Editorial Board:
Editor:
George H. Conklin,
 North Carolina
 Central University

Board:
Rebecca Adams,
 UNC-Greensboro

Bob Davis,
 North Carolina
 Agricultural and
 Technical State
 University

Catherine Harris,
 Wake Forest
 University

Ella Keller,
 Fayetteville
 State University

Ken Land,
 Duke University

Miles Simpson,
 North Carolina
 Central University

Ron Wimberley,
 N.C. State University

Robert Wortham,
 North Carolina
 Central University

Editorial Assistants

John W.M. Russell,
 Technical
 Consultant

Austin W. Ashe,
 Duke University

® 

Volume 8, Number 2

Fall/Winter 2010
 
 

Examination of
Over-the-Counter
Drug Misuse Among Youth*

by

Erin J. Farley
University of North Carolina Wilmington

and

Daniel J. O'Connell
University of Delaware

Introduction

    Potential harm from the intentional misuse of over-the-counter (OTC) medicines among youth has become an area of increased concern among medical practitioners and researchers (Bryner et al. 2006; Lessenger et al. 2008; Substance Abuse and Mental Health Services Administration (SAMHSA) 2006). Although the likelihood of death from overdose is rare, research has revealed an increase in dextromethorphan (a key ingredient in numerous cough and cold medicines) abuse cases reported to poison control centers (Bryner et al. 2006).  Equally important is the suspicion that OTC use may be a stepping stone to other forms of drug misuse and abuse. 

    While OTC misuse has garnered increased media coverage, it has not yet attracted an equivalent interest among researchers. Further, it is possible that research to date has inappropriately specified the relationship between OTC and other drug misuse.  Extant research has examined the relationship between OTC misuse and illicit drug use by utilizing a single construct, limiting the ability to completely flesh out the dimensions of this relationship between drug use. One area that needs further attention is if and how OTC misuse among youth is associated with other types of drug use.  By combining all categories of drugs under a single construct, the nuances of how particular drugs relate to OTC use is diminished. This paper examines the current state of knowledge on OTC misuse by examining the prevalence of OTC misuse and its relationship with other types of drug use among a specific cohort to expand the current understanding of the problem. 

    OTC cough and cold medicines (e.g., Coricidin and Nyquil) can be easily purchased from pharmacies and drug stores. Adolescents typically ingest OTC medicines for the ingredient dextromethorphan (DXM). DXM is a synthetic drug related to opiates, which has the ability to produce effects similar to psychotropic drugs (Bobo et al. 2004; SAMHSA 2006). These effects include sensory enhancement, perceptual distortion, and hallucinations. DXM can be found in as many as 140 different cold and cough medications (Bobo et al. 2004; SAMHSA 2008).  Misuse of these types of OTC drugs often involve youth seeking inexpensive and easily accessible substitute for other drugs that are more difficult to obtain. 

    Misuse of OTC drugs, especially in combination with other types of drugs, can lead to a variety of serious health problems., including confusion, blurred vision, slurred speech, loss of coordination, paranoia, high blood pressure, loss of consciousness, irregular heartbeat, seizure, panic attacks, brain damage, coma, and possibly death (Bobo et al. 2004; Food and Drug Administration 2005). Yet, there is a growing concern that youth who intentionally misuse OTC drugs misperceive that they are safe because these types of drugs are legal and prevalent (Johnston et al. 2006). If this misperception is contributing to the misuse of OTC drugs, the consequences can be serious. On the other hand, this same misperception also points towards potentially efficacious prevention programs focused on educating youth to the harm posed by these drugs. 

    The abuse or misuse of OTC drugs appears to be mostly a problem among younger persons. A Drug Abuse Warning Network (DAWN) report revealed that 12,584 emergency department visits were associated with DXM use in 2004 (SAMHSA 2006). Among these, 44% (5,581) were associated with the non-medical use of DXM products among patients aged 12 to 20. Findings from this report highlight that negative consequences associated with OTC misuse are more likely to occur among youth and young adults.  For example, the rate of visits to the emergency department resulting from non-medical use of DXM was 7.1 per 100,000 youths ages 12 to 20. For older age groups the rate was 2.6 visits or fewer per 100,000 (Bobo and Fulton 2004). In addition, a recent National Survey on Drug Use and Health (NSDUH) report highlighted OTC misuse as a significant problem among youth and young adults (SAMHSA 2008). According to this report, respondents age 12 to 17 years were more likely than those age 18 to 25 years to report past year misuse of OTCs (SAMHSA 2008). 

    One signal that OTC misuse is becoming of greater concern among researchers is the addition of an OTC measure ("to get high") by both the Monitoring the Future and the National Drug Use and Health in 2006 into their annual surveys.  The 2007 Monitoring the Future (MTF) survey revealed that 4% of eighth graders, 5% of tenth graders and 6% of twelfth graders report past year use of OTCs to get high (Johnston et al., 2008). For eighth graders in particular, self-report misuse of OTCs was lower than past year marijuana (10%), inhalant (8%), and alcohol (32%) use. However, OTC misuse was higher than past year hallucinogen (2%), ecstasy (2%), Oxycotin (2%), Vicodin (3%), Ritalin (2%), and tranquilizer (2%) use. 

    Extant research reveals significant gender differences in OTC misuse. A 2008 NSDUH report found an interaction of age and gender on self-report OTC misuse. While females age 12 to17 years were more likely than males in the same age group to report past year OTC misuse, males age 18 to 25 years were more likely to report past year OTC misuse in comparison to females in the same age group (SAMSHA 2008).  Other research has found significant gender differences in OTC misuse.  For instance, both Steinman's (2006) analysis of 39,345 high school students from Ohio and Ford's (2009) examination of the 2006 National Survey on Drug Use and Health data (ages 12 to 17) revealed significant gender differences with females more likely to report OTC misuse than males (Ford 2009; Steinman 2006).

    Research on racial and ethnic differences in OTC misuse is less clear.  While Steinman's (2006) findings revealed Native Americans were more likely to report misuse, followed by white, "other/mixed," Hispanic, Asian, and African-American, the national survey conducted by SAMHSA (2008) revealed whites were more likely to report OTC misuse, followed by Hispanic and African-American. Misuse by Native Americans may be an additional area of concern, but the extant data indicate that whites and females are particularly at risk. 

    While the existing literature of OTC misuse is scant, there are key observations to be noted from research on the nonmedical use of prescription drugs (NMUPDs). Prior research on the NMUPDs has repeatedly highlighted the strong relationship between illicit prescription drug use and cigarette, alcohol, marijuana, and other drug use (Boyd et al. 2006; McCabe et al. 2004; McCabe et al. 2005; Simoni-Wastila et al. 2004). These findings suggest that nonmedical users of prescription drugs may not be a qualitatively different category of drug users, but are in fact part of well-established group of poly-drug users. It is unclear from available research whether the relationship between OTC and street drugs is the same as prescribed drugs.

    Current research suggests there is reason to be concerned about the phenomena of youth mixing cough and cold medicines with other types of drugs. A 2006 DAWN report revealed that among those emergency department visits that involved DXM, 13% of 12 to 17 year old visits and 36% of 18 to 20 year old visits involved combinations of DXM and alcohol. In addition, Steinman's (2006) research on OTC misuse in Ohio high schools revealed OTC misuse was associated with alcohol, cigarette, marijuana, and other illicit drug use (e.g., cocaine, LSD, and ecstasy). Research by Ford (2009) also found a significant relationship between OTC misuse and binge drinking, marijuana use, prescription drug use, and other illicit drug use. Steinman (2006) emphasized the strong association between OTC misuse with alcohol and other illicit drugs suggesting that OTC misuse is not a "gateway" drug, but only one of a number of substance utilized by adolescents.

    The gateway drug concept suggests that there are lower tiered drugs that open the way towards other drugs, and that drug use itself is responsible for opening the gate (Kandel 1975; Kandel et al. 1975; Kandel et al. 2002).  Other studies have attempted to refute this concept, suggesting that more serious drug users may in fact use harder drugs prior to drugs like marijuana (Mackesy-Amiti et al. 1997). Early teen drug use may largely be dictated by what drugs are available to adolescents, as well as a desire to alter one's consciousness.  Access to most drugs, however, is not evenly distributed. Marijuana use by older youth may provide access to a small group of marijuana users, while another group might have access to prescription drugs, and another, access to drugs like cocaine. Unlike these other substances, almost all youth have access to OTC drugs. 

    While it has been shown empirically that "drug users use drugs," that is, using any substance increases the probability of using any other substance, this pattern may not be exclusively based on availability. In our modern consumer culture, adolescents are faced with multiple choices, and increasingly, the type of drug is one of them. Recognizing that the choice of drug is related to both availability and preference, it is important to understand the pattern of correlation between different drugs. Just as there are more choices in terms of which drugs, there are also more choices regarding where to obtain drugs. Those involved in traditional street drugs like marijuana and ecstasy are getting drugs from those who sell them, necessitating some link to a criminal element. Those using OTC drugs and prescription drugs can sidestep this path, which has important considerations for prevention policy. 

    This study intends to tease out the relationship between OTC misuse and the use of different types of drugs. Previous analyses have tended to lump "other illegal drugs" together in one category. If early teen usage is related to drug choice and availability, combining drugs may mask relationships that exist among individual drugs. The current study utilized a large enough sample to examine drugs both individually and in groups, and attempted to investigate which drugs are associated with OTC use.

    The objective of the current study is twofold: First, the prevalence of OTC misuse among a sample of eighth grade public school students is examined, including gender and race differences in OTC misuse; Second, the relationship between OTC misuse and other substance use is examined to identify patterns of use, with a specific focus on whether estimating the effects of other illegal drugs individually provides more insight than using a single construct. 

    Data for the current study are from the 2005 Delaware School Survey.  Data was collected by The Center for Drug and Alcohol Studies (CDAS) at the University of Delaware. CDAS has conducted an annual survey of eighth grade public school students since 1995 (the annual survey also measures fifth and eleventh graders). In order to ensure confidentiality and foster honesty, survey administrators are University personnel and not teachers. Passive parental and active student consent is solicited before administrating the survey. The purpose of the survey is to track prevalence rates of drug use among Delaware public school students. 

    A single question, "how often do you use OTC drugs (cough & cold meds, Nyquil) to get high?" measured eighth grade self-reports of OTC misuse. Response options included "never," "before, but not in past year," "a few times in past year," "once or twice a month," "once or twice a week," and "almost everyday." This measure was recoded into a dichotomous variable (0 = not in past year, 1 = in past year).

    Other substance questions included past year cigarette, alcohol, and marijuana use. Binge drinking was also measured and defined as three drinks at a time in the last two weeks. Other drug use (with the intent of getting high) questions included: uppers (speed, meth, crank, diet pills), sedatives (tranquilizers, barbiturates, Xanax), heroin, inhalants, ecstasy, hallucinogens, pain relievers, stimulants (Ritalin, Adderall, Cylert etc.), albuterol, and crack/cocaine. All drug measures were recoded into dichotomous variables (0 = not in past year, 1 = in past year).

    First, univariate and bivariate analyses were utilized to examine the prevalence of OTC use and the relationship with other substances; second a series of logistic regressions were used to demonstrate the difference between using a single construct "other illicit drug use" differs from utilizing each drug measure individually. 

    A total of 7,815 eighth graders completed the 2005 survey (50% female and 50% male).  The racial and ethnic distribution of students sampled consisted of 53% (3,975) white, 28% (2,065) black, 8% (632) Puerto Rican or Mexican, 2.6% (198) Asian, 1.9% (142) American Indian/Native Alaskan, and 6.8% (509) "Other." With Steinman's (2006) findings that Native Americans reported the highest levels of OTC misuse, we conducted a crosstabulation as an initial examination into racial variation.  While American Indians/Native Alaskans represented only 2.5% of the students reporting OTC misuse in the past year, this represented 13% of American Indians/Native Alaskans students, this being the highest rate of use in comparison to the other racial categories. This finding lends support to Steinman's (2006) findings. Due to small cell counts the race categories for Puerto Rican, Mexican, Asian, American Indian/Native Alaskan and "other" were collapsed into one encompassing "other" category. Subsequent crosstabulation analysis revealed no significant variation between White, Black and "other" students. As a result, the race variable was collapsed into white and non-white (0 = white, 1 = non-white) for use in the multivariate models. 

    The past year OTC misuse prevalence in eighth grade Delaware sample was 10% (n=704).  Table 1 displays the breakdown of student self-reports:  86% of eighth graders reported never misusing OTCs, 9% report past year use, and 4% report misusing OTC in the past month.

    Table 2 demonstrates a significant difference between male and female past year misuse of OTC drugs but no significant difference between white and non-white students. 

    Crosstabulations of OTC and other drugs are presented in Table 3. The percent of people using OTC drugs is given for those who used and did not use each substance in the past year. For example, the first substance column alcohol is interpreted as 5.6% of those who did not use alcohol in the past year used OTC drugs, while 15.1% of those who did use alcohol used OTC drugs.  The distribution is not uniform across drug types. There is a clear distribution of the type of adolescents most likely to be misusing OTC drugs.  There appear to be four steps in the distribution in Table 3. First, youth who do not report using a given substance remain below 10% across all substances. Second, those youth who used alcohol and marijuana used OTC drugs at the lowest rate among users, hovering between 15% and 22% (Binge drinkers). Third, those using the more traditional street drugs such as ecstasy, hallucinogens, inhalants, heroin and cocaine formed a middle tier, reporting OTC use on the 25% to 30% range. Fourth and final, there is a group of persons using prescription drugs who are more likely to use OTC drugs as well. Those youths who used sedatives, amphetamines, pain relievers and stimulants were substantially more likely to use OTC drugs, with all categories reporting over 40% OTC users and 56% of those who use pain relievers using OTC drugs as well. In order to further investigate how these relationships function, we next employed regression techniques to control for the effect of other drugs. 

    The multivariate analyses begin in Table 4, with findings from the initial logistic regression (Model 1). This model tested the traditional means of measuring the effects of other illicit drugs by utilizing a single construct. Of the 7 variables, three did not reach significance (nonwhite, past year binge drinking and past year marijuana use). The odds of females misusing OTC drugs are 1.6 times greater (OR = 1.603, p = .000) than their male counterparts, holding all other variables constant.  The odds of past year cigarette users misusing OTC drugs is 1.4 times greater (OR = 1.385, p =.011) than non-users. The odds of past year alcohol users misusing OTC drugs is 1.8 times greater (OR = 1.779, p =.000) than non-users.  Using the single construct other illicit drugs category produced the largest effect, returning an odds ratio of 7.7 (OR = 7.685, p = .000), indicating that youth who reported using any of the other drugs reported in table three increased the odds of using OTC drugs in the past year by 7.7 times. 

    The suggestion is that combining all other drugs into one construct misses variation among individual drugs. In order to tease out this concept, a logistic regression analysis examining the effect of other illicit drugs measured individually is presented as Model 2 in Tables 4A (Model 1)and 4B (Model 2). When compared to Model 1, there are no major differences in the effects of the lower tiered drugs on OTC misuse, when other variables were accounted for. The exceptions to this are the smokeable substances, cigarettes and marijuana, both of which lose significance in Model 2. 

    The odds of females misusing OTC drugs remained approximately 1.5 times greater (OR = 1.497, p = .000) than their male counterparts, holding all other variables constant.   Modest effects were again found for cigarettes smokers (OR = 1.333, p < .05) and alcohol users (OR = 1.766, p = .000). The largest effects, however, were among users of pain relievers. The odds of students who reported past year use of illicit pain relievers reporting OTC drug misuse were over 9 times more likely than those who did not report pain reliever use (OR = 9.920, p = .000). Similarly, albuterol (or other asthma medicine) misusers were 4 times more likely to report OTC misuse in comparison to non-users (OR = 4.071, p = .000). In addition, inhalant misusers were approximately twice as likely to report OTC misuse (OR = 2.302, p = .000). Similar effects were found for cocaine use (OR = 2.560, p < .01), and Ritalin use to get high (OR = 1.964, p<.01). Finally, heroin use significantly declined among those students who reported past year OTC drug misuse (OR = .321, p < .05). 

    This study questioned whether combining all drugs into one construct is an appropriate measure in the current drug environment in which youth have more choices in terms of type of drug and routes of acquiring the drugs. While the current study replicates the findings of prior research indicating that OTC use is correlated with other drug use, the study demonstrated that this relationship is by no means uniform, and that combining drugs other than marijuana and alcohol into a single "other drug" construct misses the nuanced variation between drugs. 

   The objective of this study was to examine the relationship between past year OTC misuse and other drug types including other illicit drugs and the NMUPDs. Bivariate analyses revealed that nonmedical users of prescription drugs were more likely to use OTC drugs, and users of drugs like alcohol and marijuana were least likely to misuse OTC drugs. Our full model (Tables 4A and 4B) revealed that modeling drugs individually and allowing them to essentially "fight it out" in a regression analysis showed that past year nonmedical use of pain relievers and albuterol were by far the strongest predictors of OTC misuse. 

    Unlike Steinman's (2006) findings which led him to explore answers to the question of why is OTC misuse associated with more serious drug use, our findings lead us to ask the question, why is OTC misuse significantly associated with the NMUPDs?  The significant association between OTC misuse and the NMUPDs (i.e., pain relievers, albuterol, and Ritalin) may be due to the similar accessibility or mode of acquisition for the two types of drugs. For example, both OTC drugs and prescription drugs may be easily accessible from friends at school, at home in the medicine cabinet, or, in the case of OTC drugs, from their local drug store.  Acquiring OTC or prescription drugs does not require contact with a traditional drug dealer which some students do not have access to and others might find discomforting. 

    The widespread and growing prevalence of OTC misuse is partially facilitated by its easy accessibility and the perception that OTC drugs are not as harmful as more traditional drugs.  The relationship between these OTC and NMUPD may be due to the misperception that OTC and prescription drugs are safer than other types of drugs. 

    One relationship which appears counterintuitive to the finding that OTC use is more prominently associated with the NMUPD is the significant relationship between OTC misuse and crack/cocaine use. Not only did crack/cocaine use have a larger effect on OTC misuse than cigarette use, alcohol use, inhalant use, and illicit Ritalin use, crack/cocaine use is also a notable step into more serious types of drug use.  One possible explanation is that crack/cocaine users often use some type of depressant to "take the edge off." It may thus be that some youth who are using crack/cocaine are also using OTC drugs to ease the "crash" from crack/cocaine.  Further research is needed to explore the dimensions of this relationship. 

    What appears to emerge from this study is that misusers of OTC drugs are more likely to be using pills (sedatives, stimulants, pain relievers) and asthma drugs to get high than they are the traditional marijuana, cocaine, and hallucinogens of earlier eras (See Table 2). MTF data have already shown the new drug users are more likely to initiate use through prescription drugs rather than marijuana (Mackesy-Amiti et al. 1997). That finding, coupled with those above lead us to question whether there may be a shift in adolescent drug use on the horizon or even occurring currently. 

    A general awareness about the misuse potential of OTC drugs among adolescents already exists. This awareness can be seen in the recent movement to place OTC drugs behind cashier counters and also limiting the number of OTC drugs an individual can buy at one time. The findings from this analysis help to further our understanding of OTC misuse among youth.

    Research limitations need to be acknowledged.  The data utilized for the current analysis was cross-sectional data and limits our ability to examine directionality of drug misuse. The sample was drawn from a single state, thus limiting its generalizability. In addition, no survey data is available for students who were absent the day the survey was administered.  Further, the OTC measure utilized represented one general question about OTC drug misuse instead of a list of OTC drugs by type.  This general OTC measure limits our ability to interpret differences in misuse by type of OTC drug.

    Based on the findings from this study, the authors emphasize continued education for adolescents on the dangers of misusing OTC drugs. Combating misuse should involve educating parents about the dangers of the drugs in their house and the potential for misuse, especially among youth who may not already be known for misusing or abusing drugs. OTC drug use occurs among inexperienced drug users and traditional signs of drug use among youth may not be successful in identifying youth who are abusing OTC drugs. 

Bobo, William V. and Robert B. Fulton. 2004. "Commentary on: Severe Manifestations of Coricidin Intoxication." American Journal of Emergency Medicine 22: 624-625.

Boyd Carol J., Sean E. McCabe, and Christian J. Teter. 2006. "Medical and Nonmedical Use of Prescription Pain Medication byYouth in a Detroit-Area Public School District." Drug and Alcohol Dependence 81: 37-45.

Bryner, Jodi K., Uerica K. Wang, Jenny W. Hui, Merlin Bedodo, Conan MacDougall, and Ilene B. Anderson.  2006. "Dextromethorphan Abuse in Adolescence: An Increasing Trend: 1999-2004." Archives of Pediatrics & Adolescent Medicine 160:1217-1222.

Food and Drug Administration. 2005. "FDA
Warns Against Abuse of Dextromethorphan (DXM). (Talk Paper T05-23). Rockville, MD: National Press Office. (Also available at http://www.fda/gov/bbs/topics/answers/
2005/ans01360.html.)

Ford, Jason A. 2009. "Misuse of Over-the-Counter Cough or Cold Medications Among Adolescents: Prevalence and Correlates in a National Sample." Journal of Adolescent Health 44: 505-507.

Johnston Lloyd D., Patrick M. O'Malley, Jerald G. Bachman, and John E. Schulenberg. 2006. National press release, Teen drug use continues down in 2006, particularly among older teens; but use of prescription-type drugs remains high. University of Michigan News Service, Ann Arbor.

Johnston Lloyd D., Patrick M. O'Malley, Jerald G. Bachman, and John E. Schulenberg. 2008. "Monitoring the Future National Results on Adolescent Drug Use, Overview of Key Findings, 2007."  (NIH Publication No. 08-6418). Bethesda, MD: National Institution on Drug Use. 

Kandel Denise and Richard Faust. 1975. "Sequence and Stages in Patterns of Adolescent Drug Use." Archives of General Psychiatry 32: 923–932.

Kandel Denise. 1975. "Stages in Adolescent Involvement in Drug Use." Science 190: 912–914.

Kandel D. and K. Yamaguchi. 2002.  "Stages of Drug Involvement in the US Population." Pp. 65-89 in Stages and Pathways of Drug Involvement: Examining the Gateway Hypothesis, edited by Denise B. Kandel. New York, Cambridge University Press.

Lessenger, James E. and Steven D. Feinberg. 2008. "Abuse of Prescription and Over-the-Counter Medications." Journal of the American Board of Family Medicine 21: 45-54.

Mackesy-Amiti, Mary Ellen, Michael Fendrich, and Paul J. Goldstein. 1997. "Sequence of Drug Use Among Serious Drug Users: Typical vs Atypical Progression." Drug and Alcohol Dependence 45: 185-96.

McCabe, Sean E., Carol J. Boyd, and Christian J. Teter. 2005. "Illicit Use of Opioid Analgesics by High School Seniors." Journal of Substance Abuse Treatment 28: 225-230.

McCabe, Sean E., Christian J. Teter, and Carol J. Boyd. 2004. "The Use, Misuse, and Diversion of Prescription Stimulants Among Middle and High School Students." Substance Use and Misuse 39: 1095-1116.

Steinman, Kenneth J. 2006. "High School Students' Misuse of Over-The-Counter Drugs: A Population-Based Survey in an Urban Area." Journal of Adolescent Health 38: 445-447.

Substance Abuse and Mental Health Services Administration (SAMHSA). 2006. The New Dawn Report: Emergency Department visits Involving Dextromethorphan. Office of Applied Studies. Rockville, MD.

Substance Abuse and Mental Health Services Administration (SAMHSA). 2008. "The NSDUH Report: Misuse of Over-the-Counter Cough and Cold Medications among Persons Aged 12 to 25." Office of Applied Studies. Rockville, MD.

 Simoni-Wastila, Linda, Grant Ritter, and Gail Strickler. 2004. "Gender and Other Factors Associated with Nonmedical use of Abusable Prescription Drugs." Substance Use and Misuse 39: 1-23.

*Original study supported by Delaware Health and Human Services, Division of Substance Abuse and Mental Health, through the Substance Abuse Prevention and Treatment Block Grant from the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services. Support for this study also received from The Delaware Legislature through the Delaware Health Fund. 

 Return to Sociation Today Fall/Winter 2010