Editorials

Abuse of Over-the-Counter Medications Among Teenagers and Young Adults



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Am Fam Physician. 2011 Oct 1;84(7):745-750.

In recent years, recognition of over-the-counter (OTC) medication abuse by patients—especially teenagers and young adults—has increased.1 Abuse is defined as the use of a drug to experience psychoactive effects instead of for its medical indication. OTC medications are easily abused because they are inexpensive, legal, and widely available (in supermarkets and pharmacies, and via the Internet), and because they have no age requirement or limit on the amount purchased. Many patients think that OTC medications are safer than prescription or illicit drugs.2 Abusers of prescription drugs or illicit substances may also abuse OTC medications, or substitute an OTC drug when other substances are unavailable.3

The wide variety and accessibility of OTC drugs and lack of surveillance mechanisms make it difficult to gather national data; thus, neither the National Survey on Drug Use and Health nor the Monitoring the Future survey has examined the full scope of OTC drug abuse. Nevertheless, the medical literature supports this as an emerging issue. About 3.1 million persons between 12 and 25 years of age (5.3 percent) reported using OTC cough and cold medications to get high in 2006, according to the Substance Abuse and Mental Health Services Administration.4 A Utah survey showed that 38 percent of illicit drug use among teenagers and children from 1990 to 1999 involved OTC drugs.5 Admission to drug treatment centers for OTC medication abuse increased by more than 30 percent between 1993 and 2003.5 Cases of dextromethorphan abuse that were reported to poison control centers increased sevenfold from 1999 to 2004; most of these reports involved 15-and 16-year-olds.6  Studies suggest that adolescents and young adults are at greatest risk of OTC drug abuse. Table 1 lists select OTC medications with potential for abuse; dextromethorphan is of particular concern.6

Table 1.

Select Over-the-Counter Substances with Potential for Abuse

Substance Street name Signs and symptoms of intoxication Treatment

Caffeine (e.g., energy drinks, caffeine pills)

NA

Restlessness, nervousness, insomnia, tachyarrhythmias, psychomotor agitation, withdrawal, headache

Supportive care

Chlorpheniramine

DXM, robo, CCC, skittles, poor man's PCP, velvet, rojo, candy

Respiratory depression, hyperthermia, rhabdomyolysis, seizures, flushing, tachycardia, agitated delirium, urinary retention, cardiac arrhythmias

Supportive care; benzodiazepines for seizures

Chlorpheniramine plus dextromethorphan

DXM, robo, CCC, skittles, poor man's PCP, velvet, rojo, candy

Tachycardia, somnolence, agitation, hallucinations, hypertension, disorientation, slurred speech, syncope, seizure

Supportive care; benzodiazepines for seizures

Dextromethorphan

DXM, robo, CCC, skittles, poor man's PCP, velvet, rojo, candy

Hyperexcitability, lethargy, ataxia, slurred speech, sweating, temperature instability, hypertension, nystagmus, seizures, death

Supportive care; testing for concomitant ingestion of other drugs

Dimenhydrinate

Dime tabs, dime, substance D

Euphoria, hallucinations, flushing, tachycardia, agitated delirium, convulsions, urinary retention, cardiac arrhythmias, somnolence, coma

Clozapine (Clozaril) to reduce cravings

Diphenhydramine

NA

Flushing, tachycardia, agitated delirium, convulsions, urinary retention, cardiac arrhythmias, somnolence, coma

Supportive care

Nicotine (e.g., cigarettes, smokeless tobacco, nicotine replacement therapies)

Cigs, chew, dip, snuff, shisha, hubble-bubble

Mild euphoria, agitation

Smoking cessation; supportive care

Pseudoephedrine

NA; used to make methamphetamine

Priapism, hypertension, agitation, excitability, tachyarrhythmias

Supportive care


NA = not applicable.

Table 1.   Select Over-the-Counter Substances with Potential for Abuse

View Table

Table 1.

Select Over-the-Counter Substances with Potential for Abuse

Substance Street name Signs and symptoms of intoxication Treatment

Caffeine (e.g., energy drinks, caffeine pills)

NA

Restlessness, nervousness, insomnia, tachyarrhythmias, psychomotor agitation, withdrawal, headache

Supportive care

Chlorpheniramine

DXM, robo, CCC, skittles, poor man's PCP, velvet, rojo, candy

Respiratory depression, hyperthermia, rhabdomyolysis, seizures, flushing, tachycardia, agitated delirium, urinary retention, cardiac arrhythmias

Supportive care; benzodiazepines for seizures

Chlorpheniramine plus dextromethorphan

DXM, robo, CCC, skittles, poor man's PCP, velvet, rojo, candy

Tachycardia, somnolence, agitation, hallucinations, hypertension, disorientation, slurred speech, syncope, seizure

Supportive care; benzodiazepines for seizures

Dextromethorphan

DXM, robo, CCC, skittles, poor man's PCP, velvet, rojo, candy

Hyperexcitability, lethargy, ataxia, slurred speech, sweating, temperature instability, hypertension, nystagmus, seizures, death

Supportive care; testing for concomitant ingestion of other drugs

Dimenhydrinate

Dime tabs, dime, substance D

Euphoria, hallucinations, flushing, tachycardia, agitated delirium, convulsions, urinary retention, cardiac arrhythmias, somnolence, coma

Clozapine (Clozaril) to reduce cravings

Diphenhydramine

NA

Flushing, tachycardia, agitated delirium, convulsions, urinary retention, cardiac arrhythmias, somnolence, coma

Supportive care

Nicotine (e.g., cigarettes, smokeless tobacco, nicotine replacement therapies)

Cigs, chew, dip, snuff, shisha, hubble-bubble

Mild euphoria, agitation

Smoking cessation; supportive care

Pseudoephedrine

NA; used to make methamphetamine

Priapism, hypertension, agitation, excitability, tachyarrhythmias

Supportive care


NA = not applicable.

When treating a patient for a drug overdose, it is important to screen for multiple drugs, because many OTC cough and cold medications contain more than one active ingredient. Furthermore, overdoses can occur with a combination of OTC, prescription, and illicit drugs, as well as alcohol and other substances. In such instances, toxicity may be additive. Reporting overdoses to poison control centers is crucial so that data can be collected to support policy changes, such as placing an OTC drug behind the pharmacy counter or taking it off the market.

About 70 percent of parents report discussing the risks of marijuana use with their children, but only 36 percent say they have discussed prescription drug use, and only 33 percent have discussed OTC cough or cold medication use.2 Family physicians have an important role in identifying and preventing OTC drug abuse. When appropriate, physicians should inquire about all drug use, including prescription, OTC, herbal, and illicit substances; treat pain appropriately so patients do not self-medicate; refer patients to 12-step programs or detoxification programs when a problem is detected; and educate patients and their families about OTC drug abuse.7

Address correspondence to Chih-Wen Shi, MD, PhD, at chihwen.shi@med.navy.mil. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations to disclose.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Navy Medical Department or the U.S. Navy at large.

REFERENCES

1. National Institute on Drug Abuse. NIDA InfoFacts: Prescription and over-the-counter medications. http://www.nida.nih.gov/Infofacts/PainMed.html. Accessed February 28, 2011.

2. Partnership for a Drug-Free America. The Partnership Attitude Tracking Study (PATS). Teens in grades 7 through 12, 2005. http://www.drugfree.org/wp-content/uploads/2011/04/PATS-Teens-Full-Report-FINAL.pdf. Accessed February 28, 2011.

3. Abbot FV, Fraser MI. Use and abuse of over-the-counter analgesic agents. J Psychiatry Neurosci. 1998;23(1):13–34.

4. U.S. Department of Health and Human Services. Misuse of over-the-counter cough and cold medications among persons aged 12 to 25. http://www.oas.samhsa.gov/2k8/cough/cough.htm. Accessed February 28, 2011.

5. Crouch BI, Caravati EM, Booth J. Trends in child and teen nonprescription drug abuse reported to a regional poison control center. Am J Health Syst Pharm. 2004;61(12):1252–1257.

6. Bryner JK, Wang UK, Hui JW, Bedodo M, MacDougall C, Anderson IB. Dextromethorphan abuse in adolescence: an increasing trend: 1999–2004. Arch Pediatr Adolesc Med. 2006;160(12):1217–1222.

7. Lessenger JE, Feinberg SD. Abuse of prescription and over-the-counter medications [published correction appears in J Am Board Fam Med. 2008;21(2):175]. J Am Board Fam Med. 2008;21(1):45–54.



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