Misuse and Abuse of Over the Counter Drugs

Presented by:

Connie Barker, RPh

James Byrne, JD, CASAC

Cindy Joslin, RN

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Consumer Misperceptions and Misuse of OTC Pain Relievers

American Academy of Family Physicians

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:

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.

PseudoephedrinePseudoephedrinePseudoephedrine is a decongestant that shrinks

blood vessels in the nasal passages which is which is available in a wide range of OTC productsavailable in a wide range of OTC products..

Do not use if have taken an MAOI in the last 14 Do not use if have taken an MAOI in the last 14 days; serious side effects can occur. days; serious side effects can occur.

Should avoid using if you smoke or are on any Should avoid using if you smoke or are on any stimulant medications, may increase risk of stimulant medications, may increase risk of unpleasant side effects.unpleasant side effects.

May interact with various medications including May interact with various medications including those being given for HTN, heart disease, those being given for HTN, heart disease, diabetes or thyroid disorders.diabetes or thyroid disorders.

Death may occur with misuse!!!!Death may occur with misuse!!!!

PseudoephedrinePseudoephedrine

Common side effectsCommon side effects ::

Mild loss of appetiteMild loss of appetite Warmth, tingling or redness under Warmth, tingling or redness under

skinskin Skin rash or itchingSkin rash or itching Feeling excited or restless, insomniaFeeling excited or restless, insomnia

PseudoephedrinePseudoephedrine

Serious side effectsSerious side effects ::

Fast, pounding, or uneven heartbeatFast, pounding, or uneven heartbeat Decreased or difficult urinationDecreased or difficult urination Severe dizziness, anxiety, restlessness, Severe dizziness, anxiety, restlessness,

nervousness or trouble concentratingnervousness or trouble concentrating Increased blood pressure or chest painIncreased blood pressure or chest pain Severe headache, blurred vision, unusual Severe headache, blurred vision, unusual

weakness ,numbness, or seizure.weakness ,numbness, or seizure.

Seek emergency medical attentionSeek emergency medical attention !!

PhenylephrinePhenylephrine

Phenylephrine is a decongestant that shrinks Phenylephrine is a decongestant that shrinks blood vessels in the nasal passages which is blood vessels in the nasal passages which is available in a wide range of OTC productsavailable in a wide range of OTC products..

Do not use if have if have taken MAOI in past 14 Do not use if have if have taken MAOI in past 14 days; could cause serious life-threatening side effects days; could cause serious life-threatening side effects if taken before MAO inhibitor has cleared the body.if taken before MAO inhibitor has cleared the body.

May interact with various medications including those May interact with various medications including those being given for the following conditions:being given for the following conditions:

heart disease, HTN, glaucoma, migraines, enlarged heart disease, HTN, glaucoma, migraines, enlarged prostate, bipolar or any other mental illness, as prostate, bipolar or any other mental illness, as well as those given to treat circulatory, kidney or well as those given to treat circulatory, kidney or thyroid disorders.thyroid disorders.

PhenylephrinePhenylephrine Should avoid taking if you are smoking or Should avoid taking if you are smoking or

are taking any stimulant medications to are taking any stimulant medications to prevent increased risk of side effects.prevent increased risk of side effects.

Common side effectsCommon side effects:: Headache, dizzinessHeadache, dizziness Nervousness or feeling restlessNervousness or feeling restless Upset stomach Upset stomach Difficulty sleepingDifficulty sleeping

PhenylephrinePhenylephrine

Serious side effectsSerious side effects, , death may death may occur from misuse occur from misuse ::

Extreme nervousness or restlessnessExtreme nervousness or restlessness Severe dizziness, tremors or shakingSevere dizziness, tremors or shaking Unusual thoughts or behaviorsUnusual thoughts or behaviors Hallucinations and/or insomniaHallucinations and/or insomnia Fast, pounding or uneven heartbeatFast, pounding or uneven heartbeat Fainting, numbness and tinglingFainting, numbness and tingling Decreased or lack of urinationDecreased or lack of urination

AcetaminophenAcetaminophenPain reliever/ fever reducer commonly found in a large Pain reliever/ fever reducer commonly found in a large

assortment of OTC products to treat a vast number assortment of OTC products to treat a vast number of symptoms. of symptoms.

MDD – 4 Grams/day. Higher doses can result in serious harm MDD – 4 Grams/day. Higher doses can result in serious harm especially combined with regular consumption of alcoholespecially combined with regular consumption of alcohol..

Side effects are rare when takenSide effects are rare when taken as directed. Serious side as directed. Serious side effects or signseffects or signs of possible overdose include:of possible overdose include:

Signs of an allergic reaction including: redness, rash/hives, Signs of an allergic reaction including: redness, rash/hives, swelling in the mouth or throat and/or difficulty breathingswelling in the mouth or throat and/or difficulty breathing

Low fever with nausea, stomach pain and loss of appetite.Low fever with nausea, stomach pain and loss of appetite. Dark urine , clay-colored stoolsDark urine , clay-colored stools Jaundice ( yellowing of the skin or eyes)Jaundice ( yellowing of the skin or eyes)

**The intensity of these symptoms generally depend on the **The intensity of these symptoms generally depend on the degree of consumption and time frame for misuse, severe degree of consumption and time frame for misuse, severe cases may result in Acute Liver Failurecases may result in Acute Liver Failure..

Acetaminophen OverdoseAcetaminophen Overdose*Most common cause of Acute Liver

Failure in the Unites States More than More than 56,00056,000 ER visits/year related to ER visits/year related to

Acetaminophen O.D. - most of which is accidental.Acetaminophen O.D. - most of which is accidental. Cases of Acetaminophen related Acute Liver Failure Cases of Acetaminophen related Acute Liver Failure

on the rise, ~on the rise, ~500500 deathsdeaths / year and growing. / year and growing. Unintentional overdosing usually only recognized Unintentional overdosing usually only recognized

after serious symptoms have developed - often as after serious symptoms have developed - often as the result of irreversible liver damage developed the result of irreversible liver damage developed over time.over time.

N-acetylcysteine administered within 12h of an acute N-acetylcysteine administered within 12h of an acute overdose can prevent liver injury in most cases.overdose can prevent liver injury in most cases.

Delay in administration of this therapy is associated Delay in administration of this therapy is associated with greater morbidity and mortality.with greater morbidity and mortality.

Acetaminophen / Acute Acetaminophen / Acute Liver FailureLiver Failure

Three Clinical Stages :( phases )Three Clinical Stages :( phases ) First phase – initial 12 to 24h after ingestion First phase – initial 12 to 24h after ingestion

> patient has nausea and vomiting.> patient has nausea and vomiting. Second phase - 24 to 48 h “ inactive or Second phase - 24 to 48 h “ inactive or

latent” phase > patient feels fine.latent” phase > patient feels fine. Third phase – 48 to 72h after ingestion> Third phase – 48 to 72h after ingestion>

elevated LFT’s begin to appear indicating elevated LFT’s begin to appear indicating degree of liver injury/outcome.degree of liver injury/outcome.

NSAIDS AND ASANSAIDS AND ASA

Nonsteroidal AntNonsteroidal Antii--Inflammatory DrugsInflammatory Drugs

Long term use may increase risks of heart attack, Long term use may increase risks of heart attack, stroke, renal failure and gastrointestinal bleeding.stroke, renal failure and gastrointestinal bleeding.

Should not use if sensitive to Aspirin and/or have Should not use if sensitive to Aspirin and/or have reactive airway disease.reactive airway disease.

May cause drowsiness especially if taken with May cause drowsiness especially if taken with alcohol.alcohol.

May interact with many medications which may May interact with many medications which may cause serious side effects.cause serious side effects.

Should avoid if on steroidal medications due to Should avoid if on steroidal medications due to the increased risk of GI bleeding.the increased risk of GI bleeding.

Nonsteroidal Anti-Nonsteroidal Anti-Inflammatory DrugsInflammatory Drugs

Common side effectsCommon side effects :: GI distress ( mild heartburn, diarrhea, GI distress ( mild heartburn, diarrhea,

bloating, gas, constipation) bloating, gas, constipation) Dizziness, headache, nervousnessDizziness, headache, nervousness Rash or itchingRash or itching Blurred visionBlurred vision Tinnitus ( ringing in the ears)Tinnitus ( ringing in the ears)

Nonsteroidal Anti-Nonsteroidal Anti-Inflammatory DrugsInflammatory Drugs

Serious side effects may includeSerious side effects may include:: Severe allergic reaction, bleeding, Severe allergic reaction, bleeding,

chest pain and difficulty breathingchest pain and difficulty breathing Abdominal pain, gastrointestinal Abdominal pain, gastrointestinal

bleeding, decreased urination, renal bleeding, decreased urination, renal necrosis and hepatitis.necrosis and hepatitis.

Severe headache, confusion, Severe headache, confusion, depression, impaired hearing, vision depression, impaired hearing, vision or speech, stroke or seizure.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.

DiphenhydramineDiphenhydramine

DiphenhydramineDiphenhydramineAntihistamine used to safely treat various Antihistamine used to safely treat various

symptoms of allergies and the common cold symptoms of allergies and the common cold when used as directed. Also used to when used as directed. Also used to suppress coughs, treat motion sickness and suppress coughs, treat motion sickness and to induce sleep.to induce sleep.

Common side effects includeCommon side effects include: : Sleepiness, Sleepiness, fatigue, dizziness, headachefatigue, dizziness, headache, , dry mouth, ringing in dry mouth, ringing in the ears, difficulty urinating, constipation, and the ears, difficulty urinating, constipation, and enlarged prostateenlarged prostate..

Symptoms of serious side effects or Symptoms of serious side effects or overdose include:overdose include: Extreme sleepiness and Extreme sleepiness and confusion, weakness, blurred vision, dilated pupils, confusion, weakness, blurred vision, dilated pupils, shaking, flushing, fever, hallucinations, shaking, flushing, fever, hallucinations, insomniainsomnia and possibly seizuresand possibly seizures..

Transcultural beliefsTranscultural beliefs Healthcare systems in countries of origin Healthcare systems in countries of origin

may influence individual beliefs re: may influence individual beliefs re: responsibility for health care.responsibility for health care.

In many countries pharmacists may be In many countries pharmacists may be consulted before physicians re: consulted before physicians re: medicationsmedications

In cultures where people are accustomed In cultures where people are accustomed to easily buying a wide variety of to easily buying a wide variety of medications it is common practice to share medications it is common practice to share them with family and friends.them with family and friends.

Transcultural beliefsTranscultural beliefs Of the developed nations, only the U.S. and Of the developed nations, only the U.S. and

South Africa do not have free access to health South Africa do not have free access to health care.care.

Many OTC medications abroad are now being sold Many OTC medications abroad are now being sold in blister packs only to discourage misuse.in blister packs only to discourage misuse.

U.S. encourages self-reliance with ample supply U.S. encourages self-reliance with ample supply of OTC’s and numerous media advertisements for of OTC’s and numerous media advertisements for self - medicationself - medication..

The U.S. is more restrictive than many countries The U.S. is more restrictive than many countries re: warning labels and use of OTC medications.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 DXMAlka-seltzer Plus Cold & Cough Medicine

ContacCoricidin HBP Cough and Cold

Dayquil LiquiCapsDelsymDimetapp DM

DrixoralPertussinRobitussinSudafedTriaminic

Tylenol ColdVicks 44 Cough ReliefVicks Nyquil LiquiCaps

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 1PLATEAU 1

DIZZINESS, NAUSEA, VOMITING, DIARRHEA, DIZZINESS, NAUSEA, VOMITING, DIARRHEA, LOSS OF COORDINATIONS, SWEATING, COLD LOSS OF COORDINATIONS, SWEATING, COLD FLASHES BLURRED VISION AND DILATED FLASHES BLURRED VISION AND DILATED PUPILS, SLURRED SPEECH, HEACACHESPUPILS, SLURRED SPEECH, HEACACHES

SKIN SENSITIVITY, REDNESS IN THE FACE, DRY SKIN SENSITIVITY, REDNESS IN THE FACE, DRY SKIN AND MOUTH, TREMORS AND INVOLNTARY SKIN AND MOUTH, TREMORS AND INVOLNTARY TWITCHING, LOSS OF CONSCIOUSNESSTWITCHING, LOSS OF CONSCIOUSNESS

NUMBNESS OF FINGERS AND TOES, NUMBNESS OF FINGERS AND TOES, ABDOMINAL PAIN, IRREGULAR HEARTBEAT,ABDOMINAL PAIN, IRREGULAR HEARTBEAT,

ACHES, SEIZURES, PANIC ATTACKS, PSYCHOSISACHES, 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**

NYQUILNYQUIL

ROBITUSSINROBITUSSIN

CORICIDINCORICIDIN

Photo credit: Jacob Wackerhousen

SLEEP AIDSSLEEP AIDS

LAXATIVES/DIURETICSLAXATIVES/DIURETICS

DIET PILLSDIET PILLS

CAFFEINECAFFEINE

MOTION SICKNESSMOTION SICKNESS

DimenhydrinateDimenhydrinate meclizinemeclizine cyclizinecyclizine

PAIN RELIEVERSPAIN RELIEVERS

HERBALSHERBALS

ALOE VERAALOE VERA

DANDELIONDANDELION

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/2k2/OTCtx/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-year-olds. (Bryner, 2006) http://www.mediacampaign.org/newsroom/press08/rx_rpt_2008.pdf

Siberian Amanita Muscara Powder. Botanic Specimen. For educational and research purposes only….

But it must be understood that within this mushroom is heaven and hell. While with one experiment you can find bliss, within the next you may find terror….

http://www.everyonedoesit.co.uk/online_headshop/Siberian_Amanita_Muscara_Powder.cfm?iProductID=2298&iProductCategoryID=553

Stages of Addiction  

1.   Use 1.   Use - The ingestion of alcohol or other drugs - The ingestion of alcohol or other drugs without the experience of any negative consequences. without the experience of any negative consequences.

2.   Misuse 2.   Misuse - When a person experiences negative - When a person experiences negative consequence from the use of alcohol or other drugs it is consequence from the use of alcohol or other drugs it is clearly misuse. A large percentage of the population clearly misuse. A large percentage of the population misuses drugs or alcohol at some point in their life. misuses drugs or alcohol at some point in their life.

3.   3.   Abuse Abuse - Continued use of alcohol or other drugs in - Continued use of alcohol or other drugs in spite of negative consequences. spite of negative consequences.

4.   4.   Dependency/Addiction Dependency/Addiction - The compulsive use of - The compulsive use of alcohol or other drugs regardless of adverse or negative alcohol or other drugs regardless of adverse or negative consequences. consequences.

http://www.solutions4recovery.com/addiction_stages.htm

RESOURCESRESOURCESwww.nclnet.org/takewithcare/media/misperceptions.htmwww.medicinenet.comwww.webmd.comwww.drugs.comwww.Reutershealth.comwww.mayoclinic.comwww.oas.samhsa.gov/2k2/OTCtx/OTCtx.cfm www.erowid.orgwww.samhsa.comwww.medscape.comwww.drugfree.orgwww.solutions4recovery.com/addiction

Purnell & Paulanka, eds. Transcultural Healthcare 3rd Edition, 2008