vicodin or Percocet which contained as much as 750 mg of acetaminophen in one pill. Since then, the maximum dose of acetaminophen in any single opioid pill has been lowered to 325 mg. The FDA did not make these changes arbitrarily. It was done to prevent unintentional acetaminophen poisoning. 

If you have a headache, take something for the pain. If you want to sleep, take a sleep aid. If you need both. take both. But in the absence of pain, it is just plain nuts to take the combination. Why take a full dose of a pain drug, each of which carries its own risk, when it's not needed? (4). The benefit is zero and the risk is real.

Drug companies do a lot of good. I know this - I used to work for one. But the practice of combining drugs to encourage people to take medicines that they do not need is unethical marketing and benefits only the company, not the patient. Drug companies don't look so good here. 

Notes:

(1) There is real doubt whether kids should take cough or cold medicines at all. See the 2104 FDA report: Most Young Children With a Cough or Cold Don't Need Medicines

(2) How many people who have insomnia also have pain? Not many, but if they do, they can just as easily take Benadryl and Tylenol separately should they need it. Most people do not.

(3) Next: A look at the toxicity and efficacy of Tylenol. You may be surprised.

(4) If you're sitting in your office in the middle of the day and don't have a headache, would you reach for a Tylenol or Advil bottle? Think about it.