Over the counter substances are cheap and widely available compared to other substances of abuse. Some teens view them as safe or non-addictive because they are legal. In 2020, the National Institute on Drug Abuse reported that 3.2%–4.6% of high schoolers nationwide endorsed abusing OTC cough and cold medicines in 2019. In this podcast, we will review four commonly abused substances that are legally available for purchase: Dextromethorphan, antihistamines, pseudoephedrine, and Kratom.

Published On: 1/2/2022

Duration: 16 minutes, 17 seconds

Transcript:

Dr. Feder: Over the counter substances are cheap and widely available compared to other substances of abuse. Some teens view them as safe or non-addictive because they are legal and readily available. In 2020, the National Institute on Drug Abuse reported that 3.2%–4.6% of high schoolers nationwide endorsed abusing OTC cough and cold medicines in 2019. In this podcast, Mara and I will discuss some commonly abused substances that are legally available for purchase.

Welcome to The Carlat Psychiatry Podcast.

This is a special episode from the child psychiatry team. 

I’m Dr. Josh Feder, The Editor-in-Chief of The Carlat Child Psychiatry Report and co-author of The Child

Medication Fact Book for Psychiatric Practice and the brand-new book, Prescribing Psychotropics.

Mara: And I’m Mara Goverman, a Licensed Clinical Social Worker in Southern California with a private practice. 

Let's begin by discussing Kratom, a herbal extract from Mitragyna speciosia which acts on opioid receptors. 

Kratom is available as a tea that can be brewed in hot water, in capsules, or in powders and is usually found in vape shops or on the Internet. Kratom sales exceeded $1.13 billion in 2016, and the majority of toxic exposures to kratom from 2011–2017 were in adolescents. 

But why is Kratom popular and what makes this extract dangerous?

Dr. Feder: Adolescents seek out Kratom because it has stimulant effects at low doses and euphoric effects at higher doses. Since it acts on opiate receptors, some people think it can be used to help with opioid withdrawal as well. This is a mistake, since it is unreliable and unregulated, and it should be no surprise that regular use of Kratom can lead to dependence, with a withdrawal syndrome similar to opioid withdrawal including anxiety, gastrointestinal symptoms, headache, runny nose, watery eyes, and sweating. At toxic levels, Kratom may cause tachycardia, hypertension, altered mental status, abdominal pain, and seizures. Clinicians can treat symptoms of withdrawal with medications such as clonidine and naltrexone.

Mara: So far, what I'm getting is that kratom is not only easily accessible for children and adolescents, but it can have some very severe consequences. So why isn't kratom being regulated?

Dr. Feder: Kratom is illegal in several states including Alabama, Arkansas, and Indiana, as well as some cities such as San Diego and Sarasota, but most states do not regulate kratom sales. Advocacy groups and some policymakers  argue that kratom may be beneficial for managing pain and reducing opiate addiction have hindered efforts to regulate kratom.

Mara: Talking about kratom makes me think about Dextromethorphan, the active ingredient in hundreds of OTC cough and cold products including Coricidin HBP™, Robitussin DM™, and Delsym™. Similar to kratom, adolescents abuse this drug for its euphoric and stimulant effects. However, unlike kratom, Dextromethorphan contains dissociative effects, which add to its desirable properties. 

Dr. Feder: “Yes, dextromethorphan - the medication that is now combined with bupropion to make a newly approved purportedly ‘fast-acting’ antidepressant.

Mara: Dr. Feder, at what dose does Dextromethorphan induce stimulant-like and dissociative effects?

Dr. Feder: Before I answer that, it is important to know that cytochrome CYP2D6 metabolizes Dextromethorphan with a half-life of two to four hours, and its psychoactive properties are based on dosing. In most adults, it works as a cough suppressant at doses from 15–30 mg. Dextromethorphan has a stimulant-like effect at 100–200 mg, while doses of 200–400 mg or higher produce intoxication with slurred speech, hallucinations, and impaired memory.

Mara: What are the dangers of Dextromethorphan?

Dr. Feder: Well, depending on the dose, Dextromethorphan toxicity can cause a variety of symptoms from milder nuisances like flushed skin and tachycardia to severe symptoms such as hallucinations, ataxic gait, and agitation. Chronic use of Dextromethorphan is associated with psychosis and cognitive impairment.

Mara: What are common withdrawal symptoms of Dextromethorphan? Are they life threatening? 

Dr. Feder: A chronic user who stops using Dextromethorphan is likely to have a lot of discomfort however the withdrawal if not life threatening. Withdrawal symptoms include restlessness, insomnia, muscle aches, dysphoria, and intense cravings. The other thing to remember is that Dextromethorphan will increase serotonin levels. So if you have a patient on a medication that affects serotonin levels, you will want to ask specifically about Dextromethorphan abuse to minimize the risk of serotonin syndrome and even for people who want to use Dextromethorphan clinically you want to be watching out for serotonergic type side effects.

Mara: But there is some good news. The efforts to curb adolescent abuse of Dextromethorphan in the US began in 2021, and now 21 state governments have prohibited the sales of DXM to those under 18 years old. 

Let's shift gears and talk about antihistamines, another commonly abused substance that is legally available for purchase. 

First-generation antihistamines are usually used to treat allergy symptoms or motion sickness. Commonly abused agents which cross the blood brain barrier include diphenhydramine (Benadryl™), doxylamine (found in Nyquil™), and dimenhydrinate (Dramamine™). Adolescents who abuse antihistamines seek out its sedating and anxiolytic effects at low doses, or stimulant-like effects at higher doses. 

Antihistamine toxicity can include delirium, hallucinations, seizures, and psychosis, with tachycardia, dry mouth, blurry vision, constipation, and urinary retention. Antihistamines also cause QTc prolongation, increasing the risk of dangerous arrhythmias. In addition, chronic abuse can lead to withdrawal cravings accompanied by runny nose, nausea, diarrhea, cramping, irritability, restlessness, and insomnia.

Dr. Feder: There are some easy ways to remember antihistamine toxicity and withdrawal since they are a lot like anticholinergic ones. For toxicity you may have heard the old rhyme: red as a beet, dry as a bone, mad as a hatter and hot as a fox. For withdrawal you might remember SLUD: salivation, lacrimation (tears and runny nose), urination and diarrhea. The more recent thing that comes to mind when I think about antihistamines is the 2020 “Benadryl Challenge” which dared people to ingest large amounts of diphenhydramine and post their responses on the TikTok social media platform. This coincided with increased diphenhydramine-related emergency room visits in adolescents, including at least one death. In September 2020, the US Food and Drug Administration (FDA) issued a warning that advised the public and healthcare providers about this problem. However, unfortunately, there are no current laws limiting access to antihistamines. 

Mara: Pseudoephedrine is used as a nasal decongestant and packaged with other drugs such as antihistamines, Dextromethorphan, acetaminophen, or NSAIDs. Over the counter medications that contain pseudoephedrine include brands such as Sudafed, Comtrex, Dristan and Entex.  Pseudoephedrine is available in dose ranges from 15–60 mg for immediate release and 120–240 mg for extended release.

Dr. Feder, what makes pseudoephedrine so appealing to adolescents?

Dr. Feder: Well, teens abuse pseudoephedrine for its stimulant properties. Like amphetamine, it boosts athletic and academic performance while suppressing appetite and sleep. However, like all the substances we discussed today, its toxic effects can be severe. These effects include hypertension, tachycardia, dizziness, and even seizures and psychotic symptoms. If a patient who is on stimulant medications and then takes pseudoephedrine whether for a cold or for their performance effects, this can multiply those side effects. Withdrawal symptoms are also similar to stimulant withdrawal and can include dysphoria, restlessness, and abnormal perception. 

There is some regulation over distribution of pseudoephedrine. Currently, federal law limits the daily retail sales of pseudoephedrine to 3.5 g and the monthly retail sales to 9 g per person. Iowa, Mississippi, and Oregon also have age restrictions for purchasing pseudoephedrine. 

Mara: Should providers be aware of any other medications that may interact with pseudoephedrine?

Dr. Feder: Yes thanks for asking Mara! Pseudoephedrine interacts with monoamine oxidase inhibitors (MAOIs) such as selegiline and can induce a hypertensive crisis. Make sure to counsel all your patients on MAOIs about the risks of hypertensive crisis and its specific potential interaction with pseudoephedrine. 

Mara: The last one for today is Tianeptine. Tianeptine is a tricyclic antidepressant that binds to opioid receptors. It is prescribed outside of the US but available over the counter in the US. It produces euphoria and is energizing but has rapid withdrawal symptoms similar to opiates.

Tianeptine is banned in Alabama, Georgia, Indiana, Michigan, Minnesota, and Tennessee. 

Dr. Feder:  So we added tianeptine as a latecomer when we were finishing this article because we were hearing so much news about it and we wanted to be sure you were hearing about that one. 

Mara: We want to go over a number of key points that clinicians should be aware of when discussing substance use with patients and families.  

Dr. Feder: First of all, make sure to review slang terms for substances but don’t count on precision. For example, some kids call pseudoephedrine ‘Meth’ and these days perhaps even more important is the fact that any street drug might include a deadly dose of fentanyl. You can refer to the table in the transcript to learn more about common slang terms for legal substances.

Also, try to interview parents and adolescent patients separately. Ask patients about their use of legally available substances and ask patients and families about substance use in peers and their ability to access substances both at home and in the community. 

Mara: Ask parents about unusual medicinal smells or empty medicine containers in the patient’s room. 

Counsel families on safe storage techniques and monitoring substances in the home. For example, remind parents to keep medications in a locked storage area away from children and to regularly inventory all medications. 

And safely dispose of medications that are expired or not being used. Many pharmacies and police stations have medication disposal receptacles. Do not throw them into the trash, the toilet or down the drain as these impact community soil, water systems, and wildlife. 

Dr. Feder: So that covers some assessment and prevention but you are probably wondering at this point: what about treatment? Unfortunately, there is not much data on how to treat people who misuse legal substances, so we recommend approaches similar to other substance use disorders like motivational interviewing to engage the patient in the process of reducing and stopping and cognitive-behavioral therapy to carefully pick apart, understand, and shift the thoughts, feelings, and behaviors to support healthier choices and happier days, free of both the escape into substance use and the withdrawal that reboots the vicious cycle. 

Mara: The bottom line is that we need to regularly patients about the use of legal substances such as dextromethorphan, antihistamines, pseudoephedrine, and kratom, and tianeptine need to help them weigh the risks against the perceived benefits, reminding them that intoxication with any of these can lead to dangerous side effects requiring acute management. 

Dr. Feder: The newsletter clinical update is available for subscribers to read in The Carlat Child Psychiatry Report. Hopefully, people will check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits. 

Mara: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry. 

Dr. Feder: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us to bring you unbiased information that you can trust. 

Mara: And don’t forget, you can now earn CME credits for listening to our podcasts. Just click the link in the description to access the CME post-test for this episode.

As always, thanks for listening and have a great day!

__________

The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.