Preventing Abuse and Addiction With Nonprescription Products

US Pharm. 2014;39(11):12-15.

The abuse of prescription products is a long-standing problem of great concern to the federal government and individual states. Medications such as tramadol and hydrocodone were shifted to stricter schedules as evidence of their widespread abuse accumulated. However, there is also growing awareness and considerable alarm over the less well-recognized problem of abuse of nonprescription drugs and products.

This issue is perhaps more compelling for two reasons. First, unless states act to control their sale, pharmacologically active nonprescription products can be purchased in any quantity in thousands of nonpharmacy venues, such as gas stations, hotel lobbies, and airport shops. Second, pharmacists are not present to monitor sales at these locations. Instead, anyone can sell these potentially addictive drugs, regardless of age or educational level. Some items can be purchased from vending machines, and there is little or no control over Internet sales of various addictive substances.

Expert List of Abused Medications

Michael R. Cohen, RPh, president of the Institute for Safe Medication Practices (ISMP), listed the top nonprescription medications abused by teens and adults as of early 2013.¹ Some products are addictive, and some are not, but they all share the potential for abuse, and pharmacists should be vigilant in their sale.

Pseudoephedrine: Pseudoephedrine (PSE) made the list, even though sales have been restricted to behind-the-counter as a result of the Combat Methamphetamine Act of 2005.^2,3 However, Cohen highlighted its abuse by those who wish to lose weight and by athletes who wish to increase their competitive edge.¹ Pharmacists would be well advised to question potential purchasers closely to discover whether they actually have a condition for which PSE is labeled as safe and effective (e.g., the common cold, allergic rhinitis, sinus congestion). The pharmacist should also explore any other likely health conditions prior to approving a PSE sale. If the patient has heart disease, hypertension, thyroid disease, diabetes mellitus, or trouble urinating due to an enlarged prostate, he or she is not a candidate for safe self-use of PSE, and a refusal to sell is medically justified.

By refusing to sell PSE when it is contraindicated, pharmacists force legitimate patients to seek medical care from a prescriber and may thwart abusers. Further, PSE is not to be used if the patient has a fever, and use should not be continued if the symptoms have not improved in 7 days. Exploring these issues can also halt sales to abusers.

Dextromethorphan: At least 10% of teens have abused cough medicines, most often dextromethorphan (DXM).¹ Regrettably, many websites promote DXM abuse and describe its effects in alluring terms, as opposed to legitimate websites that give reliable and correct advice on toxic effects resulting from abuse.^4-9 As a result, DXM has killed and injured countless teens and adults. Pharmacists should also be extremely cautious when patients (especially teens) request DXM-containing cough syrups or tablets. For example, nonprescription DXM cough products are contraindicated if the cough has lasted more than 7 days or recurs; if the patient also has a fever, rash, or persistent headache; or if the patient has a persistent or chronic cough such as that associated with smoking, asthma, emphysema, or a condition with excessive sputum. Any of these circumstances is ample medical justification to recommend that the patient visit a physician rather than use a DXM product.

It may be prudent to place DXM-containing items behind the counter, like PSE. By creating a voluntary “third class” of behind-the-counter drugs, the pharmacist gains the power to deny sales in suspect situations, a step that might save the life of a teen DXM addict. Of course, nothing stops addicts from visiting a nonpharmacy retailer to purchase DXM, but at least the pharmacist does not unwittingly allow an addiction to continue.

Caffeine and Energy Drinks: Cohen also pointed out the addictive potential of caffeine,¹ found as the sole ingredient in such products as NoDoz and Vivarin and in some headache remedies.^10,11 Caffeine is also an ingredient of some energy drinks (e.g., Red Bull, 5-Hour Energy). Product labels may list such ingredients as gotu kola or guarana, both of which obscure the fact that they contain caffeine. Caffeine users seek the abrupt burst of energy caffeine provides, but also may experience such problems as dehydration, reflux, panic attacks, and arrhythmias. The safety and efficacy of energy drinks is debatable, and the pharmacy can simply refuse to stock them.¹² Caffeine tablets can also be moved behind the counter to help thwart addiction.

Diet Pills, Laxatives, and Diuretics: The drive to lose weight extends beyond the teen years, and healthy weight-loss advice is readily available.¹³ However, many people refuse to follow this advice, opting instead to rely on methods that endanger their health. For instance, the only FDA-approved nonprescription weight loss product is alli (orlistat). Nevertheless, innumerable products promise weight loss without proof of safety or efficacy, a practice identified as health fraud by the FDA.^14,15 The concerned pharmacy would do well to clear its shelves of all unproven and fraudulent weight-loss products.

FDA-approved nonprescription laxatives are safe and effective for constipation, assuming all label directions are followed. Similarly, nonprescription diuretics (e.g., pamabrom, caffeine, ammonium chloride) are safe and effective for relieving menstrually related fluid retention. Some misguided people take laxatives and diuretics for weight loss, a dangerous practice. The range of abusers includes anorexics, bulimics, athletes facing a mandatory weight level, and high school students preparing for an upcoming prom. These abusers are more difficult for the pharmacist to detect, but some tips may help. For example, males would not have a legitimate medical need for nonprescription diuretics, and thus should be strongly dissuaded from purchasing them. If the problem originates with an athletic coach who is giving dangerous weight-loss advice to high schoolers, the pharmacist might be compelled to speak directly to the coach. If the conversation is nonproductive, it is best to discuss the dangers of the coach’s practices with the principal, superintendent, or school board.

The typical anorexic or bulimic individual is a thin or emaciated female. If a girl or woman of this body type repeatedly purchases laxatives, diuretics, or diet products, it may be prudent to counsel her about the inherent dangers of such abuse. If she admits she has a problem, the pharmacist should stress the importance of counseling in overcoming her adverse behaviors.

Antihistamines: Cohen described abuse of antihistamines, in which teens may take up to 40 tablets of dimenhydrinate (e.g., Dramamine) or diphenhydramine (e.g., Benadryl).¹ Apparently, such excessive doses induce feelings similar to a narcotic high, complete with hallucinations. Once again, prospective purchasers should be questioned closely about the condition for which they are supposedly buying the product. Dramamine is indicated only for motion sickness, and Benadryl is limited to the common cold or allergic rhinitis.

Unproven Nonprescription Products: With the exception of energy drinks and diet pills, the other abused products on Cohen’s list as discussed above actually have legitimate medical uses and are stocked by pharmacies for those uses. However, a host of unproven products are also subject to abuse. The Cohen list includes sexual performance products, herbal ecstasy, and other herbals/dietary supplements.¹ None of these products is known to be safe or effective for any use. Furthermore, if medical claims are made for them, such practice falls within the federal definition of health fraud.¹⁴ For these reasons, there is little justification for stocking them in the pharmacy. A refusal to supply these products would eliminate the pharmacy as a source of abusable unproven products.

Cohen pointed out that sexual stimulants are widely available via the Internet.¹ Gullible purchasers who drink alcohol may believe these products will counteract the effects of alcohol on sexual performance and guarantee the user greater satisfaction. In reality, unproven sexual stimulants can cause heart problems.¹⁵

Herbal ecstasy is an umbrella name for unproven products sold to provide a “legal high.” Most contain ma huang, a form of ephedrine. Although single-entity ephedrine was restricted to Schedule V in the United States, it is apparently still available online.¹⁶ Potentially unsafe products alleged to be herbal ecstasy are also available.¹⁷

Cohen also discussed herbal products that are abused for their ability to provide stimulation, euphoria, and/or hallucinations.¹ Abuse of herbs is attractive to people who must submit to either a scheduled or random urine screen, since herbs are seldom detected. Most can be legally purchased in a variety of locations. One example is Salvia divinorum, a herb so well known to cause hallucinations when smoked or ingested that it is regulated in at least 21 states.^1,18,19 Despite this, it is widely available on websites and in smoke shops (also known as head shops), where it is sold as “legal marijuana.”^20,21 Salvia lacks any medical use, and no pharmacy should ever stock or sell it. Users report such adverse reactions as loss of body control, extreme psychosis, and violent behavior.¹

Nutmeg is another herb of abuse.^1,22,23 Users eat a paste made of nutmeg, seeking to experience giddiness, euphoria, and hallucinations. However, nutmeg also causes blurred vision, palpitations, hypotension, tachycardia, chronic psychosis, and even death. As is the case with salvia, there is no legitimate medical use for nutmeg, and it should not be sold in the pharmacy.

“Spice” is a widely abused herbal product, sold online, in gas stations, and in head shops. A government website describes spice as a mixture of shredded herbs and synthetic chemicals, having the ability to induce alterations of the sensorium.²⁴ Products are labeled as “Not For Human Use” or disguised as incense, both being poor attempts to peddle this “synthetic marijuana” to gullible users. The Drug Enforcement Administration (DEA) made the five most frequent active chemicals in these products illegal, but manufacturers avoid legal action by altering the chemicals added. If asked, pharmacists should strongly discourage use of these dangerous mixtures.

PATIENT INFORMATION

Concerning drug abuse, a lot of attention has been focused on methamphetamine (meth) and prescription drugs such as opiates and hydrocodone. However, there is also a problem with abuse of safe and effective nonprescription drugs. Some people have also chosen to abuse a large group of unproven OTC products, such as herbals.

Abuse of Legitimate Nonprescription Products

Legitimate nonprescription products have a justified medical use for which they are safe and effective when taken according to all label directions. The problem is that abusers ignore the directions for proper doses, and use doses that are too high for safety. Additionally, abusers do not have the medical condition for which the products are indicated. Thus, they risk side effects for no reason other than to get high.

Pseudoephedrine (e.g., Sudafed), a well-accepted nasal decongestant, is abused mainly because it has become a major starter chemical for meth labs. To discourage abuse, it is kept behind pharmacy counters.

Another major abuse chemical is dextromethorphan (DXM), a legitimate cough suppressant. Potential abusers can visit Internet sites that speak in glowing terms of the high that users can reach when they take large doses of DXM. The sad fact is that DXM abuse is dangerous and has already resulted in the deaths of untold numbers of teenagers. If you suspect your teen is using DXM, you must act immediately to halt the abuse, before it causes irreversible damage or even death.

Caffeine is an addictive drug, whether it is ingested in soft drinks, as caffeine tablets (e.g., NoDoz), or in energy drinks. Users often consume higher and higher amounts in attempt to achieve stimulation. Overuse can have adverse effects on several body systems (such as the heart), and users should be encouraged to withdraw from caffeine if they are suffering side effects that may be traced to it.

Abuse of Unproven Nonprescription Products

Teens also abuse a group of products that have no legitimate medical use. This long list of abusable products includes herbals, dietary supplements (other than vitamins and minerals), sexual stimulants, and “herbal ecstasy” and other strange products. Teen abusers take incredible steps to hide their abuse from parents. For this reason, vigilance is critical.

Watch for obvious clues to drug abuse, such as falling grades, a new set of friends who are seldom brought to the house, disappearance of money from billfolds and purses, vanished possessions (from having been pawned or sold), unexplained lapses of time, furtive behavior, and lying. When these appear, it might be advisable to search the teen’s room for evidence of drug abuse, such as receipts for legitimate drugs of abuse from pharmacies, any receipts from health food stores or “head shops,” and loose tablets, capsules, or plant material. You may also notice physical signs of abuse and addiction, such as eye or nose problems, difficulty staying awake, inability to concentrate on tasks at hand, and sloppy or slurred speech.

Remember, if you have questions, Consult Your Pharmacist.

REFERENCES

1. Cohen MR. 10 over-the-counter medicines abused by teens. philly.com. January 14, 2013. www.philly.com/philly/blogs/healthcare/10-over-the-counter-medicines-abused-by-teens.html. Accessed September 26, 2014.
2. Legal requirements for the sale and purchase of drug products containing pseudoephedrine, ephedrine, and phenylpropanolamine. FDA. www.fda.gov/Drugs/DrugSafety/informationbyDrugClass/ucm072423.htm. Accessed September 26, 2014.
3. Methamphetamine abuse and addiction. National Institute on Drug Abuse. www.drugabuse.gov/sites/default/files/methrrs_web.pdf. Accessed September 26, 2014.
4. Dextromethorphan. Drug Enforcement Administration. March 2014. www.deadiversion.usdoj.gov/drug_chem_info/dextro_m.pdf. Accessed September 26, 2014.
5. Dextromethorphan. National Highway Traffic Safety Administration. www.nhtsa.gov/PEOPLE/injury/research/job185drugs/dextromethorphan.htm. Accessed September 26, 2014.
6. Dextromethorphan (DXM) and cold medicine. NIDA for Teens. http://teens.drugabuse.gov/drug-facts/dextromethorphan-dxm-and-cold-medicine-facts. Accessed September 5, 2014.
7. Dextromethorphan overdose. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/002628.htm. Accessed September 26, 2014.
8. Dextromethorphan overdose. PubMed Health. www.ncbi.nlm.nih.gov/pubmedhealth/PMH0003216/. Accessed September 26, 2014.
9. Intelligence bulletin: DXM (dextromethorphan). National Drug Intelligence Center. October 2004. www.justice.gov/archive/ndic/pubs11/11563/. Accessed September 26, 2014.
10. Caffeine. MedlinePlus. www.nlm.nih.gov/medlineplus/caffeine.html. Accessed September 26, 2014.
11. Caffeine in the diet. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/002445.htm. Accessed September 26, 2014.
12. Caffeine and alcohol. Fact sheets. CDC. www.cdc.gov/alcohol/fact-sheets/cab.htm. Accessed September 26, 2014.
13. Interested in losing weight? USDA. www.nutrition.gov/weight-management/strategies-success/interested-losing-weight. Accessed September 26, 2014.
14. CPG Sec. 120.500. Health fraud—factors in considering regulatory action. FDA. www.fda.gov/ICECI/ComplianceManuals/CompliancePolicy-GuidanceManual/ucm073838.htm. Accessed September 26, 2014.
15. Supplements for weight loss. WebMD. www.webmd.com/diet/guide/herbal-remedies. Accessed September 26, 2014.
16. Ephedrine. US Med Club. www.usmedclub.com/order/buy-ephedra/ephedrine-30mg_generic.html. Accessed September 26 2014.
17. Herbal Ecstasy brand herbal cigarettes. Monster Smokeshop. www.monstersmokeshop.com/herbalcigarettes-herbalecstacy.html. Accessed September 26, 2014.
18. Drug facts: salvia. National Institute on Drug Abuse. www.drugabuse.gov/publications/drugfacts/salvia. Accessed September 26, 2014.
19. State laws on Salvia divinorum. National Conference of State Legislatures. www.ncsl.org/research/health/state-salvia-laws.aspx. Accessed September 26, 2014.
20. Buy high quality Salvia divinorum. Salvia Supply. www.salviasupply.com. Accessed September 26, 2014.
21. Salvia divinorum. Voodoo Smokeshop. www.voodoosmokeshop.com/salvia.html. Accessed September 26, 2014.
22. Stein Y, Greyer H, Hentschel H. Nutmeg (myristicin) poisoning—report on a fatal case and a series of cases recorded by a poison information centre. Forensic Sci Int. 2001;118(1):87-90.
23. Brenner N, Frank OS, Knight E. Chronic nutmeg psychosis. J R Soc Med. 1993;86(3):179-180.
24. Spice. NIDA for Teens. http://teens.drugabuse.gov/drug-facts/spice. Accessed September 26, 2014.
25. Drug fact sheet. Kratom. DEA. www.justice.gov/dea/druginfo/drug_data_sheets/Kratom.pdf. Accessed September 26, 2104.
26. New drug that’s as addictive as heroin and perfectly legal. CBS Miami. http://miami.cbslocal.com/2013/11/21/new-drug-thats-as-addictive-as-heroin-and-perfectly-legal/. Accessed September 26, 2014.

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