These OTC medications pose a health risk

We hear a lot about drug abuse involving substances like heroin, fentanyl, and oxycodone, as well as methamphetamine. But what about other commonly abused drugs that rarely make headlines?

The Controlled Substances Act (CSA) places all agents regulated by the US government into five schedules. Categorization is based on the agent’s medical use, the potential for misuse, and safety or dependence risk. Schedule I drugs like heroin and LSD, for instance, have no place in the US pharmacopeia and are flat-out verboten. On the other end of the spectrum, Schedule V drugs have a low risk of misuse and have accepted medical indications. Other regulated drugs fall somewhere in between.

Three drugs that are not subject to the CSA, but are nevertheless considered “Drugs of Concern” by the DEA, include DXM (or, dextromethorphan), kratom, and Salvia divinorum. Although these drugs are unpoliced, they present health risks to those who misuse them. 

DXM

Dextromethorphan, or DXM, is found in more than 120 over-the-counter cold (OTC) medications, either alone or in combination with other drugs (eg, acetaminophen, antihistamines, decongestants, expectorants). Typically, adults take 15 mg or 30 mg three or four times a day, with cough suppression lasting for 5 to 6 hours after intake. When taken in therapeutic doses, DXM is safe, however, it can be abused, resulting in about 6,000 emergency department (ED) visits per year.

The “high” associated with DXM misuse involves altered time perception, heightened awareness, and visual hallucination. DXM poisoning leads to loss of coordination, agitation, dizziness, slurred speech, and hallucinations.

Publishing in Clinical Toxicology, researchers mined data from the American Association of Poison Control Centers (AAPCC) regarding DXM misuse in multiple age groups. They found that the incidence of single-substance DXM intentional misuse tripled between 2000 and 2006, but leveled off between 2006 and 2015. Those between 14 and 17 years of age were most likely to misuse the drug.

“DXM intentional abuse exposure call rates have declined among adolescents 14-17 years, since their peak in 2006,” they concluded. “The observed decline in DXM abuse call rates corresponds to a period of growing public health efforts to curtail the abuse of over-the-counter (OTC) DXM-containing products, particularly among adolescents. Further evaluation of state-level sales and abuse trends among adolescents would be valuable to better understand how restricted availability of OTC DXM cough and cold products and other efforts may affect abuse rates.”

DXM is just one of many OTC drugs that can carry health risks. Here are other commonly used OTC medications that can have dangerous effects.

Kratom

Although usually used in the Asia Pacific, kratom has become increasingly popular in the United States. Intriguingly, this drug has paradoxical effects depending on concentration; at low doses, it has stimulant effects, and at higher doses, sedative or euphoric effects occur. Derived from the leaves of the Kratom tree, it can be swallowed, smoked, brewed, or chewed.

Common uses for kratom include treatment of pain, to help prevent withdrawal from opiates (such as prescription narcotics or heroin), and for mild stimulation. Adverse effects include sweating, itching, anorexia, dry mouth, constipation, and increased urination. However, those who are dependent on the drug can experience confusion, delusions, and hallucinations. Chronic use can lead to anorexia, weight loss, and insomnia.

In a review published in Epilepsy & Behavior, the authors wrote that based on emerging reports, kratom is potentially harmful when used recreationally. 

“Seizures and neurological consequences have been reported from kratom abuse. Complex pharmacokinetics place patients at further risk of side effects and drug interactions. Still, individuals can legally purchase kratom at stores and through online distributors in capsule form or as teas, powders, and extracts under the veil of a harmless herbal remedy,” they wrote. “Without United States Food and Drug Administration oversight, kratom has a high potential for abuse and without regulatory control, threatens public safety.” 

Salvia divinorum

This psychoactive member of the mint family is native to the Sierra Mazateca region of Oaxaca, Mexico, and is abused for its hallucinogenic effects. It’s one of several plants used by Mazatec indigenous people for ritual divination. It can be chewed as fresh leaves, smoked, vaped, or ingested in extracted juice form. 

According to the DEA, adverse effects may include confusion, lethargy, tiredness, dizziness, and tachycardia. Still, little research points to major health detriment, according to the authors of a review published in Pharmaceuticals. 

“There is a lack of scientific evidence on the toxicity of S. divinorum,” they wrote. “There are no reports on acute or chronic toxicity induced by S. divinorum consumption, the occurrence of symptoms requiring treatment in an emergency department, or deaths from overdose. On one hand, this can be due to its relative safety, but, on the other hand, clinicians may have been failing to recognise S. divinorum consumption by patients arriving at medical care units.”

Bottom line

Although these drugs are unregulated by the federal government, it’s probably a good idea for clinicians to keep them on their radar. When misuse of these drugs is suspected during the medical history, patterns of misuse and dependence should be probed. Nevertheless, more research on these drugs needs to be done to fully understand their pathophysiologic effects.

Meanwhile, for those who want to learn more about commonly abused drugs in the United States, check out the latest edition of the US Drug Enforcement Agency (DEA) publication, Drugs of Abuse, A DEA Resource Guide, 2020 Edition.