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-Free America recently reported that an increasing number of teenagers are abusing a variety of prescription and OTC medications.1 Although drug-abuse rates overall have been decreasing for teens, the rate of prescription and OTC drug abuse has increased.1 Currently, 1 in 11 teens has abused an OTC medication, such as cough medicine containing dextromethorphan (DXM), and 1 in 5 has abused a prescription painkiller.1 In light of such statistics, it is important to have knowledge of how to deal effectively with the issue of teen drug abuse.
DXM, a codeine derivative, has agonist activity on serotonergic neurotransmission and inhibits re-uptake of serotonin at the synapses. Thus, toxic doses of DXM can cause serotonin syndrome; effects on the central nervous system can include stupor, ataxia, nystagmus, hyperexcitability, dystonia, toxic psychosis, and changes in muscle reflexes. An overdose of DXM can also produce respiratory depression, tachycardia, an increase in baseline seizure activity, and blurred vision.2 Furthermore, DXM has a first-pass metabolite, dextrorphan, which acts as an N-methyl-D-aspartate (NMDA) antagonist, causing additional hallucinogenic effects.2 DXM is found in a large number of OTC cough and cold remedies, usually in combination with decongestants and antihistamines. Of particular concern are sympathomimetic agents, such as pseudoephedrine or phenylephrine, or antihistamines, such as brompheniramine or chlorpheniramine. The presence of additional medications increases the likelihood of toxic effects after overdose.2
Chemical dependence on opioids occurs through binding to multiple opioid receptors (ie, mu, delta, kappa) in the brain.2 Through this action, opiates inhibit the release of the inhibitory neurotransmitter GABA and disinhibit the dopamine pathways, causing more dopamine to be released. Through their action on the neurotransmitters, opiates create effects of euphoria, analgesia, sedation, bradycardia, respiratory depression, and gastrointestinal dysmotility. Prolonged use of these agents causes the brain to stop producing endorphins, leading to chemical and physical dependence. Addiction following chronic use is common and results in withdrawal on termination.2
In many types of drug abuse, random drug testing is the tool of choice, but this is not the case in opiate and OTC medication abuse.3 With a standard drug-testing panel, oxycontin is not detected, and neither are other legal medications, such as OTC cough medicines.3 A drug-screening questionnaire also may be used, such as the CRAFFT questionnaire.1 This survey has questions formulated especially for adolescents about dangerous behaviors when using drugs and alcohol and the settings in which such usage would occur. Screening for prescription and OTC drug abuse is a responsibility of health care professionals, such as pharmacists and physicians.4 They can examine past medical history and prior and current medication use, while also explaining the safe usage of medications. Health care professionals should also be aware of patients obtaining medications from multiple sources.4,5
Currently, for acute ingestion of DXM and prescription opiates, gastric decontamination with activated charcoal is recommended. Other medications may be useful in treating overdose symptoms, however. Naloxone is commonly used to reverse central nervous system depressant and neurologic effects, while benzodiazepines play a role in the treatment of seizures, agitation, and muscle activity.2
For chronic use of opioids, several medications are available to treat addiction. These medications include naltrexone, methadone, and buprenorphine.6 These medications work in several areas of drug abuse, including detoxification, maintenance, and withdrawal. In the case of addiction, medication alone is not sufficient and should be accompanied by nonpharmacologic interventions.6 Individual or group detoxification is often recommended, and support groups such as Narcotics Anonymous have been shown to help with behavioral changes.1,6 Treatment has been shown to improve social and psychological functioning of substance abusers significantly.7 Despite these positive outcomes, many people are unsuccessful with their first round of treatment, so it is important to make sure that they are not discouraged from trying treatment again.8
The greatest risk for drug abuse is peer pressure. Children desire acceptance from their friends and classmates, and sometimes this can lead them down the path of substance abuse. Most children usually start using drugs when they are around 14 years old; however, it is not uncommon for some to begin earlier.9
National Resources to
Learn About Drug Abuse
Parents are the first line of prevention against drug abuse. They can observe their child and be aware of any warning signs, such as changes in social circles, sleep patterns, motivation, academic performance, attitude and personality, eating habits, physical changes in appearance, borrowing money often, suddenly having extra cash, or unusual odors on their child's clothes or in their child's room.10
Communication between parents and their child at an early age about drugs and related issues is a simple yet effective way to provide knowledge and support. Additionally, respecting adolescents' opinion or questions will give them a chance to participate in the discussions, allowing a dynamic conversation as opposed to a onesided lecture from an authority figure.10
When suspecting that a child is using drugs, take action immediately, because the longer one waits, the more difficult it will be to remedy the situation. Parents should closely monitor their child's activities. They also should make an effort to talk with their child, keep open those vital lines of communication, and be familiar with their child's friends and partners. Changing curfews, cell phone or computer privileges, or even taking a child directly out of the problematic social circle are some appropriate measures. In making such changes, however, the child needs to be transitioned to safer and more positive activities, such as athletics, music, dance, extracurricular clubs, and religious organizations. Parents can try to relate to their child by explaining what they see, how they feel about their child's actions, and— most importantly—their concern for their child's future well-being. Providing strong support as the concerned parent, while reinforcing the negative consequences, is a compassionate approach to a child's substance-abuse problem.11
Some cases of drug abuse cannot be controlled by parental intervention alone, and multiple resources are available to help. Health care professionals are highly trained to intervene in these situations and include physicians, nurses, psychiatrists, and also neighborhood pharmacists who can provide necessary support and information. School counselors, faith leaders, and community health centers should not be overlooked as well.11