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OTC Substance Abuse— Current Issues and Prevention Strategies Brian Fingerson, RPh KYPRN - Kentucky Professionals Recovery Network.

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Presentation on theme: "OTC Substance Abuse— Current Issues and Prevention Strategies Brian Fingerson, RPh KYPRN - Kentucky Professionals Recovery Network."— Presentation transcript:

1 OTC Substance Abuse— Current Issues and Prevention Strategies Brian Fingerson, RPh KYPRN - Kentucky Professionals Recovery Network

2 There is a unique disconnect between the scientific facts and the public’s perception about drug abuse and addiction

3 Drug abuse is a preventable behavior Partnership for a Drug-Free America Drug addiction is a treatable disease

4 Initial drug use is a voluntary behavior… A person chooses to take a drug for the first time

5 Why do people take drugs in the first place?

6 People Take Drugs To: l Feel good (sensation seeking) l Feel better (self-medication)

7 A major reason people take a drug is they like what it does to their brains

8 Prolonged drug use changes the brain in fundamental and long-lasting ways

9 Addiction is a Developmental Disease—Typically Begins in Childhood or Adolescence

10 Five Things to Know About Adolescents’ Brain Development and Use Thomas J. Crowley, MD, and Elizabeth Whitmore, PhD

11 Five Things to Know About Adolescents’ Brain Development and Use 1. The brain’s “front end,” the part above the eyes (prefrontal cortex), exists to slow us down or stop our impulsive behaviors; it considers the risks and benefits of our actions, and it helps us "hit the brakes" when we consider doing things that are too risky. 2. This part of the brain is still developing connections to the rest of the brain until adulthood, so adolescents’ brains lack some of the “wiring” that carries “brake” or “stop” messages to the rest of the brain.

12 Five Things to Know About Adolescents’ Brain Development and Use 3. Drugs of abuse are often available to adolescents; these drugs feel good, but they can be very harmful. Lacking some of the wiring for the "stop" message, adolescents’ brains may not fully weigh the risks of drug use. (if it feels good – do it ) 4. The two drugs that cause the most death are also the most available drugs: tobacco and alcohol. Late adolescence, before the brain is fully matured, is the peak time for developing dependence on these (and other) drugs.

13 Five Things to Know About Adolescents’ Brain Development and Use 5. Heavy drug use during times of critical brain development may cause permanent changes in the way the brain works and responds to rewards and consequences. Therefore, it is important to begin to address a developing substance use problem as early as possible.

14 Over-the-Counter Drug Abuse l OTC drugs, especially cough and cold medications, are becoming very popular as recreational drugs l Especially for young teenagers 13 to 16 years of age l Hospitals have reported dozens of overdoses in the past 2 years l Including five deaths where the abuse of OTC medications was a factor

15 Emergency Departments 2005 l An estimated 598,542 U.S. ED visits in 2005 involved the nonmedical use of prescription or OTC pharmaceuticals or dietary supplements l 21% higher than 2004 estimates

16 from the SAMHSA 2006 National Survey on Drug Use and Health (NSDUH) l In 2006, about 3.1 million persons aged 12 to 25 (5.3 percent) had ever used an over-the-counter (OTC) cough and cold medication to get high (i.e., “misused” the drug), and nearly 1 million (1.7 percent) had done so in the past year Among youths aged 12 to 17, females were more likely than males to have misused OTC cough and cold medications in the past year, but among young adults aged 18 to 25, males were more likely than females to have misused these medications l Among persons aged 12 to 25 who had misused an OTC cough and cold medication in the past year, 30.5 percent misused a NyQuil® product, 18.1 percent misused a Coricidin® product, and 17.8 percent misused a Robitussin® product

17 Erowid Psychoactive Vaults

18 Erowid’s Site

19 ThresholdUnknown Light 100–200 mg Common 200–400 mg Strong 300–600 mg Heavy 600–1,500 mg Risk of Death 2,500–20,000 mg Oral DXM Dosages

20 Erowid Guide to DXM in Nonprescription Drugs l Version 1.6 — June 15, 2004 l 93 products and ingredients listed for DXM products only

21 Erowid’s Guide l Introduction For those who choose to use DXM recreationally, it is extremely important to pay attention to the active ingredients list of the brand they choose to use. People knowledgeable in the field recommend that only products containing DXM alone (sometimes listed as 'Dextromethorphan hydrobromide') in the Active Ingredients list should be used.


23 Gel Cap Dosages l Drixoral Cough Liquid Caps © – 30 mg l DexAlone © – 30 mg l Robitussin Cough Gels © – 15 mg


25 Cough Syrups OTC DXM content ranges from 7.5 mg per 5 ml to 15mg per 5 ml, so…a 240ml bottle would be 360-720mg of DXM


27 Triple C’s or Coricidin Cough and Cold © l Contains: l Chlorpheniramine maleate 4 mg l Dextromethorphan hydrobromide 30 mg l Other Coricidin products contain acetaminophen and/or guaifenesin l “This product should not be used as a source for recreational DXM”— Erowid

28 DXM Plateaus l A term used by those who abuse DXM l Describes experiences associated with different recreational dosages (exceeding recommended dosages) l Experiences at different plateaus range from mild distortions of color and sound to visual hallucinations, “out-of-body” dissociative sensations, and loss of motor control l The is what many DXM users strive for, often described as the most “mind- opening” l The third plateau is what many DXM users strive for, often described as the most “mind- opening”

29 DXM Effects Positive l Mood lift, euphoria l Giggling, laughing l Dissociation of mind from body (positive when sought) l Visual and aural hallucinations (positive when sought) l Creative dreamlike experiences l Some users report empathic feelings, forgiveness, warm feelings toward others

30 DXM Effects Neutral l Pupil dilation l Confusion, disorientation l Skin sensitivity, alters tactile (touch) and skin sensations l Robotic, zombie-like walking, "robo-walk" l Discoordination, reduced agility

31 DXM Effects Negative l Upset stomach, vomiting l Dizziness l Decreased sexual functioning (difficulty achieving orgasm) l Body itching l Rash, red blotchy skin l Diarrhea l Fever l Tachycardia (racing, pounding heart) l Some users report feeling disconnected, isolated from others l Some users report hangover/depression on the following 1-2 days

32 Restricting DXM Sales l Oklahoma considering a bill that would ban the sale of any cough medicine containing DXM, as well as spray paint, to anyone under the age of 18 years l New York, other states, considering similar legislation l Throughout the country l Some stores require ID showing the purchaser is at least 18 years of age l Some place DXM products behind-the-counter

33 Inhalant Abuse: Definition l Commonly known among kids as "huffing," "bagging," or "sniffing" l The deliberate concentration and inhalation of common products found in homes, offices, and schools to get high

34 Inhalant Abuse: Statistics l l Among high school students, inhalants are 5th most-abused substance after alcohol, tobacco, marijuana, and prescription drugs l l Almost as many 8th graders have ever tried inhalants (16%) as have tried marijuana (18%), according to Monitoring the Future 2003 l l According to the 2002 Household Survey, 308,000 teens, aged 12–17 used inhalants in the past month l l Fewer than 1 in 20 parents believe their children may have ever abused inhalants (denial or ignorance?) National surveys of young people and U.S. households indicate that:

35 Why Do Young People Abuse Inhalants? l Products are legal, widely available, inexpensive, and easy to conceal l Most users do not realize how dangerous inhalants are l Many young people start because they don't think these substances can hurt them

36 >1,000 Common Products Are Potential Inhalants That Can Kill l Glue l Freon l Correction fluid l Computer agents l Deodorizers l Markers l Paint products l Gases (whippets, butane, propane) l Gasoline l Fire extinguishers l Nail polish remover l Lighter fluid l Hair spray l Cleaning agents

37 Inhalant Abuse: Harmful Effects l Chronic inhalant users can suffer severe and permanent brain damage; some die the first time they experiment l Other possible risks include: l Intoxication l Hearing loss l Bone marrow damage l Short-term memory loss l Limb spasms l Liver and kidney damage

38 Laxatives l Laxative abuse is a common feature of eating disorders l Although it is a behavior associated with bulimia, many anorectics and even over-eaters use or occasionally use laxatives

39 Laxative Abuse Problems l Severe abdominal pain l Chronic diarrhea/loss of rectum control after repeated use of laxatives l Bloating l Dehydration l Gas l Nausea, vomiting l Electrolyte disturbances which can lead to heart arrythmias and heart attacks l Chronic constipation



42 What Are Energy Drinks? l Contain large doses of caffeine and other legal stimulants l Beverages such as Red Bull, Venom, Adrenaline Rush, 180, ISO Sprint, and Whoop Ass

43 Other Energy Drink Ingredients l B vitamins l Ephedra l Glucuronolactone l Ginseng l Green tea l Guarana l Inositol l L-tyrosine l Sugar l Taurine l Yohimbine l Various others

44 “The Legal Alternative”?

45 Caffeine Content of Cocaine Energy Drink © An 8.4 oz can of Cocaine Energy Drink contains 280 mg of caffeine Cocaine is a new energy drink from Redux Beverages Available in an 8.4 oz (250 mL) can, the drink claims that it is 350% stronger than a Red Bull

46 FDA Action l l Warning letter issued April 4, 2007 l l Claims Cocaine energy drink is marketed as a dietary supplement l l “Street drug alternatives, i.e., products that claim to mimic the effects of recreational drugs, are not intended to supplement the diet and, as a result, cannot lawfully be marketed as dietary supplements.” l l FDA states that Cocaine energy drink is a new drug requiring an application to the FDA

47 Redux Beverages LLC Response l Language that FDA cited removed from Web site l New information states: l “Cocaine energy drink is an energy supplement following the guidelines set forth by the federal Food and Drug Administration for dietary supplements… It is not designed for or intended to be used to diagnose, treat, cure, mitigate, or prevent any diseases.” April 23, 2007.

48 And now: l ‘Cocaine’ drink yanked from shelves nationwide l Company plans to rebrand the energy beverage after FDA complaints

49 Here is the latest

50 'Cocaine' energy drink renamed as 'Censored' l The makers of the energy drink "Cocaine" have announced that they will be changing the name in response to criticism and pressure from the FDA and state officials saying the name glamorized illegal drug use. So, appropriately, the new name will be "Censored," because it has the "same rebellious and fun spirit" as the old name. announced that they will be changing the name pressure from the FDAannounced that they will be changing the name pressure from the FDA

51 Caffeine Doses l Oral Caffeine Dosages l Threshold10–20 mg l Common50–150 mg l Strong150–400 mg l Heavy400+ mg l Lethal3–20 g oral (estimated, see below) l LD 50 (lethal dose) 192 mg/kg in rats Onset : 5–10 minutes Duration: 1.5–5 hours Normal after effects: up to 24 hours

52 Caffeine Effects: Positive l Reduces boredom (Loke 1988) l Decreases depression l Increased alertness when tired (Wesenten 2005, Kamimori 2005) l Willingness to consider alternative theories (Martin 2006) l Increases physical stamina and reduces perceived exertion (McLellan TM 2004) l May attenuate the response-slowing effect of alcohol (Roehrs 2004) l Increases performance on boring, repetitive tasks (Smith 2002)

53 Caffeine Effects: Neutral l Research has failed to show improved memory or improvement in complex cognitive tasks Smith A. Food Chem Toxicol. 2002;40:1243–55.

54 Caffeine Effects: Negative l Increases anxiety and nervousness at high doses or in sensitive individuals (Loke 1988) l Insomnia, decreased ability to sleep (Smith 2002) l Caffeine withdrawal can worsen mood (Schuh 1997) l Caffeine withdrawal causes headaches, flu-like symptoms, feelings of lethargy and reduces motivation (Schuh 1997) l Increases jaw tension and bruxism (Erowid Self Reports 2000, Ohayon 2001)



57 Ephedra/Ephedrine/ Pseudoephedrine l Ephedra is used as a stimulant and for mild respiratory disorders, including asthma and bronchitis l In Asian medicine, it is used for fever, swelling, and bone pain l Ephedrine, the principle alkaloid, a popular ingredient in many "herbal" weight loss and body building formulas, decongestants, "legal high" alternatives, and ephedrine- based pep pills

58 Negative Effects of Ephedra l Potential side effects include sleeplessness, restlessness, irritability, headache, nausea, vomiting, urinary disorders, and rapid heartbeat l Higher doses can stimulate a sharp rise in blood pressure and disrupt heart rhythm l Chronic use can lead to tolerance and dependence, requiring ever larger doses to obtain earlier effects l Because of these dangers, ephedra should be used only for short periods of time



61 Salvia divinorum Effects Positive l Short duration (when smoked) l Radical perspective shifting l Increase in sensual and aesthetic appreciation l Creative dreamlike experience l Insight into personal issues

62 Salvia divinorum Effects Neutral l Powerful open and closed eye visuals l General change in consciousness (as with most psychoactives) l Altered perceptions l Change in body temperature, flushing l Sensation of physical push, pressure, or wind l Sensation of entering or perceiving other dimensions, alternate realities l Feeling of 'presence' or entity contact l Dissociation at high doses, walking, or standing

63 Salvia divinorum Effects Negative l Overly intense experiences l Fear, terror, and panic l Increased perspiration l Possible difficulty integrating experiences l Higher doses can cause inability to control muscles and maintain balance; falls are reported

64 Posting on You Tube l Salvia Divinorum Salvia Divinorum Salvia Divinorum l Short student documentary about Salvia Divinorum...salvia divinorum documentary l salvia divinorum documentary salviadivinorumdocumentary salviadivinorumdocumentary l Time: 07:59

65 Salvia an “Outlaw Drug” l It has been put into DEA Schedule I in a number of states - effective 1 Jan. ‘08 it is Schedule I in Illinois l Erowid keeps users abreast of what is legal or illegal based on location

66 Many Other Legal Alternatives


68 For More Information National Institute on Drug Abuse Public Information Office 301-443-1124 or National Clearinghouse on Alcohol and Drug Information 800-729-6686

69 Online Resources l l l l l l

70 Take Home Messages l Drug abuse is a preventable behavior and drug addiction is a treatable disease. l Addiction is a developmental disease typically beginning in childhood or adolescence. l Children and adolescents have access to information on misuse and abuse of substances that are widely available and legal to obtain.

71 Thank you! “Recovery” by Michael Vye Brian Fingerson, RPh KYPRN 502-749-8385


73 How Prevalent Is Cough Medicine Abuse? l Nearly 1 in 10 teens (or 2.4 million) reported abusing cough medicine to get high in 2005 l Partnership for a Drug-Free America Partnership Attitude Tracking Study

74 What Can Pharmacists Do? l Be aware of the issues l Provide education regarding the potential abuse and misuse of medications and other products l Evaluate product placement in the pharmacy l Be aware of suspect purchases l Provide education to parents and community groups

75 What Can Faculty Do? l Prepare students to address this issue when they enter practice l Awareness l Educational strategies l Role plays l Develop fact sheets l Public service announcements l Others

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