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Notes -
Tylenol is somewhat uniquely dangerous, it would possibly not have been approved as over the counter in the U.S. in today's regulatory environment.
This is for a couple of reasons.
-The therapeutic and toxic range are way too close (aka it's really easy to overdose accidentally, which does happen).
-It has significant interaction with some medical problems (aka liver metabolism). This is admittedly pretty minor in most situations.
And most importantly:
-Tylenol overdose is one of the worst possible ways to die. It is long, and slow, and for a while you think you are fine. This gives people lots of time to decline in misery knowing they made an irreversable choice. It's awful. Most other forms of overdose kill you quickly or rapidly alter your sensorium.
This creates agony on the part of the victim and their family, and also a significant amount of angst and distress in the healthcare team.
If you like you aren't paying for the minor inconvenience of harder to pull out of the packaging pills vs. fewer suicides, you are doing to reduce clinician burnout and doctors and nurses in the workforce longer.
It's also expensive to manage.
I'm not sure we'd have any OTC drugs in the US starting from zero in today's regulatory environment. Analgesics especially even get banned for prescription use (like the COX-2 inhibitors), because regulators refuse to consider that trading off risk of death against pain is valid in the first place.
That's a failing of today's regulatory environment, and has no bearing on whether I should be able to buy a big bottle of death.
My APAP related disgust is reserved for drug warriors who ensure that oxycodone with APAP is the most available formulation of oxycodone, because they consider people trying to abuse it dying horribly to be a feature and not a bug.
I think these days they would argue that the reason is mostly because of synergistic analgesia (which is not incorrect) but yes I agree it's a questionable cost/benefit.
But ultimately society is organized around tradeoffs in your rights to enable you to have rights and the conveniences of civilization. Having to deal with mildly annoying blister packs or smaller bottles doesn't seem like a high price to pay for the amount of pain you can prevent.
Yes, that's one reason the combinations are popular, but not the reason oxy with APAP (Percocet) is so favored over oxy with ASA (Percodan, no longer available) or oxy with ibuprofen (Combunox, no longer available). That's drug warrior pressure.
No, society is organized around what those with power want.
There is a bunch of research out there suggesting that OTC and milder agents are just as good as stronger agents for managing acute pain. Example:
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2786200
Lots of research. You might not find that research convincing but it is absolutely out there.
Additionally APAP is a safer choice than ASA or Ibu if taken as prescribed, which is easier to ensure in an acute course (less potential for severe side effects or interaction with chronic medical conditions).
Yes, I'm aware of the risible drug warrior shit research. The drug warriors would love to eliminate legal opiods entirely, and they will lie about this being no loss, because they're drug warriors and do not care about pain as long as they can fight drugs.
I don't know a single person in clinical medicine who wants to eliminate opioids and while I'm sure there might be some crack pots that's an extraordinary claim that requires some evidence to be taken credibly.
Reactive under-prescribing in some outpatient settings is certainly a problem but that's not really your claim.
Yeah, but I'm not talking about people in clinical medicine, though I suppose it's not out of the question there are some drug warriors there. Ask a clinician who deals with severe pain as part of their practice whether APAP or ASA or ibuprofen control pain as well as opiods, and they're going to laugh. The reason studies like this are done is to come to the conclusion "Non-opioid medications are just as good as opoids for , therefore we should move to legally discourage the use of opoids for that condition."
To be "fair" to the drug warriors, in recent years they've been moving from accepting the presence of APAP in combination drugs as a reason for lesser regulation to not doing so, instead making both the combination and the straight opoid hard to deal with. I presume this means more people with broken bones being sent home with an aspirin.
Anecdotally I've had several significant injuries some of which have been managed with controlled substances and some of which have been managed with staggered dose ibuprofen and APAP, absent the "high" effect they are comparable (for me) when it comes to pain control. The research supports this - plenty of people manage without pain control or with more deliberate OTC medication usage.
Some amount of breakthrough pain or discomfort is normal and to an extent beneficial. Some research suggests that that the desire for total pain control and numbing is a somewhat American cultural specific desire and part of why we have addiction problems in this country.
Analgesia and addiction considerations aside, the medications have a number of problematic side effects that need to be considered. They do have their use though, and the people doing research in this area are aware of that.
Looking at a JAMA article and saying this clinical research is fabricated by non-clinician puritans is conspiratorial thinking, especially because the types of people have cultural sway for this kinda of thing at the moment are probably best categorized as dangerously pro-opioid - see: safe injection sites, methadone clinics, and pushing of Suboxone as the best solution to the problem.
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