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CORK Bibliography: Over-the-counter Drugs

70 citations. January 2004 to present

Prepared: June 2009

Acocella CM. Using diaries to assess nonprescription drug use among university students. Journal of Drug Education 35(4): 267-274, 2005. (8 refs.)

Nonprescription drug use among university students was investigated using survey and behavioral diary methodologies to assess usage of nonprescription drug use and to compare survey and diary methodologies. Surveys were completed by 183 students (136 females and 47 males) that asked how often they used nonprescription drugs and what those drugs were. Of these participants, 61 (53 females and 8 males) voluntarily completed behavioral diaries for nonprescription drug use for a three week period. Survey data showed 83.1% of participants used nonprescription drugs in the past week, with pain relievers being the most common drug used. There was a significant correlation between the number of times participants reported using nonprescription drugs on the surveys and what the participants reported in their diaries, with no differences in the mean number of uses between survey and diary. This indicates that participants can recall information about their medication-taking behavior with some accuracy. Behavioral diaries were also able to show some of the misuse that is associated with using nonprescription medications. In most cases of misuse, too large a dose was taken. Students should be provided with information about the possible long- and short-term effects of these medications.

Akram G; Roberts K. Pharmacists' management of over-the-counter medication requests from methadone patients. Journal of Substance Use 8(4): 215-222, 2003. (32 refs.)

Aim: To determine how pharmacists respond to requests for over-the-counter (OTC) medicines by patients on a methadone maintenance programme. Design: Postal self-administered questionnaire distributed to all Greater Glasgow Health Board (GGHB) pharmacies. Participants: Community pharmacists involved in the GGHB methadone maintenance programme. Findings: Pharmacists are consulted most frequently for advice about colds/flu and gastrointestinal symptoms. Analgesics (by specific brand) were found to be the most often requested OTC product. Most requests (either for advice or sale of a product) were dealt with personally by the pharmacist. In most instances, pharmacists were suspicious of these requests and were reluctant to make a supply. The most common product for which sales were refused was Nytol (diphenhydramine), a sedative antihistamine. Although no statistical difference was found between gender, a greater proportion of those denying sales were female. However, no difference was found in pharmacist propensity to deny or allow a sale and their age (determined by year of registration). Conclusion: This study has given an insight into how community pharmacists deal with OTC medication requests and the nature of such requests. Pharmacists were found to be cautious when dealing with methadone patients, although requests for OTC products from this group were few in number.

Andersen A; Holstein BE; Hansen EH. Is medicine use in adolescence risk behavior? Cross-sectional survey of school-aged children from 11 to 15. Journal of Adolescent Health 39(3): 362-366, 2006. (32 refs.)

Purpose: To examine the association between smoking, drunkenness, and medicine use for headache, stomachache in getting to sleep, and nervousness in a representative sample of 11- to 15-year-old school-aged children. Methods: Design: Cross-sectional school-based survey. Setting: A random sample of schools in Denmark in 2002. Participants: All students in the fifth, seventh and ninth grades in these schools, n = 4824. Measurements: Self-reported medicine use for headache, stomachache, difficulties in getting to sleep, and nervousness within the last month; self-reported experience of drunkenness; self-reported smoking. Results: There was a strong and graded association between drunkenness and medicine use, even in models adjusted for the symptom for which the medicine was taken. There was a similar association between medicine use and smoking. Conclusions: The findings suggest that medicine use can be regarded as part of a cluster of risk behaviors among young people.

Armstrong DJ; Chester N. IOC regulations in relation to drugs used in the treatment of respiratory tract disorders. IN: Mottram DR, ed. Drugs in Sport, 3rd edition. New York: Routledge, 2003. pp. 102-137. (78 refs.)

Drugs used to treat respiratory problems are of concern to both participants and those responsible for drug testing. This chapter will describe the pathophysiology of asthma, exercise-induced asthma and of coughs and colds. It will discuss the treatments of those conditions with reference to current British Thoracic Society (BTS) guidelines and to the IOC Regulations. It will also provide some historical background to the problems encountered by sportspersons as counsel to those who have used or might anticipate using these drugs, albeit inadvertently.

Baume N; Mahler N; Kamber M; Mangin P; Saugy M. Research of stimulants and anabolic steroids in dietary supplements. Scandinavian Journal of Medicine & Science in Sports 16(1): 41-48, 2006. (38 refs.)

The purpose of this study was to analyze the composition of 103 dietary supplements bought on the internet. The supplements were dispatched in four different categories according to their announced contents [creatine, prohormones, "mental enhancers" and branched chain amino acids (BCAA)]. All the supplements were screened for the presence of stimulants and main anabolic steroids parent compounds. At the same time, the research was focused on the precursors and metabolites of testosterone and nandrolone. The study pointed out three products containing an anabolic steroid, metandienone, in a very high amount. The ingestion of such products induced a high quantity of metandienone metabolites in urines that would be considered as a positive antidoping test. The results have also shown that one creatine product and three "mental enhancers" contained traces of hormones or prohormones not claimed on the labels and 14 prohormone products contained substances other than those indicated by the manufacturer. The oral intake of the creatine product revealed the presence of the two main nandrolone metabolites (19-norandrosterone and 19-noretiocholanolone) in urine.

Bentur Y; Bloom-Krasik A; Raikhlin-Eisenkraft B. Illicit cathinone ("Hagigat") poisoning. Clinical Toxicology 46(3): 206-210, 2008. (37 refs.)

Introduction. Khat leaves (mainly cathinone and cathine) have been chewed for centuries as stimulants. Hagigat (capsules of 200mg cathinone) have been marketed in Israel as a natural stimulant and aphrodisiac. The consequences of illicit exposure to cathinone are reported. Methods. Prospective observational study of calls to the Poison Center regarding exposure to Hagigat during the course of 10 months. Demographic and clinical data were abstracted from patients' records and telephone follow up was performed. Results. Data of 34 consecutive patients aged 16-54 years were analyzed. The amount consumed was 1/2 - 6 capsules (ingestion - 32, sniffing - 2). Main clinical manifestations were headache, vomiting, hypertension, nausea, tachycardia, dyspnea, chest pain, and myalgia. Main complications were myocardial ischemia (3), pulmonary edema (2), and intracerebral hemorrhage (1), all in young subjects. Treatment was supportive; one patient underwent neurosurgery. Conclusion. Exposure to illicitly synthesized cathinone is associated with serious cardiovascular and neurological toxicity, even in young subjects.

Berridge V. Why alcohol is legal and other drugs are not: An examination of the relevance of past experiences to current policy-making. History Today 54(5): 18-20, 2004. (0 refs.)

All drugs, of whatever sort, have been legal or illegal at some stage in some societies, and forms of legal and regulatory control have varied. In England you could buy opiates over the counter until the 1860s, just as alcohol was available. Laudanum (opium dissolved in alcohol) was a semi-medical/ semi-recreational pick-me-up. This essay considers two questions: How can we make sense of these changes? Do they stem from the relative harmfulness of the substances concerned? And how can understanding of historical variety feed into current policy-making? There is discussion of two different, and at times divergent or convergent, perspectives, those of medicine and those involving legal controls.

Black RA; Hill DA. Over-the-counter medications in pregnancy. American Family Physician 67(12): 2517-2524, 2003. (30 refs.)

Pregnant women commonly use over-the-counter medications. Although most over-the-counter drugs have an excellent safety profile, some have unproven safety or are known to adversely affect the fetus. The safety profile of some medications may change according to the gestational age of the fetus. Because an estimated 10 percent or more of birth defects result from maternal drug exposure, the U.S. Food and Drug Administration has assigned a risk category to each drug. Many drugs have not been evaluated in controlled trials and probably will not be because of ethical considerations. Of the commonly used over-the-counter medications, acetaminophen, chlorpheniramine, kaolin and pectin preparations, and most antacids have a good safety record. Other drugs, such as histamine H-2-receptor blockers, pseudoephedrine, and atropine/diphenoxylate should be used with caution. If use of smoking cessation products is desired, the intermediate-release preparations minimize the amount of nicotine while maintaining efficacy. With all over-the-counter medications used during pregnancy, the benefit of the drug should outweigh the risk to the fetus.

Blank MD; Sams C; Weaver MF; Eissenberg T. Nicotine delivery, cardiovascular profile, and subjective effects of an oral tobacco product for smokers. Nicotine & Tobacco Research 10(3): 417-421, 2008. (17 refs.)

The tobacco industry markets potential reduced exposure products (PREPs) to smokers, including oral products that are intended to be used in situations where cigarettes cannot. For example, Ariva, marketed by Star Scientific, is a tablet made from compressed tobacco powder and is intended for "adult smokers in situations where they cannot or choose not to smoke." No objective data are available regarding Ariva's effects in smokers, including its nicotine delivery, cardiovascular profile, or subjective effects. In this single-session, clinical laboratory study, 10 overnight-abstinent cigarette smokers were administered one Ariva tablet, followed 90min later by two Ariva tablets, followed 90min later by three Ariva tablets. Participants allowed each dose to dissolve in their mouths according to package instructions. Blood was sampled, heart rate monitored, and subjective effects assessed regularly. Ariva delivered nicotine in a dose-dependent manner; mean (SD) nicotine levels increased from 2.4ng/ml (0.9) at baseline, to 3.4ng/ml (1.4) 45min post-1 tablet, 7.3ng/ml (4.0) 45min post-2 tablets, and 9.7ng/ml (4.4) 45min post-3 tablets. Heart rate increased after tablet administration, independent of dose. The tablets also significantly decreased subjective ratings of craving and urge, and increased ratings of nausea. Based on this short-term laboratory evaluation, Ariva exposes users to nicotine and may suppress some symptoms of tobacco abstinence, though its nausea-inducing characteristics may limit initial acceptability.

Brewer C. Emergency naloxone for heroin overdose: Naloxone is not the only opioid antagonist. (letter). British Medical Journal 333(7571): 754-755, 2006. (3 refs.)

This letter is in response to the editorial in this journal by J Strang J, M Kelleher, D Best, S Mayet, V Manning, Emergency naloxone for heroin overdose, 333(7569): 714-715, 2006.

Byrne A. Emergency naloxone for heroin overdose - Over the counter availability needs careful consideration. (letter). British Medical Journal 333(7571): 754-754, 2006. (5 refs.)

This letter is in response to the editorial in this journal by J Strang J, M Kelleher, D Best, S Mayet, V Manning, Emergency naloxone for heroin overdose, 333(7569): 714-715, 2006.

Camacho A; Matthews SC; Dimsdale JE. Use of GHB compounds by HIV-positive individuals. American Journal on Addictions 13(2): 120-127, 2004. (29 refs.)

Gamma hydroxybutyrate (GHB) has been used by body-builders to enhance performance and by young adults in rave parties. Warnings have been posted about its addictive potential. The use of these dietary compounds is currently banned by the Food and Drug Administration, but they are widely available through the Internet and in certain communities. The purpose of the study was to examine the use of these compounds by HIV-positive individuals and to investigate their knowledge of the addictive potential of GHB and its related dietary compounds. One hundred HIV-positive individuals from the UCSD outpatient HIV clinic responded to an anonymous survey that inquired about their knowledge, use, and effects produced by GHB containing dietary compounds. The most common reported dietary compound beside GHB was Growth Hormone Release Extract (GHRE). Fifty-two percent of individuals reported using at least one GHB containing dietary compound. Gay subjects reported the highest use of GHB compounds (76.9%; p less than or equal to 0.001). The most common effect reported by users was increased energy (71%). Only 24% of the total responders knew about GHB's addictive potential. Among reported users of GHB containing compounds, fourteen (27%) knew about its addictive potential and nine (17%) knew that the compound is illegal. This study shows that HIV-positive gay individuals attending our clinic are using GHB compounds. Reported GHB users have limited knowledge about its addictive potential and serious adverse effects. More controlled studies are needed to evaluate long-term effects of dietary compounds containing GHB, especially among HIV-positive individuals who are actively receiving antiretroviral treatment.

Centers for Disease Control. Unintentional deaths from drug poisoning by urbanization of area -- New Mexico, 1994-2003. MMWR. Morbidity and Mortality Weekly Report 54(35): 870-873, 2005. (9 refs.)

New Mexico experienced an increase in poisoning deaths during the 1990s and in 2002 was the state with the highest death rate (14.1 per 100,000 population) from unintentional poisoning, more than twice the national rate (6.1). The majority of these unintentional poisoning deaths were caused by ingestion of drugs, including illicit, prescription, and over-the-counter drugs. New Mexico is geographically diverse, with communities ranging from urban centers to sparsely populated counties. Data from the New Mexico Medical Examiner was reviewed for 1994-2003, to ascertain any differences by the nature of the community. The analysis showed that deaths from illicit-drug poisoning were twice as likely to occur in metropolitan areas than nonmetropolitan areas. However, deaths from prescription-drug poisoning were most likely to occur in micropolitan areas. Decedent characteristics (e.g., sex, race/ethnicity, and drugs causing death) were analyzed, and age-adjusted drug-poisoning death rates per 100,000 population by urbanization of area were calculated for 1994--2003. Drugs causing death were categorized as illicit drugs (i.e., heroin, cocaine, or methamphetamine), over-the-counter drugs, or prescription drugs (i.e., methadone, other opioid painkiller, tranquilizer/muscle relaxant, antidepressant, barbiturate, or other prescription drug. During 1994--2003, a total of 1,982 drug-poisoning deaths were identified in New Mexico; data on four deaths did not include county of decedent residence. Statewide, 71.3% of decedents resided in metropolitan areas, 25.3% in micropolitan areas, and 3.4% rural. Compared with decedents from micropolitan and nonstatistical areas, a significantly larger proportion from metropolitan areas died from heroin overdose (52.6% versus 48.8% and 35.3%, respectively). However, a larger proportion from rural areas died from any prescription drug (50.0% versus 37.2% and 40.2%) or from opioid painkillers other than methadone (38.2% versus 19.6% and 22.8%). Illicit drug poisonings had the highest death rate (8.1 per 100,000 population), with a higher poisoning death rate from heroin than from cocaine or methamphetamine (5.8 versus 4.4 and 0.6). The death rate from any prescription drug was 4.4, with the highest rate among prescription drugs from opioid painkillers other than methadone (2.4). Metropolitan areas had the highest rates for all drug-poisoning deaths (12.6 versus 9.5 for micropolitan areas and 7.4 for nonstatistical areas), any illicit drug (9.0 versus 6.8 for micropolitan areas and 4.4 for nonstatistical areas), heroin (6.6 versus 4.7 for micropolitan areas and 2.6 for nonstatistical areas), and cocaine (4.8 versus 3.7 for micropolitan areas and 2.4 for nonstatistical areas). Metropolitan areas also had the highest death rates from methadone (1.6) and over-the-counter drugs (1.0). rural areas had the highest death rate from opioid painkillers other than methadone (2.8); micropolitan areas had the highest death rate from alcohol and drug cointoxication (3.7).

Public Domain

Centers for Disease Control; Burt A; Annest JL; Ballesteros. Nonfatal, unintentional medication exposures among young children. United States, 2001-2003. MMWR. Morbidity and Mortality Weekly Report 55(1): 1-4, 2006. (10 refs.)

During 2001-2003, over 53,000 children age 4 and under were treated in hospital emergency rooms for unintentional exposure to prescription and over-the-counter medicaitons. Most of these occurred in the home. These children were nearly four times as likely to hospitalized or transferred for specialized care as other children in the same age group, treated for all unintentional causes of injury (9.7% versus 2.5%). Over-the-counter preparations represented 42%, and prescription medicatons 39%. The most common medications were central nervous sysem agents (e.g. acetaminophen). those most commonly involved in hospital admissions were anticonvulsant agents, calcium-channel-blocking, and antidepressant and mood-stabilizing agents. Data is summarized in three tables.

Public Domain

Chaturvedi AK; Craft KJ; Canfield DV; Whinnery JE. Toxicological findings from 1587 civil aviation accident pilot fatalities, 1999-2003. Aviation, Space, and Environmental Medicine 76(12): 1145-1150, 2005. (24 refs.)

introduction: The prevalence of drug and ethanol use in aviation is monitored by the Federal Aviation Administration (FAA). Under such monitoring, toxicological studies for the 1989-1993 and 1994-1998 periods indicated lower percentages of the presence of controlled substances (illegal drugs) than that of prescription and nonprescription (over-the-counter) drugs in aviation accident pilot fatalities. In continuation, a toxicological assessment was made for an additional period of 5 yr. Methods: Biosamples from aviation accident pilot fatalities submitted to the FAA Civil Aerospace Medical Institute (CAMI) are analyzed, and those findings are stored in a database. This database was examined for the 1999-2003 period for the presence of controlled substances (Schedules I-V), prescription/nonprescription drugs, and ethanol in the fatalities. Results: Out of 1629 fatal aviation accidents from which CAMI received biosamples, pilots were fatally injured in 1587 accidents. Drugs and/or ethanol were found in 830 (52%) of the 1587 fatalities. Controlled substances from Schedules I-II (SI-II) and Schedules III-V (SIII-V) were detected in 113 and 42 pilots, respectively. Prescription drugs were present in 315 pilots, nonprescription drugs in 259, and ethanol in 101. SI-II substances were detected in 5 of 122 first-class medical certificate-holding airline transport pilots. In addition to the controlled substances, many of the prescription/nonprescription drugs found in the fatalities have the potential for impairing performance. Conclusions: Findings from this study were consistent with those of two previous toxicological studies and support the FAA's programs aimed at reducing the usage of performance-impairing substances.

Crouch BI; Caravati EM; Booth J. Trends in child and teen nonprescription drug abuse reported to a regional poison control center. American Journal of Health-System Pharmacy 61(12): 1252-1257, 2004. (29 refs.)

Purpose. Trends in child and teen nonprescription drug abuse reported to a regional poison control center over a 10-year period were examined. Methods. Human exposures to toxic substances reported to the Utah Poison Control Center between January 1990 and December 1999 were reviewed. Cases were selected for analysis if the exposure involved a nonprescription drug, the patient was 6-19 years old, and the reason for exposure was intentional abuse. Frequencies and cross-tabulations were calculated to identify trends in nonprescription drug abuse. Results. There were 2214 reports of intentional drug abuse among children and teenagers 6-19 years old. Of those, 844 (38.1%) involved nonprescription drugs. The percentage of exposures involving nonprescription products varied every year and declined over time. Exposures were slightly more common in males (51.7%). The site of exposure was a residence in 65% of cases and a school in 10% of cases. The majority of patients with exposures (68.4%) were treated in a health care facility. The most common types of nonprescription medications abused were drugs with anticholinergic properties, caffeine, dextromethorphan, and nonprescription stimulants. Conclusion. Reports of the intentional abuse of nonprescription drugs by children and teenagers were common at a regional poison control center. There was significant variation in the type of nonprescription medication most commonly abused. The knowledge of these trends may assist public health policymakers, physicians, pharmacists, and child educators in their attempts to curb nonprescription drug abuse.

Desai S; Aldea D; Daneels E; Soliman M; Braksmajer AS; Kopes-Kerr CP. Chronic addiction to dextromethorphan cough syrup: A case report. Journal of the American Board of Family Medicine 19(3): 320-323, 2006. (12 refs.)

Background: Serious drug abuse and addiction related to dextromethorphan-containing cough preparations has been a problem in the United States since the 1950s, but few physicians are aware of it. Physicians must be alert to the type of substances and quantities used and misused by patients in obtaining a thorough routine history of over-the-counter medication use. Methods: We describe the case of a 66-year-old clerical worker who ingested 4 to 16 oz of dextromethorphan on a regular basis over an 8-year period. We consulted with our local Poison Control Center and undertook a literature search to research previous reports of similar cases to identify the features that would aid physicians in recognition and management of this problem. Results and Conclusion: Despite the availability of a substantial number of case reports in specialty journals, there are almost no reports in the primary care literature of chronic dextromethorphan addiction. Our case highlights the difficulties in making an appropriate diagnosis and in obtaining effective help for the patient.

Dickerson DL; Schaepper MA; Peterson MD; Ashworth MD. Coricidin HBP (R) abuse: Patient characteristics and psychiatric manifestations as recorded in an inpatient psychiatric unit. Journal of Addictive Diseases 27(1): 25-32, 2008. (13 refs.)

Coricidin HBP (R), a cold medication containing dextromethorphan, has become a popular agent abused among adolescents. This retrospective chart review examines the potential psychiatric manifestations of Coricidin HBP (R) misuse and patterns of use among patients treated in an inpatient child and adolescent psychiatric unit. Coricidin HBP (R) use was documented in 47 patient. The data revealed that Coricidin HBP (R) use was associated with: (a) predominantly depressive symptomatology; (b) transient substance-induced psychosis; (c) cardiac toxicity; and (d) greater quantities used per episode by Caucasians. Clinicians treating adolescents need to be aware of the abuse potential and psychiatric manifestations of this dextromethorphan-containing product.

Doughty C; Walker A; Brenchley J. Herbal mind altering substances: An unknown quantity? Emergency Medicine Journal 21(2): 253-255, 2004. (13 refs.)

Herbal drugs are increasingly marketed as a "safe" alternative to illict drugs. The variety of consituents in these compounds and their potential pharmacological activity an present difficultis for the emergency physicain in management of intoxicated patients. After a case as at a recent music festival, we prsent a case report and review of herbal compounds. The cas report involved a young women who had taken herbal drugs )"road runners") and alcohol. She was conscience but hyperventilating, tachycardic with dilated pupils, who became increasingly agitated and after arrival at a festival medical station had a grand mal seizure. She was tranferred to a local emergency department. The chemical analysis of the preparation is presented, the predominant ingredients being ephedrine and caffeine.

Fleming GF; McElnay JC; Hughes CM. Development of a community pharmacy-based model to identify and treat OTC drug abuse/misuse: A pilot study. Pharmacy World & Science 26(5): 282-288, 2004. (36 refs.)

Objective: The aim of this study was to develop and pilot a harm-minimisation model for the identification and treatment of over-the-counter (OTC) drug abuse/misuse by community pharmacists. Method, Extensive consultation was conducted during the development of the model. This included an exploratory conference involving an interdisciplinary group of delegates and detailed individual consultation with a range of healthcare practitioners. Consultation with a psychologist specialising in communication skills allowed development of the communication aspects of the model. A comprehensive manual detailing the model was prepared, Results: The model is designed to be used by community pharmacists in conjunction with other healthcare professionals. It focuses on the abuse/misuse of opioids, laxatives and antihistamines and can be broadly divided into three phases, namely: patient identification and recruitment, treatment/referrals and data collection/outcome measurement. Client identification is via record-keeping which is implemented alongside an information campaign promoting safe use of OTC medicines. Once identified, the pharmacist aims to recruit clients using the developed communication strategies. Treatment depends on whether the problem is misuse or abuse and on the product. Several treatment paths are available including treatment according to an agreed protocol and referring to the GP or community addiction team (CAT). Two pharmacists were recruited and trained to pilot the model. Of the clients, 18 were identified as abusing/misusing OTC products over a one-month period. The subject of inappropriate OTC use was raised with 14 of these clients. Some success was noted in that clients agreed to stop using the product and/or to try safer alternatives. As expected, some sales had to be refused, as the client was unwilling to accept the pharmacist's intervention. Conclusion: This study represents the first reported structured attempt by community pharmacists in the UK to address the abuse/misuse of OTC medication. Work is now ongoing to modify this model in light of the pilot study findings.

Ford JA. Misuse of over-the-counter cough or cold medications among adolescents: Prevalence and correlates in a national sample. Journal of Adolescent Health 44(5): 505-507, 2009. (10 refs.)

The current research examines the misuse of over-the-counter cough/cold medications among adolescents with data from the 2006 National Survey on Drug Use and Health. Findings indicate that age, gender, family income, physical and mental health, and the use of alcohol and other drugs are correlates of the misuse of over-the-counter cough/cold medications.

Hammond D; Reid JL; Driezen P; Cummings KM; Borland R; Fong GT et al. Smokers' use of nicotine replacement therapy for reasons other than stopping smoking: Findings from the ITC Four Country Survey. Addiction 103(10): 1696-1703, 2008. (38 refs.)

Aims: To measure the prevalence and correlates of nicotine replacement therapy (NRT) use for reasons other than quitting smoking among smokers in four countries. Design and setting: Population-based, cross-sectional telephone survey with nationally representative samples of adult smokers in Canada, the United States, the United Kingdom and Australia, conducted in 2005. Participants A total of 6532 adult daily smokers in Canada (n = 1660), the United States (n = 1664), the United Kingdom (n = 1617) and Australia (n = 1591). Measurements Survey questions included demographics, smoking behaviour, use of NRT and reasons for NRT use, as well as access and availability of NRT. Findings Approximately 17% of smokers surveyed had used NRT in the past year. Among NRT users, approximately one-third used NRT for a reason other than quitting smoking, including temporary abstinence or reducing the number of cigarettes smoked. The prevalence of non-standard NRT use was remarkably consistent across countries. Using NRT for reasons other than quitting was associated with higher education level, heavier smoking, having no quit intentions, having no past-year quit attempts, the type of NRT product used and accessing NRT without a prescription. Conclusions: The use of NRT for purposes other than quitting smoking is fairly common and may help to explain the difficulty in detecting significant quitting benefits associated with NRT use in population studies. Tobacco control policies, including the accessibility of NRT, may have important implications for patterns of NRT use.

Hasford J; Fagerstrom KO; Haustein KO. A naturalistic cohort study on effectiveness, safety and usage pattern of an over-the-counter nicotine patch: Cohort study on smoking cessation. European Journal of Clinical Pharmacology 59(5/6): 443-447, 2003. (17 refs.)

Introduction. Nicotine replacement therapies (NRT) are effective for smoking cessation. After having received over-the-counter (OTC) status in Germany, concerns grew about effectiveness, increased risks, especially of adverse cardiovascular reactions, and inappropriate use of NRT. Thus, a pharmacy-based cohort study was launched. Objectives. To assess effectiveness, safety and appropriateness of use of an OTC nicotine patch (Nicotinell, Novartis Ltd.). Every customer who bought an OTC Nicotinell patch was eligible. All data were collected by self-administered questionnaires at weeks 2, 4, 8, 12 and 24 after inclusion. Six hundred and thirty-three customers were admitted, median duration of smoking was 19 years. Of the participants, 6% smoked up to 10 cigarettes per day, 43.6% between 11 and 20, 34.3% between 21 and 30, and 16.1% more than 30 cigarettes. Twenty-four weeks later, 351 participants replied: 28% (177 of 633) had quit smoking completely. Considering replies only the proportion of complete responders raised to 50.4%. There were no serious adverse events reported; 62.9% complied with the directions for use and did not use the patch for more than 3 months. About 45% smoked simultaneously with NRT. Pharmacy-based cohort studies are feasible. This study indicates that the nicotine patch is effective and safe in an OTC setting. There is still room to improve compliance with the directions for use.

Hendrickson RG; Cloutier RL. "Crystal Dex": Free-base dextromethorphan. Journal of Emergency Medicine 32(4): 393-396, 2007. (11 refs.)

Dextromethorphan (DXM) is a common component of combination cold medications that has become a popular drug of abuse for young adults. Abusers of DXM have developed a simple acid-base extraction technique to "free-base," or extract, the DXM from the unwanted guaifenesin, coloring agents, sweeteners, and alcohol that are typically included in combination cold preparations. We report a case of DXM overdose after ingestion of this purified "Crystal Dex" and discuss the "Agent Lemon" and single-phase extraction techniques that are used to free-base the dextromethorphan.

Hughes JR; Shiffman S; Callas P; Zhang J. A meta-analysis of the efficacy of over-the-counter, nicotine replacement. Tobacco Control 12(1): 21-27, 2003. (12 refs.)

Objective: To determine whether over-the-counter (OTC) nicotine replacement therapy (NRT) is pharmacologically efficacious, whether it produces abstinence rates similar to those in prescription settings, and to estimate the long term (that is, greater than six month) abstinence rate with OTC NRT. Method: Systematic literature review. Data sources: Medline, Psych Abstracts, bibliographies, requests of scientists. Study selection: Studies comparing OTC NRT versus OTC placebo or studies comparing OTC NRT versus prescription NRT that reported abstinence rates and for which a full study report was available. Data extraction: Two of the authors independently reviewed studies and compared results. Data synthesis: Meta-analysis was performed by first testing for homogeneity across studies, then combining odds ratios (ORs) weighting by inverse variance and proportions weighting by study sample size. Results: One OTC NRT versus OTC placebo nicotine gum study was excluded due to small sample size and different setting. The four remaining studies were randomised trials of nicotine versus placebo patch with ORs of 2.1-3.2. These outcomes were homogenous and when combined resulted in an OR favouring NRT of 2.5 (95% confidence interval (CI) 1.8 to 3.6). Among the two randomised and two non-randomised trials of OTC NRT versus prescription NRT, one small study had an OR of 0.3, two others had ORs of 1.0 and 1.4, and a fourth study had an OR of 3.6. These results were not homogenous; however, when combined via a random effects model the estimated OR was not less than 1.0-that is, OR 1.4 (95% Cl 0.6 to 3.3). The long term (that is, greater than six months) quit rates for OTC NRT was 1% and 6% in two studies and 8-11% in five other studies. These results were not homogenous; however, when combined the estimated OR was 7% (95% Cl 4% to 11%). Conclusions: OTC NRT is pharmacologically efficacious and produces modest quit rates similar to that seen in real world prescription practice.

Hyland A; Bradford D; Gitchell J. Drug counselor report of adolescents abuse of nicotine replacement therapy. Journal of Addictive Diseases 24(4): 105-113, 2005. (9 refs.)

Background. Nicotine replacement products (NRT) are formulated and marketed to reduce their abuse liability among adolescents. Few studies have examined the extent of adolescent abuse. The objective of this manuscript is to describe the youth abuse rate for NRT and other over-the-counter (OTC) abusable substances. Methods. Two cross-sectional telephone surveys of Safe and Drug Free School Coordinators were conducted in 1996/7 (N = 562) and 1998/9 (N = 501). Abuse of NRT and other OTC drugs and circumstances surrounding NRT abuse was ascertained. Results. NRT abuse rates were low and did not change significantly between the two surveys (2.7% in 1996/7 to 4.6% in 1998/9). NRT abuse rates were well below those of other OTC abusable substances (e.g., diet pills and inhalants). Conclusions. Concerns over promotion of youth dependence to nicotine by offering the sale of NRT OTC to adults have not been realized and policymakers should consider reducing barriers to access these products.

Hyland A; Rezaishiraz H; Giovino G; Bauer JE; Cummings KM. Over-the-counter availability of nicotine replacement therapy and smoking cessation. Nicotine & Tobacco Research 7(4): 547-555, 2005. (22 refs.)

In 1996, the FDA approved over-the-counter (OTC) availability of nicotine gum and two brands of nicotine skin patches. Little is known about how this reclassification has influenced the effectiveness and use of nicotine replacement therapy (NRT) and whether it has been a public health benefit. Data for the present study came from a prospective cohort study of 1,639 adult smokers surveyed by telephone in 1993, as part of the National Cancer Institute's Community Intervention Trial for Smoking Cessation (COMMIT), and resurveyed in 2001. NRT-assisted quit rates, NRT use rates, and the characteristics of NRT users were calculated before and after the 1996 OTC reclassification. Also calculated was the percentage of NRT users who quit by year. Results are presented for patch and gum separately and combined. OTC NRT use rates were lower for Hispanics and higher for those with no desire to quit at baseline. The quit rate decreased for patch-assisted quit attempts after OTC reclassification (22.5% to 18.5%, p=.05), but it did not change for gum-assisted quit attempts (11.9% to 10.5%, p=.54). NRT use rates increased for both patch and gum by about 60% following reclassification. A greater percentage of gum users had quit in the post-OTC period than in the pre-OTC period (9.7% vs. 14.6%, p=.05). Long-term quit rates in patch users were similar in both periods. Insurance coverage of NRT and concurrent attendance in a stop smoking clinic decreased for both patch- and gum-assisted attempts in the post-OTC period. The results suggest that OTC reclassification may have contributed to the increased use of NRT, compared with the pre-OTC period, whereas the efficacy for quitting decreased slightly for those using nicotine patch and remained about the same for those using the gum.

Johnson KC; Klesges LM; Somes GW; Coday MC; DeBon M. Access of over-the-counter nicotine replacement therapy products to minors. Archives of Pediatrics & Adolescent Medicine 158(3): 212-216, 2004. (18 refs.)

Background: Public health policy guidelines recommend that health care providers (eg, physicians, nurses, others) counsel adolescent smokers to quit and that nicotine replacement therapy (NRT) may be considered to aid in smoking cessation for nicotine-dependent youth. This recommendation is discrepant with Food and Drug Administration-approved labeling of NRT products, stating that they not be sold to persons younger than 18 years. It is not clear how easily minors are able to purchase NRT products in retail markets. Objective: To explore youth access to NRT by conducting the first study, to our knowledge, to determine the ability of minors to purchase over-the-counter NRT products. Design: Observational case series of NRT purchase attempts and survey description of store characteristics. Setting: Retail businesses in Memphis, Tenn. Participants: Population-based sample of 165 stores that sold over-the-counter medications. Main Outcome Measure: Successfully completed purchase attempts of NRT by the minor buyer. Results: In most stores that stocked NRT products, the age of the minor was not queried at any time during the purchase attempt (79%) and the minor was able to successfully purchase the product (81%). If the minor was asked her age, the store was much less likely to sell the NRT product. Stores in which a cash register gave an age query prompt or in which alcohol was sold were more likely to inquire about the minor's age and less likely to sell NRT products. Conclusions: Nicotine replacement therapy products were successfully obtained in most purchases by a minor buyer without proof of age. While ease of purchasing NRT products is potentially beneficial to young smokers attempting to quit, these purchases are discrepant with Food and Drug Administration labeling regarding the sale of NRT products to minors.

Juhn MS. Popular sports supplements and ergogenic aids. (review). Sports Medicine 33(12): 921-939, 2003. (135 refs.)

This article reviews the evidence-based ergogenic potential and adverse effects of 14 of the most common products in use by recreational and elite athletes today. Both legal and prohibited products are discussed. This is an aggressively marketed and controversial area of sports medicine worldwide. It is therefore prudent for the clinician to be well versed in the more popular supplements and drugs reputed to be ergogenic in order to distinguish fact from fiction.Antioxidants, proteins and amino acids are essential components of diet, but additional oral supplementation does not increase endurance or strength. Caffeine is ergogenic in certain aerobic activities. Creatine is ergogenic in repetitive anaerobic cycling sprints but not running or swimming. Ephedrine and pseudoephedrine may be ergogenic but have detrimental cardiovascular effects. Erythropoietin is ergogenic but increases the risk of thromboembolic events. beta-Hydroxy-beta-methylbutyrate has ergogenic potential in untrained individuals, but studies are needed on trained individuals. Human growth hormone and insulin growth factor-I decrease body fat and may increase lean muscle mass when given subcutaneously. Pyruvate is not ergogenic. The androgenic precursors androstenedione and dehydroepiandrosterone have not been shown to increase any parameters of strength and have potentially significant adverse effects. Anabolic steroids increase protein synthesis and muscle mass but with many adverse effects, some irreversible. Supplement claims on labels of product content and efficacy can be inaccurate and misleading.

Krome CN; Tucker AM. Cardiac arrhythmia in a professional football player: Was ephedrine to blame? Physician and Sportsmedicine 31(12): 21+, 2003. (30 refs.)

The use of over-the-counter dietary supplements has risen dramatically, and adverse events can be severe. Physicians should recognize the dangers that ephedrine-containing supplements present and remain vigilant for sympathomimetic symptoms in young, otherwise healthy, patients. This case illustrates how the use of a popular weight-loss supplement by a 27-year-old professional football player apparently resulted in cardiac arrhythmia requiring direct cardioversion.

Laure P; Lecerf T; Friser A; Binsinger C. Drugs, recreational drug use and attitudes towards doping of high school athletes. International Journal of Sports Medicine 25(2): 133-138, 2004. (26 refs.)

The purpose of this investigation was to determine the substances used, and the attitudes towards doping of high school athletes. A four-page, self-completed questionnaire was designed to determine the drugs used (licit, illicit and doping substances) along with beliefs about doping and the psychosociological factors associated with their consumption. The questionnaire was distributed to all the high school students enrolled in a school sports association in the Lorraine region in Eastern France. The completed forms were received from 1459 athletes: 4% stated that they had used doping agents at least once in their life (their main source of supply being peers and health professionals). Thirty-four percent of the sample smoked some tobacco, 66% used alcohol, 19% cannabis, 4% ecstasy, 10% tranquillizers, 9% hypnotics, 4% creatine and 41% used vitamins against fatigue. Beliefs about doping did not differ among doping agent users and non-users, except for the associated health risks which were minimized by users. Users of doping agents stated that the quality of the relations that they maintain with their parents is sharply degraded, and they reported that they are susceptible to influence and difficult to live with. More often than non-doping agent users, these adolescents are neither happy, nor healthy, while paradoxically, they seem less anxious and they are more self-confident. Our findings suggest that doping prevention among young athletes cannot be limited uniquely to the list of banned drugs.

Lessenger JE; Feinberg SD. Abuse of prescription and over-the-counter medications. (review). Journal of the American Board of Family Medicine 21(1): 45-54, 2008. (46 refs.)

The nonmedical use of prescription or over-the-counter (OTC) medications implies that the user is using them for reasons other than those indicated in the prescribing literature or on the box label. The abuse of these medications is a national issue. Intentional drug abuse of prescribed and OTC medicines has climbed steadily. Data from the 2005 National Survey on Drug Use and Health demonstrated that 6.4 million (2.6%) people aged 12 or older had used prescription drugs for nonmedical reasons during the past month. Of these, 4.7 million used pain relievers, 1.8 million used tranquilizers, and 1.1 million used stimulants. The nonmedical use of prescription drugs in the past month among young adults aged 18 to 25 increased from 5.4% in 2002 to 6.3% in 2005, primarily because of an increase in the abusive use of pain relievers. Physicians need to watch for prescription and OTC medication abuse. Treatment strategies include (1) inquiring about prescription, OTC, and herbal drug use at the initial examination (even though many individuals are drug-abuse savvy, some are naive and do not realize that OTC medications can be problematic); (2) inquiring about drug use during office visits; (3) providing disposal containers that patients can use to dispose of their unused or unneeded prescription or OTC medications; (4) treating pain aggressively and appropriately; (5) practicing careful record keeping of prescription refills and controls over prescription blanks; (6) referring patients who are addicted to medications to 12-step programs such as Alcoholic Anonymous, Narcotics Anonymous, and Pills Anonymous; and (7) considering detoxification.

Levine DA. 'Pharming': The abuse of prescription and over-the-counter drugs in teens. (review). Current Opinion in Pediatrics 19(3): 270-274, 2007. (27 refs.)

Purpose of review Prescription and over-the-counter cough and cold medication abuse is rapidly becoming a national health concern for adolescents. Increased awareness of this growing epidemic is essential toward diagnosing, treating and preventing this type of substance abuse. Recent findings Data from surveys and poison control center records demonstrate an increased nonmedical use of prescription and over-the-counter cough and cold preparations, particularly those containing dextromethorphan. The nonmedical use of prescription medications may result in serious clinical effects with potential life-threatening complications, dependence and withdrawal syndromes. Dextromethorphan causes alterations in mental status that may contribute to judgment impairment leading to injury or fatality. Coingestion of other substances found in over-the-counter medications may also cause significant morbidity. Alcohol and illicit drug use is highly associated with the abuse of these medications. The incentive for abuse, such as easy accessibility, low cost and decreased perception of potential for harm, and potential interventions are described, Summary: The recent trend of prescription and dextromethorphan-containing over-the-counter medication abuse in adolescents is alarming. Improved awareness for these readily available, seemingly benign yet highly dangerous medications is essential. Prevention and early education on substance abuse in young teens are critical in combating this recent epidemic.

Lo A; Shalansky S; Leung M; Hollander Y; Raboud J. Patient characteristics associated with nonprescription drug use in intentional overdose. Canadian Journal of Psychiatry 48(4): 232-236, 2003. (12 refs.)

Objective: Over-the-counter (OTC) medications remain freely available to suicidal patients, despite their potential lethality and common use in suicide. The study's main objective was to identify patient characteristics, particularly psychiatric diagnosis associated with the use of OTC medications in intentional overdose. Methods: We retrospectively reviewed 95 charts from patients who presented to St Paul's Hospital from August 1, 1997, to July 31, 1998, with a discharge diagnosis of intentional drug overdose. Univariate analysis was carried out to identify potential risk markers for OTC medication use, and logistic regression was performed using these variables. Results: When the variables age, sex, and concurrent psychiatric diagnoses were controlled, use of OTC medications in overdose was significantly lower in patients with a DSM-IV diagnosis of substance abuse (OR 0.11, P = 0.005) and in those who possessed prescription medications at the time of overdose (OR 0.18, P = 0.007). Most patients in this cohort (82%) had at least 1 of these 2 traits. Although not statistically significant, younger patients appeared more likely to choose OTC medications for overdose. Conclusion: Suicide-prone patients with a diagnosis of substance abuse and who possess prescription medications are unlikely to use OTC medications in overdose. For this cohort, this represents a relatively small proportion of patients whom clinicians should consider to be at greater risk for attempting suicide when using OTC medication, especially acetaminophen.

Mahadevan S; Park Y. Multifaceted therapeutic benefits of Ginkgo biloba L.: Chemistry, efficacy, safety, and uses. (review). Journal of Food Science 73(1): R14-R19, 2008. (83 refs.)

The new age of nutraceuticals is now embracing the centuries old herbal extract of Ginkgo biloba (Mantissa Plantarum Altera, 1771, Ginkgoceae). The standardized preparation of the Ginkgo leaf extract (EGb 761) contained 2 main bioactive constituents, flavonoid glycosides (24%) and terpene lactones (6%), along with less than 5 ppm of the allergenic component, ginkgolic acid. The Ginkgo leaf extract has been reported to have neuroprotective, anticancer, cardioprotective, stress alleviating, and memory enhancing effects and possible effects on tinnitus, geriatric complaints, and psychiatric disorders. The therapeutic mechanisms of action of the Ginkgo leaf extract are suggested to be through its antioxidant, antiplatelet, antihypoxic, antiedemic, hemorrheologic, and microcirculatory actions, where the flavonoid and the terpenoid constituents may act in a complementary manner. Toxicity studies show that the Ginkgo leaf extract is relatively safe for consumption, although a few side effects have been reported, that is, intracerbral hemorrhage, gastrointestinal disturbances, headaches, dizziness, and allergic skin reactions. The use of Ginkgo leaf extract may be promising for treatment of certain conditions, although its long-term use still needs to be evaluated.

McBride AJ; Pates R; Ramadan R; McGowan C. Delphi survey of experts' opinions on strategies used by community pharmacists to reduce over-the-counter drug misuse. Addiction 98(4): 487-497, 2003. (30 refs.)

Aim: To explore the views of experts within the fields of pharmacy and addiction on the value of current strategies and possible alternatives and to reach an agreement on best practice in the sale of over-the-counter (OTC) medicines which are liable to misuse. Design Using a modified Delphi approach, an anonymous, international, three-stage, postal questionnaire was conducted that generated both qualitative and quantitative data. Participants: Of those contacted by telephone (164) from the United Kingdom, Canada, Australia, New Zealand and United States, 109 experts (66%) agreed to take part. Forty-three per cent (47/109) completed all three stages of the study. Measurements: A Delphi technique was employed to gather data. The second and final questionnaires were constructed from the responses to the preceding questionnaires. Content analysis of the qualitative data was carried out at each stage. Statistical analyses of the influence of demographic factors, degree of shift in overall opinion between the first and second stages and degree of agreement between respondents at each stage were also conducted. Findings: A consensus was reached on the strategies considered the most important and effective. Key areas include improving access to current information, improved staff training, addressing the issues of non-pharmacy outlets and Internet pharmacy sites. Concerns were expressed regarding the possible conflict between commercial and customer interests. Conclusions: The consensus view presented offers practical and realistic guidance for policy-makers and community pharmacists on the sale of OTC products. It reflects the best evidence to date of expert views in this area and accords with current UK guidelines. The effective implementation of these strategies can only be achieved with improved communication and coordination at local and national level.

McCabe SE. Misperceptions of non-medical prescription drug use: A web survey of college students. Addictive Behaviors 33(5): 713-724, 2008. (35 refs.)

Objectives: This study compared undergraduate students' perceived versus actual prevalence rates of non-medical use of marijuana, prescription opioids and prescription stimulants. Methods: In 2005, a randomly selected sample of 3639 college students self-administered a Web survey regarding their substance use behaviors and attitudes (68% response rate). Results: The majority of undergraduate students overestimated the prevalence of non-medical use of prescription stimulants (70.2%) and prescription opioids (69.9%) and marijuana use (50.5%) among peers on their campus. The mean difference between perceived versus actual past-year use was considerably greater for non-medical use of prescription stimulants (mean difference=12.2, 95% CI=11.7-12.7) and prescription opioids (mean difference=8.8, 95% CI=8.3-9.2) than marijuana (mean difference=2.9, 95% CI=2.2-3.6). Multivariate regression analysis revealed overestimation of non-medical use of prescription drugs was significantly associated with gender and medical use of prescription drugs. Conclusions: The findings provided strong evidence of misperception of non-medical prescription drug use among college students. Future research and prevention efforts should assess the impact of correcting misperceived norms on reducing non-medical prescription drug use.

Metzger KB; Mostashari F; Kerker BD. Use of pharmacy data to evaluate smoking regulations' impact on sales of nicotine replacement therapies in New York City. American Journal of Public Health 95(6): 1050-1055, 2005. (26 refs.)

Objectives. Recently, New York City and New York State increased cigarette excise taxes and New York City implemented a smoke-free workplace law. To assess the impact of these policies on smoking cessation in New York City, we examined over-the-counter sales of nicotine replacement therapy (NRT) products. Methods. Pharmacy sales data were collected in real time as part of nontraditional surveillance activities. We used Poisson generalized estimating equations to analyze the effect of smoking-related policies on pharmacy-specific weekly sales of nicotine patches and gum. We assessed effect modification by pharmacy location. Results. We observed increases in NRT product sales during the weeks of the cigarette tax increases and the smoke-free workplace law. Pharmacies in low-income areas generally had larger and more persistent increases in response to tax increases than those in higher-income areas. Conclusions. Real-time monitoring of existing nontraditional surveillance data, such as pharmacy sales of NRT products, can help assess the effects of public policies on cessation attempts. Cigarette tax increases and smoke-free workplace regulations were associated with increased smoking cessation attempts in New York City, particularly in low-income areas.

Mottram D; Chester N; Atkinson G; Goode D. Athletes' knowledge and views on OTC medication. International Journal of Sports Medicine 29(10): 851-855, 2008. (13 refs.)

A questionnaire was administered to elite athletes from Australia, Canada, the UK, and the USA representing 10 Olympic sports in order to explore knowledge and understanding of over-the-counter (OTC) medication since the removal of many of these substances from the World Anti-Doping Agency (WADA) Prohibited List, in 2004. Athletes demonstrated limited knowledge and understanding. Around half (50.5%) knew the penalty incurred following a doping violation involving a banned OTC stimulant. The terms Monitoring Program and Specified Substance List were understood by 43.3% and 67.5% of respondents, respectively. Overall, the status of substances in relation to the Prohibited List was correctly identified in just 35.1% of cases. As a whole, athletes were of the opinion that OTC stimulants posed a risk to health, were performance enhancing and that their use was against the spirit of sport. They were undecided as to whether these drugs should be returned to the Prohibited List. Elite athletes require targeted education programmes that will enable them to make informed decisions on the potential of OTC medications for therapeutic or performance enhancing purposes.

Murao S; Manabe H; Yamashita T; Sekikawa T. Intoxication with over-the-counter antitussive medication containing dihydrocodeine and chlorpheniramine causes generalized convulsion and mixed acidosis. Internal Medicine 47(11): 1013-1015, 2008. (17 refs.)

We report a 35-year-old man who was referred to our hospital with generalized convulsion and mixed acidosis presumably caused by abuse of SS-BRON (TM) tablets, an over-the-counter (OTC) antitussive medication sold in Japan. These tablets contain dihydrocodeine phosphate, methylephedrine, chlorpheniramine, and caffeine. Although it is difficult to discern which component caused these symptoms, it seems that dihydrocodeine phosphate or methylephedrine was involved in the addiction to SS-BRON (TM) and chlorpheniramine may have caused the generalized convulsion. It should be recognized that an OTC antitussive, which is quite easy to obtain, can be abused and subsequently induce serious intoxication.

Myers B; Siegfried N; Parry CDH. Over-the-counter and prescription medicine misuse in Cape Town: Findings from specialist treatment centres. South African Medical Journal 93(5): 367-370, 2003. (11 refs.)

Objective. To provide community-level public health surveillance information on over-the-counter (OTC) and prescription medicine misuse. Methods. A retrospective study of OTC and prescription medicine misuse among 9 063 patients from 23 specialist substance abuse treatment centres in Cape Town, South Africa, between 1998 and 2000. Results. OTC and prescription medicine misuse places a burden on health and social services in South Africa. This is evidenced through the constant demand for treatment for OTC/prescription medicine misuse. Benzodiazepines are the class of medicines for which users most often receive treatment, followed by analgesics. Analgesic misuse is most often accounted for by the use of codeine-containing medicines, many of which are available over the counter. Patients using OTC/prescription medicines as their primary drug of abuse are significantly more likely to be female, and aged over 40 years. In contrast, patients using OTC/prescription medicine as an additional drug of abuse tend to be male and over 40 years of age. Conclusions. This study points to the need to develop primary health care protocols for detection, management and referral of patients misusing OTC/prescription drugs and the need to debate the re-scheduling of codeine as a prescription-only substance. The study also points to the need for further community-based research on the nature and extent of OTC/prescription drug misuse among the general population.

Myers RP; Shaheen AAM; Li B; Dean S; Quan H. Impact of liver disease, alcohol abuse, and unintentional ingestions on the outcomes of acetaminophen overdose. Clinical Gastroenterology and Hepatology 6(8): 918-925, 2008. (43 refs.)

Background & Aims: Acetaminophen overdose is the most common cause of acute liver failure in the U.S. and other Western countries. Unintentional overdoses, alcohol abuse, and underlying liver disease might increase the risk of hepatotoxicity. In this population-based study, we examined outcomes of acetaminophen overdose, with particular attention to these risk factors. Methods: Patients hospitalized for acetaminophen overdose between 1995 and 2004 were identified retrospectively by using administrative data. Comorbid conditions, suicidal intent, and hepatotoxicity were identified by using International Classification of Diseases-Ninth Revision-Clinical Modification and International Statistical Classification of Diseases and Health-Related Problems, 10th revision diagnostic codes. Results: During the 10-year interval, 1543 patients were hospitalized for acetaminophen overdose; 34% were alcohol abusers, 3% had liver disease, and 13% overdosed unintentionally. Seventy patients (4.5%) developed hepatotoxicity. Unintentional overdoses (odds ratio [OR], 5.18; 95% confidence interval [CI], 3.00 - 8.95), alcohol abuse (OR, 2.21; 95% CI, 1.30-3.76), underlying liver disease (OR, 3.50; 95% CI, 1.57-7.77), and N-acetylcysteine treatment (OR, 6.75; 95% CI, 2.78-16.39) were independently associated with hepatotoxicity. Fifteen patients (1.0%) died in-hospital; risk factors included older age, unintentional overdoses, alcohol abuse, comorbidities including liver disease, and hepatotoxicity (14% vs 0.3%; P <.0005). During a median follow-up of 5.2 years (range, 1 day-11.0 years), 79 patients (5.1%) died. Approximately half of these deaths were due to preventable conditions including suicide, substance abuse, and trauma. Conclusions: In this population-based study, acetaminophen overdose had a relatively benign short-term course but was associated with substantial long-term mortality caused by preventable conditions. Acetaminophen-related hepatotoxicity is more common in patients with unintentional overdoses, alcohol abuse, and underlying liver disease.

Nakada N; Komori K; Suzuki Y; Konishi C; Houwa I; Tanaka H. Occurrence of 70 pharmaceutical and personal care products in Tone River basin in Japan. Water Science and Technology 56(12): 133-140, 2007. (6 refs.)

The occurrence of 70 pharmaceutical and personal care products (PPCPs) was investigated in the Tone River. The river has the largest basin in Japan, and the water is utilized not only for farming, but also as a source of water supply. One day in both January and October 2006, surface waters in the river and its tributaries and effluents from sewage treatment plants (STPs) directly discharging into the Tone River were collected, the location of which ranged over 150 km along the river. The 70 PPCPs in the samples were concentrated by solid phase cartridge and were measured by LC-MS/MS using three analytical methods. Fifty-seven PPCPs were detected in one or more samples. Bezafibrate, caffeine, carbamazepine, clarithromycin, crotamiton and sulpiride were frequently detected. Mass flow profiles of some PPCPs (e.g., crotamiton) were comparable to cumulative inhabitants in the basin, suggesting that these PPCPs could be markers of population. Total load of each PPCP into the basin from upstream, the tributaries, and the STPs were calculated. The contribution of selected PPCPs from the tributaries with lower sewerage system coverage was dominant compared to those from upstream and the STPs, suggesting the installation of sewerage systems is necessary to reduce the load of PPCPs in the Tone River basin.

Office of Applied Studies; Ball J; Garfield T; Morin C; Steele D. Emergency Department Trends from the Drug Abuse Warning Network: Final Estimates 1995-2002. DAWN Series D-24. Rockville MD: NIDA, 2003. (24 refs.)

This issue of ED Trends From DAWN examines the nature of U.S. trends in drug-related ED episodes and focuses almost exclusively on the final estimates for 2002 with statistical comparisons to 2001. Semi-annual estimates for the 10 half years from 1998 through 2002 are provided for reference, but are not discussed. In the full-year tables, statistical tests are used to compare final 2002 estimates with those for 2001, 2000, and 1995. For half years, estimates for the latest half-year period are compared with those for the previous 2 half years. Each table displays the percentage change for statistically significant differences. The presentation of ED findings in this publication is divided into the following sections: (1) Trends in major substances of abuse, such as alcohol-in-combination, cocaine, heroin, and "club drugs;" (2) Trends in other substances of abuse, such as prescription and OTC drugs; (3) Trends for the 21 metropolitan areas oversampled in DAWN; (4) Trends in demographic characteristics of patients treated in drug-related ED episodes; (5) Trends in characteristics of the episodes themselves; and (6) Discussion of results. Population-based rates are discussed within these sections by topic, because the rates are best used to supplement the other estimates of episodes and mentions. By considering the estimates of drug mentions and episodes relative to the size of the population at risk, the rates yield standardized measures that can be compared across selected drugs, metropolitan areas, and gender and age groups.

Public Domain

Office of Applied Studies; Steele D; Mallonee E. Mortality Data from the Drug Abuse Warning Network. DAWN Series D-25. Rockville MD: Office of Applied Studies, Substance Abuse Mental Health Administration, 2004. (0 refs.)

This publication presents information on deaths related to drug abuse based on data collected through the Drug Abuse Warning Network (DAWN) for calendar year 2002. This ongoing national surveillance system collects data from 31 major metropolitan areas on drug abuse deaths from medical examiners and coroners. Deaths include those directly caused by drugs as well as those in which drug use in a contributing factor. Among the significant findings is that (1) as previously, the typical case involved between two and four different drugs. (2) Three drugs were among those most commonly reported, heroin/morphine, cocaine, or alcohol-in-combination with another substance, in all among three of the areas these were the most common. (3) There are geographical differences, with methamphetamine most commonly reported in the west and midwest; marijuana mentions, are much lower and among the top 3 drug mentions in only 3 areas. Beyond describing the methodology and the "drug vocabulary" used, the bulk of the report provides detailed data on each of the metropolitan area. These presentations provide information on area population, deaths by sex, age, and race/ethnicity, the top ten drugs mentioned, the mentions by drug category for a five year period, and drugs involved by sex and age groups, and manner or death (suicide, accident, drug-induced, drug-related, and number of drugs involved.

Office of Applied Studies; Ball J; Mallonee E; Steele D; Morin C. Drug Abuse Warning Network, 2003: Area Profiles of Drug-Related Mortallity. DAWN Series D-27. Rockville MD: Office of Applied Studies, Substance Abuse Mental Health Administration, 2005. (0 refs.)

This volume introduces the new DAWN system, which profiles drug-repated deaths reported by participating medical exaiminers and coroners for 2003. A total of 122 jurisdictions in 35 metropolitan areas and 6 states submit data to the DAWN netork. The key features of the report are described. These changes do not allow comparisons to earlier DAWN reports. Deaths associated with substance abuse, both intentional and accidental are included, and drugs with therapeutic uses as well as illict drugs. The profile for each reporting area is provided in seven different tables/graphs. The informaion provided includes: map with the jurisdictions within the metropolitan area indiated, the totoal of drug-related deaths, total area population; mix of cases (e.g. accidental, homicide, suicide); place of death; five most common drugs reported to DAWN.

Office of Applied Studies, Substance Abuse and Mental Health Administration. The New DAWN Report: Emergency Department Visits Involving Dextromethorphan. Issue 32. Rockville MD: Substance Abuse and Mental Health Services Administration, 2006. (6 refs.)

This issue is part of an occasional series based on information gathered as part of the Drug Abuse Warning Network (DAWN) that monitors drug related morbidity and morality, by monitoring emergency department visits in selected metropolitan areas. This issue focuses upon the emergency department visits that involve dextromethorphan (DXM), an ingredient commonly found in over-the-counter cough and cold remedies. When taken in large amounts dextromethorphancan induce a "high" similar to those produced by hallucinogens, and have side effects including blurred vision, loss of coordination, rapid heart beat. These side effects can be amplified by the other ingredients found in cold products, such as antihistamines, or acetaminophen, or psuedoepedrine. Recently DXM has been sold over the Internet in bulk form, leading to increased concern about nonmedical use. Data from the DAWN system shows that in 2004 there were an estimated 12,584 emergency medicine visits involving DSM; this represented 0.7% of all drug-related ED visits. Those age 12 to 20 had the highest rate of DXM visits, at 7.1 for each 100,00 persons in the population. This rate was two and a half times higher than the rate for other age groups. Those age 12 to 20 accounted for virtually half (48%) of all ED visits for non-medical use of DXM. The reasons for DXM-related visits were attributable to non-medial use (48%), adverse reactions associated with medical use accounted for about 30% of all DXM-related emergency department visits. Suicides attempts accounted for 14% of visits. Visits related to accidental ingestion were very rare and were almost exclusively among children under age 12.

Office of Applied Studies, Substance Abuse and Mental Health Services Administration. The DAWN Report. Emergency Department Visits Involving Dextromethorphan. Issue 32. Rockville MD: Substance Abuse and Mental Health Services Administration, 2006. (6 refs.)

Dextromethorphan is a cough suppressant approved by the Food and Drug Administration found in many over-the-counter (OTC) remedies. Taken in large amounts it can produce hallucinations and a "high" similar to psychotropic drugs. Side efffects can include blurred vision, loss of coordination, abdominal pain and rapid heartbeat. In recent years it has become available over the internet in bulk powdered form and concern has grown over the nonmedical use by teannagers. This issue focuses upon data from the 2004 Drug Abuse Warning Network (DAWN) survey of emergency-department visits involving dextromethorphan. In that year, an estimated 12,584 visits involving dextromethorphan. The rate of ED visits resulting from nonmedical use for that ages 12-20 was 7.1 visits per 100,000, compared to 2.6 visits or fewer per 100,000 for other age groups. Those age 12-20 accounted for nearly half of all ED visits for the drug. The rate of ED visits resulting from any type of DXM in that age group was 10.3 per 100,000 compared with 4.3 visits for the overall population. Alcohol was implicated in about a third (36%) of ED visits involving nonmedical use of DXM for those aged 18-20 and in 13 percent of visits for those aged 12-17.

Office of Applied Studies, Substance Abuse and Mental Health Services Administration. The NSDUH Report: Misuse of over-the-counter cough and cold medication among persons aged 12-25. (January 10, 2008). Rockville MD: Substance Abuse and Mental Health Services Administration, 2008. (8 refs.)

The cough suppressant dextromethorphan (DXM) is found in more than 140 over-the-counter (OTC) cough and cold medications. Dextromethorphan is generally safe when taken in recommended doses but in large amounts can cause dangerous side effects and has led to increased poison control calls involving dextromethorphan. Based on SAMHSA's National Survey on Drug Use and Health, in 2006 about 3.1 million persons aged 12 to 25 (5.3%) reported having ever used an over-the-counter cough or cold medication to get high, i.e., used it nonmedically. Nearly 1 million persons aged 12 to 25 (1.7%) had done so in the past year. Those ages 18 to 25 were more likely than youth aged 12 to 17 to have used OTC cough and cold medications nonmedically in their lifetime (6.5% vs. 3.7%) but less likely to do so in the past year (1.6% vs. 1.9%). Among those 12 to 25 years old, non-medical use of cough and cold medications use is more common among Whites (2.1%) than Hispanics (1.4%) and blacks (0.6%). There are differences in use based on gender. Among those aged 12 to 17, females nonmedical use of these products is more common among females. However, for those ages18 to 25, males were more likely to have misused these preparations. 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(r) product, 18.1 percent misused a Coricidin(r) product, and 17.8 percent misused a Robitussin(r) product.

Public Domain

Peters RJ; Kelder SH; Markham CM; Yacoubian GS; Peters LA; Ellis A. Beliefs and social norms about codeine and promethazine hydrochloride cough syrup (CPHCS) onset and perceived addiction among urban Houstonian adolescents: An addiction trend in the City of Lean. Journal of Drug Education 33(4): 415-425, 2003. (15 refs.)

In the current study, we used a qualitative approach to investigate relevant beliefs and norms associated with codeine and promethazine hydrochloride cough syrup (CPHCS) consumption, initiation, and perceived addiction among 48 alternative school students who identified themselves as current CPHCS users. In general, both boys and girls believed that CPHCS addiction started during an individual's initial consumption. A majority of both groups reported that their second CPHCS event was initiated during the same or next day after their first event. Our findings suggest that friends and an innovative form of hip-hop music called "screw" are strong reinforcers of CPHCS use.

Pyle KR. FDA v. ephedra: Is it time to lift the ban? Food and Drug Law Journal 61(4): 701-751, 2006. (557 legal refs.)

After more than a decade of deliberation, FDA issued its Final Rule on February 6, 2004, prohibiting the sale of all dietary supplements containing ephedrine alkaloids. The regulation went into effect on April 12, 2004. Ephedra, then, became the first dietary supplement to be banned by FDA under the Dietary Supplement Health and Education Act (DSHEA), a 1994 amendment to the FDCA. The rulemaking process to regulate ephedra began in June of 1997, when FDA published a proposed rule that declared a dietary supplement that contained more than 8 mg of ephedra alkaloids per serving, or a dosage that resulted in 24 mg or more to be consumed in a 24-hour period, according to either labeling or recommended conditions of use, to be adulterated. The rule also proposed that: 1) claims or uses requiring long-term intake be prohibited and that ephedra should not be used for more than seven days; 2) that ephedrine alkaloids not be combined with other stimulants (e.g., caffeine); 3) that warning labels be used to advise consumers of possible drug interactions, particularly those who may be at risk because of certain pre-existing medical conditions; and 4) claims encouraging short-term, higher than usual intakes be accompanied by a warning statement of possible serious side effects. In reaching its Final Rule, FDA had used a "risk/benefits" standard to determine whether ephedra supplements posed an "unreasonable risk of illness or injury under the conditions of use recommended or suggested in labeling, or ... under ordinary conditions of use (in the absence of labeling)" under the Dietary Supplement Health and Education Act (DSHEA). The district court deemed this standard "improper," and also stated that "FDA's requirement that ephedrine-alkaloid dietary supplements (EDS) demonstrate a benefit is contrary to the clear intent of Congress." The note review the peer-reviewed scientific literature, reported adverse events,

Rassool GH. Alcohol and Drug Misuse: A Handbook for Students and Health Professionals. London: Routledge, 2008

During recent years, the misuse of nicotine, alcohol, prescribed medications, over-the-counter drugs and illicit psychoactive substances have increased dramatically, resulting in health and socio-economic problems - to which every health care professional will need to recognize and respond. The book is organized into three parts. Part I provides an overview, including historical attitudes toward addiction and policy approaches. Part II is comprised of separate chapters devoted to specific drugs: alcohol, opiates, cannabis, stimulants (amphetamine, cocaine and khat), hallucinogens steroids, sedatives, inhalants, nicotine, and over-the-counter preparations. Part III includes discussion of special issues and special populations, i.e. blood-borne infection, women, those with comorbid psychiatric illness, racial and ethnic groups and vulnerable populations (the elderly and the homeless) and the young. Part IV focuses upon prevention and strategies for change. Part V examines different types of interventions, from harm reduction to health interventions for overdose and intoxication, to psychosocial and pharmacological therapies, with special attention to nicotine and alcohol. The book concludes with discussion of professional development.

Coyright 2008, Project Cork

Rastegar DA; Fingerhood MI. Addiction Medicine: An Evidence-Based Handbook. Baltimore: Lippincott Williams & Wilkins, 2005. (Chapter refs.)

This handbook, intended for those in clinical medicine, provides practical and evidence-based guidelines for evaluating, treating, and managing patients with substance abuse problems. It is organized into 17 chapters. The initial four chapters provide an overview of basic constructs, responding to addictions in the primary care setting, the medical interview and an overview of treatment. This discussion includes consideration of different models for understanding addiction problems, the natural history of addiction and the recovery process, the basic clinical skills around screening, the use of drug testing, motivational interviewing, and responding to denial, and a introduction to the basic elements of treatment and the settings in which it is provided. The bulk of the book (10 chapters) are directed to the examination of a specific drug, its epidemiology, acute effects, diagnostic considerations, associated medical complications, and drug-specific treatment elements. Individuals chapters are devoted to alcohol, sedative-hypnotics, opioids, tobacco, cocaine and other stimulants, hallucinogens, marijuana, inhalants, and steroids. The final four chapters consider medical care for the addicted patient, including issues such as problems associated with the route of administration, issues around pain management, and "the difficult" patient. Another chapter is devoted to prescription drug abuse -- markers of abuse, strategies to avoid prescription drug abuse, the products most commonly abuse, as well as discussion too of over-the-counter products. The concluding chapters consider special populations -- women, the elderly, adolescents, prisoners -- as well as issues related to co-occurring mental illness.

Saseen JJ. Does acetaminophen affect liver function in alcoholic patients? (editorial). Journal of Family Practice 52(3): 187-188, 2003. (1 refs.)

Schuckit MA. Drug and Alcohol Abuse: A Clinical Guide to Diagnosis and Treatment, 6th edition. New York: Springer, 2006

This sixth edition of a clinical guide addresses major drugs of use/abuse, along with acute and chronic problems associated with use, as well as treatment including both psychological and pharmacological agents. Following an introductory overview, the next nine chapters deal with different drug classes - depressants, alcohol, stimulants, opioids and other analgesics, marijuana, hallucinogens and related drugs, glues, inhalants and aeorsols, other-the-counter and prescription drugs, as well as caffeine and nicotine. The concluding chapters address multiple drug use and dependence, emergency problems, and rehabilitation.

Sheth A; Khurana R; Khurana V. Potential liver damage associated with over-the-counter vitamin supplements. Journal of the American Dietetic Association 108(9): 1536-1537, 2008. (8 refs.)

The growing popularity and availability of over-the-counter (OTC) health products, including vitamins, raises serious concern about vitamin toxicity. We report a case of cirrhosis in a patient with habitual daily ingestion of an OTC dietary supplement that contained 13,000 mu g vitamin A and was associated with marked clinical improvement after discontinuation. This case highlights the potential for liver damage that may be associated with long-term intake of OTC vitamin supplements, and indicates the need for medical supervision of such products.

Shiffman S; Hughes JR; Di Marino ME; Sweeney CT. Patterns of over-the-counter nicotine gum use: Persistent use and concurrent smoking. Addiction 98(12): 1747-1753, 2003. (18 refs.)

Aims: To examine the occurrence of persistent use (i.e. use beyond 12 weeks) and concurrent use of nicotine gum with cigarettes among consumers who purchase nicotine gum over-the-counter (OTC). Design: Assessment of gum use was conducted in the context of a smoking cessation trial among smokers who purchased Nicorette gum and enrolled in the optional Committed Quitters smoking cessation program. Eligible participants were contacted by telephone 6 weeks and 12 weeks following their self-selected target quit date. Those who reported gum use at 12 weeks were contacted again at week 24. Participants: A total of 2655 current smokers who purchased nicotine gum and enrolled in a clinical efficacy trial of the Committed Quitters program. Measurements: Detailed information on smoking and gum use, including frequency of use, amount used and reasons for use was obtained at each of the three follow-up assessments. Findings: At the 24-week assessment, 6% of participants reported current use of nicotine gum (i.e. persistent use). Those engaging in persistent use averaged 4.7 (SD = 2.5) days of gum use per week and 3.2 (SD = 3.5) pieces of gum per day. Sixty-six per cent of persistent users reported at week 24 that they were not currently smoking, and 67% of persistent users reported they were using gum to establish or maintain abstinence. At the 6-, 12- and 24-week assessments, 14%, 10% and 2% of participants, respectively, reported current use of nicotine gum and current cigarette smoking (i.e. concurrent users). Those concurrent users reported at the 12-week follow-up that they did so an average of 4.4 (SD = 2.1) days per week, that they chewed an average of 2.6 (SD = 3.5) pieces of nicotine gum per day and that they smoked an average of 8.7 (SD = 8.6) cigarettes per day. Conclusion: Extended use of nicotine gum is rare. Concurrent use with cigarettes is uncommon. In both cases, the amount of gum use is small. OTC marketing of nicotine gum does not appear to have increased use contrary to labeling nor resulted in patterns of use that should warrant clinical or public health concerns.

Shiffman S; Sweeney CT. Ten years after the Rx-to-OTC switch of nicotine replacement therapy: What have we learned about the benefits and risks of non-prescription availability? Health Policy 86(1): 17-26, 2008. (69 refs.)

Objective: Review the history of the Rx-to-OTC switch of nicotine replacement therapy (NRT) in the US, outlining concerns expressed before the switch, discussing how concerns were addressed, and presenting data on the actual experience in the decade following the switch. Methods: Literature review of studies examining trends in NRT utilization pre- and post-switch, the efficacy and safety of NRT in the OTC setting, and patterns of OTC NRT use. Results: OTC availability of NRT increased access to and utilization of treatment. Studies show that OTC NRT has been used safely and effectively, without substantial misuse or abuse, and with continued physician engagement and wide access to proven behavioral treatment. Conclusions: With other medications that challenge the traditional OTC paradigm being proposed for OTC switch, the NRT case study serves as a useful example in highlighting the potential role that Rx-to-OTC switch can play in addressing public health challenges. The NRT experience suggests that advance identification and analysis of concerns, implementation of plans to manage concerns, including appropriate marketing and post-marketing surveillance, can ensure that OTC switch of medications for behavior change and disease prevention can help minimize risks and maximize public health benefits.

Steinman KJ. High school students' misuse of over-the-counter drugs: A population-based study in an urban county. Journal of Adolescent Health 38(4): 445-447, 2006. (9 refs.)

A survey of high school students (n = 39,345) found 4.7% occasionally misuse over-the-counter drugs (i.e., to get high) and an additional 2.1% reported misuse during the past month. Misuse was more common among older white and Native American youths and was associated with depressive affect and other substance use, especially alcohol and illicit drugs.

Stevens AB; McDaniel KS; Glover ED; Wallace LS. Are instructions for over-the-counter nicotine replacement therapy products readable? American Journal of Health Behavior 31(Supplement 1): S79-S84, 2007. (32 refs.)

Objective: To examine readability characteristics of step-by-step directions presented in "How to Use" sections of over-the-counter (OTC) nicotine replacement therapy (NRT) products. Methods: Step-by-step directions of all (n=6) currently available OTC NRTs were assessed on reading grade level, text point size, dimensions, and illustrations. Results: The mean readability was at grade level 10.5 +/- 0.8, whereas the average text point size was 9.2 +/- 1.3. Two OTC NRT products provided illustrations to supplement step-by-step directions. Conclusion: As currently presented, the readability characteristics of "How to Use" sections of OTC NRTs do not facilitate consumer understanding.

Strang J; Kelleher M; Best D; Mayet S; Manning V. Emergency naloxone for heroin overdose - Should it be available over the counter? (editorial). British Medical Journal 333(7569): 614-615, 2006. (1 refs.)

There are three letters in response to this editorial, 333(7571): 754-755, 2006, which point out that naloxone is not the only available antagonist, as well as pointing out the potential dangers associated with naloxone.

Swann JP. The FDA and the practice of pharmacy: Prescription drug regulation before 1968. IN: Erlen J; Spillane FJ, eds. Federal Drug Control: The Evolution of Policy and Practice. Binghamton NY: Haworth Press, 2004. pp. 145-174. (83 refs.)

This chapter by a historian for the US Food & Drug Administration deals with the efforts to initiative drug regulation of a rangeof phramaceutical products, those beyond psychoactive drugs. It was not until 1951, that the federal government had a clear mandate to decide which productes could be sold over-the-counter and which required a prescription, and how refills of prescriptions would be handled. It was only in 1965 that federal authority was established over other dependence causing drugs, such as barbiturates and amphetamines.

Sweileh WM; Arafat RT; Al-Khyat LS; Al-Masri DM; Jaradat NA. A pilot study to investigate over-the-counter drug abuse and misuse in Palestine. (editorial). Saudi Medical Journal 25(12): 2029-2032, 2004. (5 refs.)

Varlibas F; Delipoyraz I; Yuksel G; Filiz G; Tireli H; Gecim NO et al. Neurotoxicity following chronic intravenous use of Russian Cocktail. Clinical Toxicology 47(2): 157-160, 2009. (19 refs.)

Introduction. Recently, neurological abnormalities in methcathinone users have been attributed to manganese. We report similar toxicity in three patients following the use of a mixture similar to methcathinone: potassium permanganate, ephedrine, and aspirin. Case Reports. Three teenagers (15 to 19 years old) presented with extrapyramidal abnormalities and movement disorders following chronic intravenous use of a mixture known as Russian Cocktail. All three patients had multiple movement disorders. One patient had normal blood manganese concentration (19 g/L) and MRI. The other two had elevated blood manganese (2100 g/L and 3176 g/L) and MRIs showing bilateral symmetric hyper-intensities on T1-weighted-images in the dentate nucleus, subcortical white substance of cerebellar hemisphere, globus pallidus, and putamen. Abstinence and treatment with EDTA, levodopa, and para-aminosalicylic acid was associated with decreasing blood manganese concentrations and subjective improvement, but no change in objective findings. Discussion. The Russian Cocktail likely contains manganese as a result of the oxidation of ephedrine by potassium permanganate in water acidified by acetylsalicylic acid. We believe that manganese with the possible contribution of methcathinone caused the neurological impairments. Conclusions. Three toxic substances have been made into a mixture administered intravenously, similar to methcathinone. Our patients learned of this mixture, called Russian Cocktail, from their friends. The toxicity from repeated use of this mixture is one of extrapyramidal abnormalities and movement disorders. Standard therapies were unsuccessful in reversing the clinical toxicity.

Waldstein A. Mexican migrant ethnopharmacology: Pharmacopoeia, classification of medicines and explanations of efficacy. Journal of Ethnopharmacology 108(2): 299-310, 2006. (81 refs.)

This paper describes the ethnopharmacological knowledge of women in an urban Mexican migrant community in Athens, GA, USA. Data were collected using free-list, pile-sort and semi-structured interviews. The pharmacopoeia of this community includes herbal remedies, over-the-counter medications such as non-steroidal anti-inflammatory drugs (NSAIDs) and prescription medicines. Multi-dimensional scaling analysis of pile-sort data revealed that Mexican women living in Athens classify medicines into four categories: herbal remedies, salves, pastillas (pills-both prescription and non-prescription) and other commercial preparations. Herbal remedies are viewed as natural and safe while pastillas are thought to be dangerous and potentially addictive. Comparisons of Mexican explanations for the actions of five medicines (Matricaria recutita L. [Asteraceae], Mentha spp. L. [Lamiaceae], Ruta spp. L. [Rutaceae], Ocimum basilicum L. [Lamiaceae] and paracetemol) with the pharmacological literature show several similarities and confirm that migrant women use these medicines effectively. Mexican migrant women use medicinal plants in combination with commercially produced medicines, but most have a strong preference for the herbal remedies that they make themselves, over drugs prescribed by physicians. Some of their descriptions of the actions of medicines are supported by the pharmacological literature, but ethnopharmacologists have not fully investigated all of the attributes that migrant women ascribe to them.

Wazaify M; Hughes CA; McElnay JC. The implementation of a harm minimisation model for the identification and treatment of over-the-counter drug misuse and abuse in community pharmacies in Northern Ireland. Patient Education and Counseling 64(1-3): 136-141, 2006. (23 refs.)

Objective: This study tested an intervention model which sought to minimise over-the-counter (OTC) drug misuse and abuse in community pharmacies. Method: Pharmacists in six community pharmacies in the Greater Belfast area volunteered to participate in the study. The intervention model consisted of client identification and recruitment, treatment and referrals, and finally follow-up data collection and outcome measurements. All pharmacists participated in semi-structured interviews to explore their views and experiences of the study. Results: Pharmacists identified 196 cases of suspected abuse/misuse. Pharmacists approached 70 of the identified clients during the six-month study; some clients agreed to stop using the product of abuse/misuse, used an alternative, or had been switched to a maintenance prescription under general practitioner (GP) supervision. No client proceeded to completion of the follow-up phase (e.g. health-related quality of life). Analysis of the interviews revealed that pharmacists had encountered some difficulties in approaching potential clients, but had used skills gained in the study in other aspects of their practice. Conclusions: Some difficulties were encountered in implementing the harm minimisation model, but these may be alleviated by further training and greater collaborative working. Practice implications: Notwithstanding the challenges faced in the study, this approach to harm minimisation should be considered for wider implementation in community pharmacy.

Wazaify M; Kennedy S; Hughes CM; McElnay JC. Prevalence of over-the-counter drug-related overdoses at Accident and Emergency departments in Northern Ireland: A retrospective evaluation. Journal of Clinical Pharmacy and Therapeutics 30(1): 39-44, 2005. (26 refs.)

BACKGROUND AND OBJECTIVES: One major concern associated with misuse/abuse of over-the-counter (OTC) products is the potential for over-dosage. The aim of this research study was to evaluate, over a 3-month period, OTC medicine-related overdoses (those involving OTC drugs only and OTC drugs in combination with other drugs) that led to patients presenting at the Accident and Emergency (A & E) departments in four Belfast hospitals. METHODS: A data collection sheet was designed to capture the information required from the A & E records in each hospital. A retrospective week-by-week data collection, reviewing A & E records, took place over a 3-month period (starting on 1 December 2002). All data related to cases presenting at the A & E departments because of drug overdoses (either accidental or deliberate according to Read Clinical Classification) were included in the study. Data were coded and entered into a custom designed SPSS database for analysis, using Chi square and Fisher exact tests. RESULTS: OTC drug-related overdoses comprised 40.1% of all overdoses, of which 24.0% were OTC-only overdoses. Those who overdosed on OTC drugs (solely or combined with other drugs) were mainly female (62.3%) and in the age category 31-50 years (44.9%; P <0.05). The majority (n=215) of OTC-related overdoses were intentional, whereas only 28 were accidental. Of those who attended the A & E departments and had an overdose history, one-third overdosed on OTC-related products and two-thirds overdosed on OTC drugs only. CONCLUSIONS: OTC drugs accounted for a significant proportion of overdose presentations at the A & E departments in Northern Ireland. Higher awareness of the potential of OTC product use in overdose cases (intentional or accidental) is recommended for both the public and health care professionals.

Wazaify M; Shields E; Hughes CM; McElnay JC. Societal perspectives on over-the-counter (OTC) medicines. Family Practice 22(2): 170-176, 2005. (36 refs.)

BACKGROUND: Over-the-counter (OTC) medicines are increasingly used for self-medication, but such products can be misused/abused. OBJECTIVES: The aim of this study was to investigate the general public's opinion and perceptions of OTC medicines, including the misuse/abuse of such preparations. METHODS: Data were collected using a survey administered to 1000 members of the public in 10 study sites in Northern Ireland, using a structured interview technique. The questionnaire was divided into four sections addressing: (a) attitudes towards community pharmacy and patients' contact with pharmacies; (b) attitudes towards the use of OTC medicines; (c) views on OTC medicines in terms of safety, potency and effectiveness; and (d) knowledge and opinion of abuse/misuse of OTC medicines. Data were coded and entered into a custom designed SPSS database for statistical analysis. RESULTS: The majority of participants (74.6%) visited a community pharmacy at least once per month. Almost one-third (32.2%) of participants reported buying OTC drugs at least once per month and the majority (86.4%) would always or often follow the directions on the product. The general public in Northern Ireland were highly aware of the abuse potential of some OTC drugs, with the majority naming painkillers as the products most liable for abuse. Almost one third of the participants reported having personally encountered cases of OTC abuse. CONCLUSIONS: This survey revealed that the general public had a high level of awareness of the abuse potential of OTC medicines. These findings indicate that pharmacists could be more proactive in the management of inappropriate OTC drug use.

Welsh C. A case of rectal abuse of Preparation H. American Journal on Addictions 16(6): 528-529, 2007. (7 refs.)

The article presents a case of a 41-year-old Caucasian male who was transferred to the University of Maryland Medical Center in Baltimore, Maryland for cardiac catheterization after a myocardial infarction. The man had a medical history significant for hypertension, migraine headaches and a perirectal abscess. He had used cocaine many times intranasally about 15 years earlier and denied any use of methamphetamine. The total contribution of his phenylephrine use to the representing symptoms and myocardial infarction cannot be proven. However, the phenylephrine use daily had some effect on his blood pressure and may have been a primary reason for the difficulty in managing it.

Ziaee V; Hamed EA; Hoshmand A; Amini H; Kebriaeizadeh A; Saman K. Side effects of dextromethorphan abuse, a case series. Addictive Behaviors 30(8): 1607-1613, 2005. (20 refs.)

The aim of this study was to investigate the Dextromethorphan (DXM) abuse side effects. Subjects were 53 volunteers who had consumed DXM with mean age 23.4 years. The mean of side effects during first day was 12.49 and during first week was 5.57. The causes of repeated DXM abuse were psychological dependency 46.5%, recreational abuse in 32.6%. Neurological and psychological symptoms were the most common of side effects in DXM abusers.