At the conclusion of this chapter, students will be able to:
Medicines that can be purchased without a prescription from a health care provider are called over-the-counter (OTC) medicines. There are two OTC medicines that are most commonly misused: (1)Dextromethorphan (DXM), a cough suppressant found in many OTC cold medicines; and (2) Loperamide, an anti-diarrheal that is available in tablet, capsule, or liquid form. Other common OTC medicines include pain relievers like acetaminophen (Tylenol) and ibuprofen (Advil), cough suppressants such as dextromethorphan (Robitussin) and antihistamines like loratadine (Claritin 24H), and antidiarrheals like Lomotil. These drugs are usually dispensed in pharmacies and grocery stores. OTC medicines are used to treat a variety of illnesses and their symptoms including pain, coughs and colds, diarrhea, constipation, acne, and others. Some OTC medicines have active ingredients with the potential for misuse at higher-than-recommended dosages. People misuse OTC medicines by taking medicine in a frequency or dose other than directed on the package; taking medicine for the effect it causes, for example, to get high, rather than that which it is indicated for; and mixing OTC medicines together to create new products.
DXM is an opioid without effects on pain reduction and does not act on the opioid receptors. When taken in large doses, DXM causes a depressant effect and sometimes a hallucinogenic effect, similar to PCP and ketamine. Repeatedly seeking to experience that feeling can lead to addiction-a chronic relapsing brain condition characterized by inability to stop using a drug despite damaging consequences to a person’s life and health.
Loperamide is an opioid designed not to enter the brain. However, when taken in large amounts and combined with other substances, it may cause the drug to act in a similar way to other opioids. Other opioids, such as certain prescription pain relievers and heroin, bind to and activate opioid receptors in many areas of the brain, especially those involved in feelings of pain and pleasure. Opioid receptors are also located in the brain stem, which controls important processes, such as blood pressure, arousal, and breathing.1,2
Short-term effects of DXM misuse can range from mild stimulation to alcohol- or marijuana-like intoxication. At high doses, a person may have hallucinations or feelings of physical distortion, extreme panic, paranoia, anxiety, and aggression. Other health effects from DXM misuse can include the following:
Misuse of DXM products containing acetaminophen can cause liver damage.
In the short-term, loperamide is sometimes misused to lessen cravings and withdrawal symptoms; however, it can cause euphoria, similar to other opioids. Loperamide misuse can also lead to fainting, stomach pain, constipation, eye changes, and loss of consciousness. It can cause the heart to beat erratically or rapidly, or cause kidney problems. These effects may increase if taken with other medicines that interact with loperamide. Other effects have not been well studied and reports are mixed, but the physical consequences of loperamide misuse can be severe.
Use and Abuse of non-Prescription Medicines
Many people associate overdose with strong illicit drugs like cocaine and heroin. However, every year, tens of thousands of Americans overdose on common over-the-counter medicines like DXM and loperamide. An overdose occurs when a person uses enough of the drug to produce a life-threatening reaction or death. As with other opioids, when people overdose on DXM or loperamide, their breathing often slows or stops. This can decrease the amount of oxygen that reaches the brain, a condition called hypoxia. Hypoxia can have short- and long-term mental effects and effects on the nervous system, including coma and permanent brain damage and death. A person who has overdosed needs immediate medical attention and emergency care. If the person has stopped breathing or if breathing is weak, begin CPR. DXM overdoses can also be treated with naloxone. Certain medications can be used to treat heart rhythm problems caused by loperamide overdose. If the heart stops, health care providers will perform CPR and other cardiac support therapies.
Addiction to Non-Prescription Drugs
The misuse of DXM or loperamide can lead to addiction. An addiction develops when continued use of the drug causes issues, such as health problems and failure to meet responsibilities at work, school, or home. The symptoms of withdrawal from DXM and loperamide have not been well studied. There are no medications approved specifically to treat DXM or loperamide addiction. Behavioral therapies, such as cognitive-behavioral therapy and contingency management, may be helpful. Cognitive-behavioral therapy helps modify the patient's drug-use expectations and behaviors, and effectively manage triggers and stress. Contingency management provides vouchers or small cash rewards for positive behaviors such as staying drug-free.2,3