OTC, Prescription Drug Abuse Increasing Among Adolescents

Ms. Patel, Mr. Kelly, Ms. Capparelli, and Ms. Kuti are PharmD candidates at the University of Rhode Island, Kingston. Dr. Matson is a clinical assistant professor in the College of Pharmacy, Department of Pharmacy Practice, at the University of Rhode Island.

The Partnership for a Drug-FreeAmerica recently reported thatan increasing number of teenagersare abusing a variety of prescriptionand OTC medications.¹ Althoughdrug-abuse rates overall have beendecreasing for teens, the rate of prescriptionand OTC drug abuse hasincreased.¹ Currently, 1 in 11 teens hasabused an OTC medication, such ascough medicine containing dextromethorphan(DXM), and 1 in 5 hasabused a prescription painkiller.¹ In lightof such statistics, it is important to haveknowledge of how to deal effectivelywith the issue of teen drug abuse.

Pharmacologic and Clinical Effects

DXM, a codeine derivative, has agonistactivity on serotonergic neurotransmissionand inhibits re-uptake ofserotonin at the synapses. Thus, toxicdoses of DXM can cause serotonin syndrome;effects on the central nervoussystem can include stupor, ataxia, nystagmus,hyperexcitability, dystonia,toxic psychosis, and changes in musclereflexes. An overdose of DXM can alsoproduce respiratory depression, tachycardia,an increase in baseline seizureactivity, and blurred vision.² Furthermore,DXM has a first-pass metabolite,dextrorphan, which acts as anN-methyl-D-aspartate (NMDA) antagonist,causing additional hallucinogeniceffects.² DXM is found in a large numberof OTC cough and cold remedies,usually in combination with decongestantsand antihistamines. Ofparticular concern are sympathomimeticagents, such as pseudoephedrineor phenylephrine, or antihistamines,such as brompheniramine orchlorpheniramine. The presence ofadditional medications increases thelikelihood of toxic effects after overdose.²

Chemical dependence on opioidsoccurs through binding to multiple opioidreceptors (ie, mu, delta, kappa) inthe brain.² Through this action, opiatesinhibit the release of the inhibitory neurotransmitterGABA and disinhibit thedopamine pathways, causing moredopamine to be released. Through theiraction on the neurotransmitters, opiatescreate effects of euphoria, analgesia,sedation, bradycardia, respiratorydepression, and gastrointestinal dysmotility.Prolonged use of these agentscauses the brain to stop producingendorphins, leading to chemical andphysical dependence. Addiction followingchronic use is common and resultsin withdrawal on termination.²

Screening Tools

In many types of drug abuse, randomdrug testing is the tool of choice, butthis is not the case in opiate and OTCmedication abuse.³ With a standarddrug-testing panel, oxycontin is notdetected, and neither are other legalmedications, such as OTC cough medicines.³A drug-screening questionnairealso may be used, such as the CRAFFTquestionnaire.¹ This survey has questionsformulated especially for adolescentsabout dangerous behaviorswhen using drugs and alcohol and thesettings in which such usage wouldoccur. Screening for prescription andOTC drug abuse is a responsibility ofhealth care professionals, such aspharmacists and physicians.⁴ They canexamine past medical history and priorand current medication use, while alsoexplaining the safe usage of medications.Health care professionals shouldalso be aware of patients obtainingmedications from multiple sources.^4,5

Treatments for Overdose and Addiction

Currently, for acute ingestion of DXMand prescription opiates, gastric decontaminationwith activated charcoalis recommended. Other medicationsmay be useful in treating overdosesymptoms, however. Naloxone is commonlyused to reverse central nervoussystem depressant and neurologiceffects, while benzodiazepines play arole in the treatment of seizures, agitation,and muscle activity.²

For chronic use of opioids, severalmedications are available to treataddiction. These medications includenaltrexone, methadone, and buprenorphine.⁶These medications work in severalareas of drug abuse, includingdetoxification, maintenance, and withdrawal. In the case of addiction, medicationalone is not sufficient andshould be accompanied by nonpharmacologicinterventions.⁶ Individual orgroup detoxification is often recommended,and support groups such asNarcotics Anonymous have been shownto help with behavioral changes.^1,6 Treatmenthas been shown to improvesocial and psychological functioning ofsubstance abusers significantly.⁷ Despitethese positive outcomes, manypeople are unsuccessful with their firstround of treatment, so it is importantto make sure that they are not discouragedfrom trying treatment again.⁸

Counseling Options for Parents

The greatest risk for drug abuse ispeer pressure. Children desire acceptancefrom their friends and classmates,and sometimes this can leadthem down the path of substanceabuse. Most children usually startusing drugs when they are around 14years old; however, it is not uncommonfor some to begin earlier.⁹

National Resources to Learn About Drug Abuse

• National Institute on Drug Abuse: www.nida.nih.gov
• US Department of Health and Human Services National Clearinghouse for Alcohol & Drug Information: ncadistore.samhsa.gov
• National Institute on Alcohol Abuse and Alcoholism: www.niaaa.nih.gov
• Substance Abuse and Mental Health Services Administration: www.family.samhsa.gov

Parents are the first line of preventionagainst drug abuse. They can observetheir child and be aware of anywarning signs, such as changes insocial circles, sleep patterns, motivation,academic performance, attitudeand personality, eating habits, physicalchanges in appearance, borrowingmoney often, suddenly having extracash, or unusual odors on their child'sclothes or in their child's room.¹⁰

Communication between parentsand their child at an early age aboutdrugs and related issues is a simple yeteffective way to provide knowledgeand support. Additionally, respectingadolescents' opinion or questions willgive them a chance to participate inthe discussions, allowing a dynamicconversation as opposed to a onesidedlecture from an authority figure.¹⁰

When suspecting that a child is usingdrugs, take action immediately, becausethe longer one waits, the moredifficult it will be to remedy the situation.Parents should closely monitortheir child's activities. They also shouldmake an effort to talk with their child,keep open those vital lines of communication,and be familiar with theirchild's friends and partners. Changingcurfews, cell phone or computer privileges,or even taking a child directly outof the problematic social circle aresome appropriate measures. In makingsuch changes, however, the childneeds to be transitioned to safer andmore positive activities, such as athletics,music, dance, extracurricular clubs,and religious organizations. Parentscan try to relate to their child byexplaining what they see, how theyfeel about their child's actions, and—most importantly—their concern fortheir child's future well-being.Providing strong support as the concernedparent, while reinforcing thenegative consequences, is a compassionateapproach to a child's substance-abuse problem.¹¹

Some cases of drug abuse cannot becontrolled by parental interventionalone, and multiple resources are availableto help. Health care professionalsare highly trained to intervene in thesesituations and include physicians, nurses,psychiatrists, and also neighborhoodpharmacists who can providenecessary support and information.School counselors, faith leaders, andcommunity health centers should notbe overlooked as well.¹¹

References

• Generation Rx: national study reveals new category of substance abuse emerging: teens abusing Rx and OTC medications intentionally to get high [press release]. Washington, DC: Partnership for a Drug Free America; April 21, 2005. Available at: www.drugfree.org. Accessed April 22, 2007.
• Micromedex Healthcare Series. Greenwood Village, CO: Thomson Healthcare Inc. 2006.
• Wilder J. Drug screening methods unreliable. Gannett Healthcare Group; May 3, 2007. Available at: http://news.nurse.com. Accessed April 19, 2007.
• McPherson TL, Hersch RK. Brief substance use screening instruments for primary care settings: a review. J Subst Abuse Treat. 2000;18:193-202.
• National Institute on Drug Abuse. Preventing and recognizing drug abuse. Available at: www.nida.nih.gov/ResearchReports/Prescription/prescription6.html. Accessed March 24, 2007.
• Tommasello AC. Substance abuse and pharmacy practice: what the community pharmacist needs to know about drug abuse and dependence. Harm Reduct J. 2004;1:3-18.
• National Institutes of Drug Abuse. NIDA Infofacts: Understanding Drug Abuse and Addiction. Available at: www.drugabuse.gov/Infofacts/understand.html. Accessed April 22, 2007.
• University of Virginia Health System. Pediatrics: Substance Abuse/Chemical Dependence. Available at: www.healthsystem.virginia.edu/uvahealth/adult_pediatrics/. Accessed April 22, 2007.
• Teens & Drugs Web site. Available at: www.tqnyc.org/NYC051857/pd.html. Accessed August 29, 2007.
• US Department of Education, Office of Intergovernmental and Interagency Affairs, Educational Partnerships and Family Involvement Unit. Tips for Parents on Keeping Children Drug Free. Available at: www.ed.gov/parents/academic/involve/drugfree/drugfree.pdf.
• American Academy of Pediatrics. Suspect Your Teen Is Using Drugs or Drinking? A Brief Guide to Action for Parents. Available at: www.mediacampaign.org/early_intv/parent_broch.pdf. Accessed August 29, 2007.