Cough and Cold Medication Abuse: Not in Theory, But in Practice

In theory, patients are more likely to abuse opioids and benzodiazepines. But in practice, emergency department (ED) personnel see drug abuse involving more than controlled substances.

More than 1.2 million ED visits involved nonmedical use of prescription and OTC drugs in 2011. In fact, the number of patients admitted to the ED for diphenhydramine abuse rose from 10,457 in 2004 to 19,012 in 2011—an 82% increase. Overall, the majority of ED visits for drug abuse and overdose problems in that time period involved noncontrolled medications.

In a recent issue of the Southern Medical Journal, researchers from the Veterans Administration Medical Center in Jackson, Mississippi, examined evidence of abuse of common medications that theoretically do not have abuse potential, including cough and cold preparations.

They determined cough and cold medications are frequently abused, particularly by minors. Of particular concern is the decongestant pseudoephedrine, a sympathomimetic drug that promotes dopamine release and may be abused for stimulatory effects.

Some young people use pseudoephedrine to lose weight or improve athletic performance, and ED personnel report rare instances of intravenous abuse. Although less popular, decongestants with stimulant properties, such as ephedrine and oxymetazoline, also have abuse potential when used in large doses.

Reports of dextromethorphan (DXM) abuse date back to the late 1960s. As the cough suppressant is associated with intoxication, hallucinations, and dissociative effects, DXM remains popular among adolescents who take 5 to 10 times the recommended dose. Alarmingly, anyone can find extraction procedures online to manufacture concentrated DXM powder at home.

Also, in the 1980s, addicts took tripelennamine with pentazocine to produce heroin-like intoxication until the manufacturer created the first known abuse-deterrent drug formulation.

Today, minors widely abuse chlorpheniramine, cyclizine, and diphenhydramine. They tend to seek sedation resulting from H₁-receptor antagonism, though antihistamines may also impact dopaminergic transmission, resulting in a cocaine-like effect.

Noncontrolled medication abuse is a reality. A plethora of Internet forums exist that often contain personal narratives of medication abuse, detailed advice, and sometimes frank encouragement of illicit use.

Clinicians need to expand their index of suspicion regarding the potential for abuse of noncontrolled medications—many of which are OTC—that have the ability to impact the central nervous system. These medications should be prescribed and dispensed with caution to patients with substance abuse histories and those demonstrating evidence of drug abuse.