Cough syrup psychosis

High doses of dextromethorphan induced shock and convulsions in a 19-year-old female: A case report

BACKGROUND

Dextromethorphan is a prevalent antitussive agent that can be easily obtained as an over-the-counter medication. There has been a growing number of reported cases of toxicity in recent years. Generally, there are numerous instances of mild symptoms, with only a limited number of reports of severe cases necessitating intensive care. We presented the case of a female who ingested 111 tablets of dextromethorphan, leading to shock and convulsions and requiring intensive care that ultimately saved her life.

CASE SUMMARY

A 19-year-old female was admitted to our hospital via ambulance, having overdosed on 111 tablets of dextromethorphan (15 mg) obtained through an online importer in a suicide attempt. The patient had a history of drug abuse and multiple self-inflicted injuries. At the time of admission, she exhibited symptoms of shock and altered consciousness. However, upon arrival at the hospital, the patient experienced recurrent generalized clonic convulsions and status epilepticus, necessitating tracheal intubation. The convulsions were determined to have been caused by decreased cerebral perfusion pressure secondary to shock, and noradrenaline was administered as a vasopressor. Gastric lavage and activated charcoal were also administered after intubation. Through systemic management in the intensive care unit, the patient’s condition stabilized, and the need for vasopressors ceased. The patient regained consciousness and was extubated. The patient was subsequently transferred to a psychiatric facility, as suicidal ideation persisted.

CONCLUSION

We report the first case of shock caused by an overdose of dextromethorphan.

Antipsychotic Drugs Efficacy in Dextromethorphan-Induced Psychosis

Psychosis is known as a broad term of symptoms that cause serious disorganization of behavior, thinking, and perception of reality. One of the medicines that recently gained much attention in terms of its psychotic potential is dextromethorphan (DXM). DXM, a widely used antitussive drug, is a commonly abused drug because of its euphoric, hallucinogenic, and dissociative properties. To date, DXM is a legally marketed cough suppressant that is neither a controlled substance nor a regulated chemical under the Controlled Substances Act. The management of DXM-related psychosis is dependent on the type of psychotic symptoms. Atypical neuroleptics (i.e., olanzapine, risperidone, quetiapine) and typical haloperidol have been used in symptomatic treatment due to their efficacy, especially in positive symptoms (hallucinations and delusions). These agents are also recognized as the preferred option in the symptomatic treatment of DXM-related psychosis due to their better efficacy and safety profile than typical haloperidol in the short-term course. The focus of the present review concerns the current stage of knowledge about DXM psychotic potency as well as the management of DXM-related psychoses with a special emphasis on atypical antipsychotic drugs (i.e., olanzapine, risperidone, quetiapine, and haloperidol).

Misuse of medication in adult substance misuse services: a systematic review protocol

INTRODUCTION

There is a growing concern about the misuse of over the counter (OTC) and prescription only medication (POM) because of the impact on physical and mental health, drug interactions, overdoses and drug-related deaths. These medicines include opioid analgesics, anxiolytics such as pregabalin and diazepam and antidepressants. This protocol outlines how a systematic review will be undertaken (during June 2021), which aims to examine the literature on the pattern of OTC and POM misuse among adults who are accessing substance misuse treatment services. It will include the types of medication being taken, prevalence and demographic characteristics of people who access treatment services.

METHODS AND ANALYSIS

An electronic search will be conducted on the Cochrane, OVID Medline, Pubmed, Scopus and Web of Science databases as well as grey literature. Two independent reviewers will conduct the initial title and abstract screenings, using predetermined criteria for inclusion and exclusion. If selected for inclusion, full-text data extraction will be conducted using a pilot-tested data extraction form. A third reviewer will resolve disagreements if consensus cannot be reached. Quality and risk of bias assessment will be conducted for all included studies. A qualitative synthesis and summary of the data will be provided. If possible, a meta-analysis with heterogeneity calculation will be conducted; otherwise, Synthesis Without Meta-analysis will be undertaken for quantitative data. The reporting of this protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

ETHICS AND DISSEMINATION

Ethical approval is not required. Findings will be peer reviewed, published and shared verbally, electronically and in print, with interested clinicians and policymakers.

PROSPERO REGISTRATION NUMBER

CRD42020135216.

Focus on Over-the-Counter Drugs' Misuse: A Systematic Review on Antihistamines, Cough Medicines, and Decongestants

Background: Over the past 20 years or so, the drug misuse scenario has seen the emergence of both prescription-only and over-the-counter (OTC) medications being reported as ingested for recreational purposes. OTC drugs such as antihistamines, cough/cold medications, and decongestants are reportedly the most popular in being diverted and misused. Objective: While the current related knowledge is limited, the aim here was to examine the published clinical data on OTC misuse, focusing on antihistamines (e.g., diphenhydramine, promethazine, chlorpheniramine, and dimenhydrinate), dextromethorphan (DXM)- and codeine-based cough medicines, and the nasal decongestant pseudoephedrine. Methods: A systematic literature review was carried out with the help of Scopus, Web of Science databases, and the related gray literature. For data gathering purposes, both the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and PROSPERO guidelines were followed (PROSPERO identification code CRD42020209261). Results: After completion of the selection, eligibility, and screening phases, some 92 articles were here taken into consideration; case reports, surveys, and retrospective case series analyses were included. Findings were organized according to the specific OTC recorded. Most articles focused here on DXM (n = 54) and diphenhydramine (n = 12). When specified, dosages, route(s) of administration, toxicity symptoms (including both physical and psychiatric ones), and outcomes were here reported. Conclusion: Results from the systematic review showed that the OTC misusing issues are both widespread worldwide and popular; vulnerable categories include adolescents and young adults, although real prevalence figures remain unknown, due to a lack of appropriate monitoring systems. Considering the potential, and at times serious, adverse effects associated with OTC misusing issues, healthcare professionals should be vigilant, and ad hoc preventative actions should be designed and implemented.

Protective effect of Lycium Barbarum polysaccharides on dextromethorphan-induced mood impairment and neurogenesis suppression

Dextromethorphan (DXM) is one of the common drugs abused by adolescents. It is the active ingredient found in cough medicine which is used for suppressing cough. High dosage of DXM can induce euphoria, dissociative effects and even hallucinations. Chronic use of DXM may also lead to depressive-related symptoms. Lycium barbarum, commonly known as wolfberry, has been used as a traditional Chinese medicine for the treatment of ageing-related neurodegenerative diseases. A recent study has shown the potential beneficial effect of Lycium barbarum to reduce depression-like behavior. In the present study, we investigated the role of Lycium barbarum polysaccharide (LBP) to alleviate DXM-induced emotional distress. Sprague Dawley rats were divided into 4 groups (n=6 per group), including the normal control (vehicles only), DXM-treated group (40 mg/kg DXM), LBP-treated group (1 mg/kg LBP) and DXM+ LBP-treated group (40 mg/kg DXM and 1 mg/kg LBP). After two-week treatment, the DXM-treated group showed increased depression-like and social anxiety-like behaviors in the forced swim test and social interaction test respectively. On the other hand, the adverse behavioral effects induced by DXM were reduced by LBP treatment. Histological results showed that LBP treatment alone did not promote hippocampal neurogenesis when compared to the normal control, but LBP could lessen the suppression of hippocampal neurogenesis induced by DXM. The findings provide insights for the potential use of wolfberry as an adjunct treatment option for alleviating mood disturbances during rehabilitation of cough syrup abusers.

A cross-sectional examination of medicinal substance abuse and use of nonmedicinal substances among Canadian youth: findings from the 2012-2013 Youth Smoking Survey

BACKGROUND

Medicinal substance abuse is prevalent in Canada; however, little is known about patterns of abuse among young people. In this study, we sought to characterize the abuse of medicinal substances, such as prescription medications and selected over-the-counter substances, as well as that of licit and illicit nonmedicinal substances, using a nationally representative sample of young people.

METHODS

Cross-sectional, nationally representative data for children in grades 7-12 were obtained from Health Canada's 2012-2013 Youth Smoking Survey (n = 38 667). Multinomial regression analyses were conducted to examine subgroup differences in medicinal substance abuse and comorbid abuse of both medicinal and nonmedicinal substances.

RESULTS

About 5% of youth reported abusing medicinal substances in the previous year. Dextromethorphan, a substance found in many cough and cold syrups, was the most widely abused (2.9%), followed by pain medications (2.6%), sleeping medications (1.8%), stimulants (1.7%) and sedatives (1.0%). Abuse of nonmedicinal substances aside from tobacco and alcohol was reported by 21.3% of the population, and abuse of any substances was detected in 23.0% of the surveyed population. Girls at each grade level reported higher rates of abuse of medicinal substances than boys. Regional differences were seen with regard to the types of substances abused across Canada.

INTERPRETATION

A substantial minority of Canadian youth report abusing medicinal substances, including over-the-counter medications (e.g., cough syrup) and prescriptions medications (e.g., pain medication). In contrast to nonmedicinal substances, girls were more likely than boys to report abuse of medicinal substances.

Repeated, high-dose dextromethorphan treatment decreases neurogenesis and results in depression-like behavior in rats

Abuse of cough mixture is increasingly prevalent worldwide. Clinical studies showed that chronic consumption of cough mixture at high dosages may lead to psychiatric symptoms, especially affective disturbances, with the underlying mechanisms remain elusive. The present study aims at exploring the effect of repeated, high-dose dextromethorphan (DXM, a common active component of cough mixture) treatment on adult hippocampal neurogenesis, which is associated with pathophysiology of mood disturbances. After treatment with a high-dose of DXM (40 mg/kg/day) for 2 weeks, Sprague-Dawley rats showed increased depression-like behavior when compared to the control animals. Neurogenesis in the hippocampus was suppressed by DXM treatment, which was indicated by decreases in number of proliferative cells and doublecortin (an immature neuron marker)-positive new neurons. Furthermore, the dendritic complexity of the immature neurons was suppressed by DXM treatment. These findings suggest that DXM induces depression- and anxiety-like behavior and suppresses neurogenesis in rats. The current experimental paradigm may serve as an animal model for study on affective effect of cough mixture abuse, rehabilitation treatment options for abusers and the related neurological mechanisms.

Dextromethorphan Abuse: A Literature Review

Objective:

To review dextromethorphan abuse patterns from 2002–2012 and emphasize the pharmacist's role in prevention, education, and sales surveillance.

Data Sources:

A literature search was conducted through PubMed (2002-November 2012), EMBASE (2002-November 2012), and International Pharmaceutical Abstracts (2002-November 2012), using the search term dextromethorphan abuse. The Drug Enforcement Administration and National Association of Boards of Pharmacy websites were searched for dextromethorphan abuse and legislative updates. The search was limited to a 10-year period to identify the most current case reports and studies.

Study Selection and Data Extraction:

The limits used were studies/case reports evaluating humans and published in the English language. Only studies and case reports that assessed dextromethorphan abuse were included in the review. Eight studies and 9 case reports met the inclusion criteria.

Data Synthesis:

Case reports and studies demonstrate that there are patterns associated with dextromethor phan abuse. A study using data reported to the National Poison Data System identified Coricidin as the most (65.5%) commonly abused dextromethorphan product until 2006; its abuse has decreased since that time (p < 0.0001). The most common abuse effects and toxicities cited in studies and case reports include agitation, confusion, central nervous system depression, tachycardia, hypertension, lethargy, psychosis, hallucinations, mydriasis, dizziness, and cardiotoxicity. One study identified that 96% of samples tested positive for other substances in addition to dextromethorphan. Coingestion of other substances is also common among dextromethorphan abusers.

Conclusions:

Case reports and studies demonstrate that there are patterns associated with dextromethorphan abuse. It is difficult to identify dextromethorphan as the causative agent of abuse effects because of coingestion of other substances. Studies should examine the pharmacist's role and the association between dextromethorphan sales restrictions and abuse patterns.

Intentional Coricidin product exposures among Illinois adolescents

OBJECTIVES

We sought to describe the demographics and trends of Coricidin product abuse in children in Illinois and to calculate an approximate total charge to the health-care system.

METHODS

In this retrospective database review, we identified 652 cases of intentional exposure to Coricidin products among children < 18 years old in the Illinois Poison Center database from 2001 to 2006. Demographic, historical, clinical, and outcome data were recorded.

RESULTS

The mean (standard deviation) age was 15.7 (1.58) years. A significant increase in exposures occurred during the study period which showed a cyclic nature with peaks in the fall months. Of the patients with disposition data available, 28.6% were admitted to a critical care unit, 15.2% to a noncritical care hospital unit, 6.3% were admitted for inpatient psychiatric care, and 46.4% were evaluated in the emergency department and discharged home. Moderate or major outcomes were reported in 42.7% of cases in which data were available. No deaths were reported. The total approximate hospital charge was $2,119,881.90 or $353,313.65/year.

CONCLUSIONS

Intentional abuse of Coricidin products reported to the poison center occurred primarily among adolescents and was often associated with significant short-term clinical effects and a clear financial burden to the health-care system.

SCIENTIFIC SIGNIFICANCE

This investigation demonstrates that Coricidin product abuse continues to be a problem particularly among adolescents. Parents and clinicians need to continue to be aware of these substances as drugs of abuse and curbing sales to adolescents should be considered.