Misuse and Abuse of Over the Counter Drugs

Misuse and Abuse of Over the Counter Drugs D S I Y V I R S C I O U N S O E F S U T N U D I E V N T E R A F S I T Y F Presented by: A I Connie Barker, RPh R S James Byrne, JD, CASAC Cindy Joslin, RN

Consumer Misperceptions and Misuse of OTC Pain Relievers American Academy of Family Physicians n Misuse of OTC pain relievers can lead to medical problems, such as gastrointestinal bleeding, ulcers, kidney and liver damage.

Consumer Misperceptions and Misuse of OTC Pain Relievers Factors that may be contributing misuse: n n n Limited understanding of the ingredients A belief that more is better Unrealistic expectations about the normal range and duration of symptoms Ability of any medicine to fully relieve symptoms A perception among the public that OTC medicines are not “real” medicine.

Pseudoephedrine is a decongestant that shrinks blood vessels in the nasal passages which is available in a wide range of OTC products. Do not use if have taken an MAOI in the last 14 days; serious side effects can occur. n Should avoid using if you smoke or are on any stimulant medications, may increase risk of unpleasant side effects. n May interact with various medications including those being given for HTN, heart disease, diabetes or thyroid disorders. § Death may occur with misuse!!!! n

Pseudoephedrine Common side effects : n Mild loss of appetite n Warmth, tingling or redness under skin n Skin rash or itching n Feeling excited or restless, insomnia

Pseudoephedrine Serious side effects : Fast, pounding, or uneven heartbeat Decreased or difficult urination Severe dizziness, anxiety, restlessness, nervousness or trouble concentrating n Increased blood pressure or chest pain n Severe headache, blurred vision, unusual weakness , numbness, or seizure. n n n Seek emergency medical attention !

Phenylephrine n Phenylephrine is a decongestant that shrinks blood vessels in the nasal passages which is available in a wide range of OTC products. Do not use if have taken MAOI in past 14 days; could cause serious life-threatening side effects if taken before MAO inhibitor has cleared the body. n May interact with various medications including those being given for the following conditions: heart disease, HTN, glaucoma, migraines, enlarged prostate, bipolar or any other mental illness, as well as those given to treat circulatory, kidney or thyroid disorders. n

Phenylephrine n Should avoid taking if you are smoking or are taking any stimulant medications to prevent increased risk of side effects. Common side effects: n n Headache, dizziness Nervousness or feeling restless Upset stomach Difficulty sleeping

Phenylephrine Serious side effects, death may occur from misuse : n n n n Extreme nervousness or restlessness Severe dizziness, tremors or shaking Unusual thoughts or behaviors Hallucinations and/or insomnia Fast, pounding or uneven heartbeat Fainting, numbness and tingling Decreased or lack of urination

Acetaminophen Pain reliever/ fever reducer commonly found in a large assortment of OTC products to treat a vast number of symptoms. MDD – 4 Grams/day. Higher doses can result in serious harm especially combined with regular consumption of alcohol. Side effects are rare when taken as directed. Serious side effects or signs of possible overdose include: Signs of an allergic reaction including: redness, rash/hives, swelling in the mouth or throat and/or difficulty breathing n Low fever with nausea, stomach pain and loss of appetite. n Dark urine , clay-colored stools n Jaundice ( yellowing of the skin or eyes) **The intensity of these symptoms generally depend on the degree of consumption and time frame for misuse, severe cases may result in Acute Liver Failure. n

Acetaminophen Overdose *Most common cause of Acute Liver Failure in the Unites States n n n More than 56, 000 ER visits/year related to Acetaminophen O. D. - most of which is accidental. Cases of Acetaminophen related Acute Liver Failure on the rise, ~500 deaths / year and growing. Unintentional overdosing usually only recognized after serious symptoms have developed - often as the result of irreversible liver damage developed over time. N-acetylcysteine administered within 12 h of an acute overdose can prevent liver injury in most cases. Delay in administration of this therapy is associated with greater morbidity and mortality.

Acetaminophen / Acute Liver Failure Three Clinical Stages : ( phases ) First phase – initial 12 to 24 h after ingestion > patient has nausea and vomiting. n Second phase - 24 to 48 h “ inactive or latent” phase > patient feels fine. n Third phase – 48 to 72 h after ingestion> elevated LFT’s begin to appear indicating degree of liver injury/outcome. n

NSAIDS AND ASA

Nonsteroidal Anti-Inflammatory Drugs n n n Long term use may increase risks of heart attack, stroke, renal failure and gastrointestinal bleeding. Should not use if sensitive to Aspirin and/or have reactive airway disease. May cause drowsiness especially if taken with alcohol. May interact with many medications which may cause serious side effects. Should avoid if on steroidal medications due to the increased risk of GI bleeding.

Nonsteroidal Anti-Inflammatory Drugs Common side effects : n GI distress ( mild heartburn, diarrhea, bloating, gas, constipation) n Dizziness, headache, nervousness n Rash or itching n Blurred vision n Tinnitus ( ringing in the ears)

Nonsteroidal Anti-Inflammatory Drugs Serious side effects may include: n Severe allergic reaction, bleeding, chest pain and difficulty breathing n Abdominal pain, gastrointestinal bleeding, decreased urination, renal necrosis and hepatitis. n Severe headache, confusion, depression, impaired hearing, vision or speech, stroke or seizure. www. drugs. com

Aspirin Early symptoms of overuse : Gastrointestinal distress, bruising, tinnitus and hearing impairment. Signs of Aspirin Poisoning include: Rapid breathing, vomiting, bleeding, double vision, extreme drowsiness, confusion, coma and eventually death. * Aspirin has been linked to Reye’s Syndrome, a rare but serious condition that can affect children, usually under the age of 18, who are recovering from a viral infection.

Diphenhydramine

Diphenhydramine Antihistamine used to safely treat various symptoms of allergies and the common cold when used as directed. Also used to suppress coughs, treat motion sickness and to induce sleep. n Common side effects include: Sleepiness, fatigue, n Symptoms of serious side effects or overdose include: Extreme sleepiness and confusion, weakness, dizziness, headache, dry mouth, ringing in the ears, difficulty urinating, constipation, and enlarged prostate. blurred vision, dilated pupils, shaking, flushing, fever, hallucinations, insomnia and possibly seizures.

Transcultural beliefs Healthcare systems in countries of origin may influence individual beliefs re: responsibility for health care. n In many countries pharmacists may be consulted before physicians re: medications n In cultures where people are accustomed to easily buying a wide variety of medications it is common practice to share them with family and friends. n

Transcultural beliefs n Of the developed nations, only the U. S. and South Africa do not have free access to health care. n Many OTC medications abroad are now being sold in blister packs only to discourage misuse. n U. S. encourages self-reliance with ample supply of OTC’s and numerous media advertisements for self medication. n The U. S. is more restrictive than many countries re: warning labels and use of OTC medications.

People use potentially addicting prescription or OTC medications in the following manners: For legitimate, prescribed medical treatment; for example, methamphetamines for narcolepsy and opiates for severe trauma. As an additional drug to use when the DOC is unavailable on the streets. As a booster for a more intense high. As an alternative addictive drug when their DOC has been eliminated from use by drug testing. As an alternative addictive drug prescribed by physicians; for example, amphetamines in diet clinics. These prescriptions may be issued either naively by the physician or for profit. [9, 10]

Data from the Drug Abuse Warning Network demonstrate the following about people who abuse prescription or OTC medications: They tend to be white. They tend to be younger (when stimulants are the DOC). They tend to use opiates. They tend to be women; women tend to use tranquilizers and sedatives. They tend to mix their medications with alcohol. They tend to use prescription and OTC medications in conjunction with alcohol as a vehicle for suicide.

Nearly one in five teens (19 percent or 4. 5 million) report abusing prescription medications to get high; and one in 10 (10 percent or 2. 4 million) report abusing cough medicine to get high. More than half of teens (55 percent or 13 million) don’t agree strongly that using cough medicines to get high is risky.

A Short List of OTC Medicines with DXM Alka-seltzer Plus Cold & Cough Medicine Contac Coricidin HBP Cough and Cold Dayquil Liqui. Caps Delsym Dimetapp DM Drixoral Pertussin Robitussin Sudafed Triaminic Tylenol Cold Vicks 44 Cough Relief Vicks Nyquil Liqui. Caps

Street Names for DXM: Candy C-C-C Dex DM Drex Red Devils Robo Rojo Skittles Tussin Velvet Vitamin D. Street Names for DXM Abuse: Dexing Robotripping Robodosing

PLATEAU 1 DIZZINESS, NAUSEA, VOMITING, DIARRHEA, LOSS OF COORDINATIONS, SWEATING, COLD FLASHES BLURRED VISION AND DILATED PUPILS, SLURRED SPEECH, HEACACHES SKIN SENSITIVITY, REDNESS IN THE FACE, DRY SKIN AND MOUTH, TREMORS AND INVOLNTARY TWITCHING, LOSS OF CONSCIOUSNESS NUMBNESS OF FINGERS AND TOES, ABDOMINAL PAIN, IRREGULAR HEARTBEAT, ACHES, SEIZURES, PANIC ATTACKS, PSYCHOSIS

Figure 2. Percentages of Use of Specific Over-the-Counter (OTC) Cough or Cold Medications in the Past Year among Past Year OTC Cough and Cold Medication Misusers Aged 12 to 25: 2006**

NYQUIL

ROBITUSSIN

CORICIDIN

Photo credit: Jacob Wackerhousen

SLEEP AIDS

LAXATIVES/DIURETICS

DIET PILLS

CAFFEINE

MOTION SICKNESS n Dimenhydrinate n meclizine n cyclizine

PAIN RELIEVERS

HERBALS

ALOE VERA

DANDELION

Physicians need to watch for prescription and OTC medication abuse. Treatment strategies include (1) inquiring about prescription, OTC, and herbal drug use at the initial examination (even though many individuals are drug-abuse savvy, some are naïve and do not realize that OTC medications can be problematic); (2) inquiring about drug use during office visits; (3) providing disposal containers that patients can use to dispose of their unused or unneeded prescription or OTC medications; (4) treating pain aggressively and appropriately; (5) practicing careful record keeping of prescription refills and controls over prescription blanks; (6) referring patients who are addicted to medications to 12 -step programs such as Alcoholic Anonymous, Narcotics Anonymous, and Pills Anonymous; and (7) considering detoxification

The DASIS Report: Prescription and Over-the. Counter Drug Abuse Admissions In 1999, 87 percent of substance abuse treatment admissions for prescription and over-the-counter (OTC) drug abuse were among Whites. Substance abuse treatment admissions for abuse of tranquilizers and sedatives were more likely to be female. Admissions for abuse of prescription stimulants and OTC drugs were more likely to be male. http: //www. oas. samhsa. gov/2 k 2/OTCtx. cfm From 1999 to 2004, there was a seven-fold increase in cases related to the abuse of DXM reported to poison control centers nationwide. Most of these cases were among 15 - and 16 -yearolds. (Bryner, 2006) http: //www. mediacampaign. org/newsroom/press 08/rx_rpt_2008. pdf

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Stages of Addiction 1. Use - The ingestion of alcohol or other drugs without the experience of any negative consequences. 2. Misuse - When a person experiences negative consequence from the use of alcohol or other drugs it is clearly misuse. A large percentage of the population misuses drugs or alcohol at some point in their life. 3. Abuse - Continued use of alcohol or other drugs in spite of negative consequences. 4. Dependency/Addiction - The compulsive use of alcohol or other drugs regardless of adverse or negative consequences. http: //www. solutions 4 recovery. com/addiction_stages. htm

RESOURCES www. nclnet. org/takewithcare/media/misperceptions. htm www. medicinenet. com www. webmd. com www. drugs. com www. Reutershealth. com www. mayoclinic. com www. oas. samhsa. gov/2 k 2/OTCtx. cfm www. erowid. org www. samhsa. com www. medscape. com www. drugfree. org www. solutions 4 recovery. com/addiction Purnell & Paulanka, eds. Transcultural Healthcare 3 rd Edition, 2008