Adolescents' Misuse of Over-The-Counter Medications: The Need for Pharmacist-led Intervention

Over-the-counter medications encountered in the postmortem pediatric population from 2010-2020

In forensic toxicology, the pediatric population requires special focus when evaluating positive findings because of the many toxicokinetic and toxicodynamic differences (e.g., metabolic capabilities, body size, etc.) between the pediatric and adult populations. In particular, the administration of over-the-counter (OTC) medications needs careful consideration, as dosages given to the pediatric population (0 days-18 years), particularly those given to individuals <5 years of age, tend to be lower than those given to individuals closer to adulthood. Postmortem pediatric data from 11 years (2010-2020) was compiled. A total of 1413 positive cases contained one or more of the following common OTC medications: antihistamines (brompheniramine, chlorpheniramine, diphenhydramine, doxylamine and pheniramine), pain relievers (acetaminophen, naproxen, ibuprofen and salicylates), cold/flu medications (dextro/levomethorphan, guaifenesin, ephedrine and pseudoephedrine), gastrointestinal aids (dicyclomine and loperamide) and/or sleep aids (melatonin). Antihistamines, cold/flu medications and pain relievers are the most common classes of drugs encountered in the postmortem pediatric population. To evaluate trends, three main age groups were created: ≤5 years old (5 U, birth-5 years old), middle childhood (MC, 6-11 years old), and early adolescence (EA, 12-18 years old). When considering the data, it must be noted that many of these drugs may be co-administered in single and/or multi-drug formulations. In addition, some drugs may have a variety of uses, e.g. antihistamines may also be used as sleep aids. Of note, the prevalence of cases involving those aged 6-11 years old was far less than their younger and older pediatric counterparts. With the widespread availability of OTC medications, unintentional overdoses, recreational misuse and suicidal overdoses can occur in the vulnerable, pediatric population.

Comparison of patients with benzodiazepine receptor agonist-related psychiatric disorders and over-the-counter drug-related psychiatric disorders before and after the COVID-19 pandemic: Changes in psychosocial characteristics and types of abused drugs

AIM

To investigate changes in the clinical characteristics of patients who abused benzodiazepine receptor agonists (BZRA) or over-the-counter (OTC) drugs before and after COVID-19 based on the 2018 and 2022 data of the "Nationwide Psychiatric Hospital (NPH) Survey on Drug-related Psychiatric Disorders."

METHOD

A total of 446 and 155 cases, and 435 and 273 cases, who mainly abused BZRAs or OTC drugs, respectively, were extracted from the database of the two NPH Surveys. Demographic variables, education, employment, criminal record, drug use during the previous year, psychiatric diagnosis, and types of abused drugs were compared between 2018 and 2022.

RESULT

A comparison of BZRA abusers revealed a decreased number of users during the previous year and an increase in the comorbidity rate of other disorders (F3 and F4 in ICD-10) in 2022. Etizolam, flunitrazepam, triazolam, and zolpidem were used most in both years, with an increase in zolpidem and a decrease in triazolam in 2022. A comparison of OTC drug abusers revealed a higher proportion of women and young patients in 2022. An increase in the comorbidity rate of F3 and F9 and a significant increase in the use of dextromethorphan products were observed in 2022, although codeine products were in the majority in both years.

CONCLUSION

By comparing NPH Surveys before and after the COVID-19 pandemic, both BZRA abusers and OTC drug abusers present complex pathologies, requiring tailor-made treatment. The younger OTC drug abusers were particularly evident among women, and the abuse of dextromethorphan-containing OTC drugs has increased alarmingly.

Evaluating healthcare professionals' perceptions of dispensing separation and sale of pharmacy medicine in Brunei Darussalam

BACKGROUND

Pharmacy medicine (P) is obtained exclusively from a pharmacy under the supervision of a pharmacist. This study aims to understand the perception of healthcare professionals towards the dispensing separation, as well as the dispensing of pharmacy medicine by community pharmacies to enhance patient health outcomes in Brunei Darussalam.

METHODS

A cross-sectional study was conducted between 1st March 2023 and 20th April 2023 among healthcare professionals. A newly designed and validated questionnaire was used. Its face and content validity, along with internal consistency, was adequately established. Convenient sampling was employed to recruit participants for the study. Statistical analysis using one-way ANOVA was performed, considering a p-value < 0.05 as statistically significant.

RESULTS

The study compiled data from 108 participants, comprising doctors (38.9%) and pharmacy technicians (45.4%). Approximately 28.7% of respondents had 11-20 years of healthcare experience, while 25.9% had less than 5 years. Nearly all respondents (98.1%) agreed on the vital role pharmacists and pharmacy technicians play in prescription checks. A significant number of participants (93.5%) agreed that Brunei's current medicine dispensing system needs improvement. The mean total score for the perception of medicine dispensing in Brunei was 3.79 ± 1.103. A statistically significant difference was found between the perception score and the respondents' profession (p = 0.018), but not with their age, experience, or place of work. Respondents' awareness score showed no statistically significant correlation with their profession, age, experience, or place of work.

CONCLUSION

The study underscores the necessity for more patient-centered care in community pharmacies in Brunei Darussalam. The country's healthcare professionals should recognize the potential advantages of expanding pharmacy services. However, to implement these services successfully, regulatory restrictions and infrastructure limitations must be addressed.

Classics in Chemical Neuroscience: Dextromethorphan (DXM)

Dextromethorphan (DXM) was introduced in 1958 as the first non-opioid cough suppressant and is indicated for multiple psychiatric disorders. It has been the most used over-the-counter cough suppressant since its emergence. However, individuals quickly noticed an intoxicating and psychedelic effect if they ingested large doses. DXM's antagonism at N-methyl-d-aspartate receptors (NMDAr) is thought to underly its efficacy in treating acute cough, but supratherapeutic doses mimic the activity of dissociative hallucinogens, such as phencyclidine and ketamine. In this Review we will discuss DXM's synthesis, manufacturing information, drug metabolism, pharmacology, adverse effects, recreational use, abuse potential, and its history and importance in therapy to present DXM as a true classic in chemical neuroscience.

Repeated dextromethorphan administration in adolescent rats produces long-lasting behavioral alterations

Initiation of non-medical dextromethorphan (DXM) use often occurs in adolescence, yet little is known about the consequences when use begins during this developmental period. The current experiments examined the acute response and the effects of repeated exposure to DXM in adolescence on behavior in adulthood. We examined locomotor activity, locomotor sensitization, and cognitive function, in rats that received repeated administration of DXM. Groups of adolescent (PND 30) and adult (PND 60) male rats were treated with DXM (60 mg/kg) once daily for 10 days. Locomotor activity in response to DXM was assessed following the first injection, on the 10th day of injection (adolescent - PND 39; adult - PND 69), and following 20 days of abstinence (adolescent - PND 60; adult - PND 90). Acute locomotor effects and locomotor sensitization were compared in adolescents and adults; cross-sensitization to ketamine, another dissociative with abuse potential, was also examined. In a separate group of rodents cognitive deficits were assessed following a 20 day abstinence period (adolescent - PND 60; adult - PND 90) in spatial learning and novel object recognition tasks. The locomotor stimulant effect of DXM was much greater in adolescents than adults. Also, only adolescent rats that were repeatedly administered DXM demonstrated locomotor sensitization at the end of 10 days of injection. However, sensitization occurred after the abstinence period in all rats regardless of age. Nonetheless, cross-sensitization to ketamine was only evident in adolescent-treated rats. DXM also led to an increase in perseverative errors in reversal learning only in the adolescent-treated group. We conclude that repeated use of DXM produces long-lasting neuroadaptations that may contribute to addiction. Deficits in cognitive flexibility occur in adolescents, although further work is necessary to confirm these findings. The results extend the understanding of potential long-term consequences of DXM use in adolescents and adults.

Knowledge and Use of Over-the-counter Drugs in Italy: An Exploratory Survey-based Study in the General Population

BACKGROUND

During the past decade, the misuse of over-the-counter (OTC) medicines has become a global public health concern, especially among young people. In this study, we aimed to explore the OTC consumption and related misuse in Italy and identify the demographic characteristics of people/individuals involved in this phenomenon, understanding eventual risk factors.

METHODS

The study consisted of an anonymous online survey distributed by direct contact and via the Internet between June-November 2021 to the general population living in Italy. Descriptive statistics were reported, and binary regression analyses were performed to identify risk factors for lifetime misuse of OTC. The University of Hertfordshire approved the study (aLMS/SF/UH/02951).

RESULTS

The final sample size was composed of 717 respondents. The sample was mainly represented by female (69.3%) students (39.9%) in the 20-25 years age group (30.0%). Based on the survey responses, study participants were divided into two groups according to the presence/absence of OTC abuse/misuse (127 versus 590), which were compared for possible predictors of OTC diversion. Multivariate regression showed that OTC abuse/misuse was associated with the knowledge of the effects of OTC [odds ratio/OR = 2.711, 95%Confidence Interval/CI 1.794-4.097, p <0.001]. On the contrary, the educational level appeared to be a protective factor [OR = 0.695, 95%CI 0.58-0.94, p = 0.016].

CONCLUSION

Although, according to our data, the phenomenon of OTC abuse appeared to be limited, increasing attention is needed because of possible underestimation and high-risk outcomes. Preventive strategies, including simplified access to information, may play a key role in limiting OTC misuse.

Over-The-Counter Analgesics: A Meta-Synthesis of Pain Self-Management in Adolescents

BACKGROUND

The consumption prevalence of OTC medication ranges between 57% and 78% among adolescents in the United States of America; however, the reasons for self-medication with OTC analgesics have not been systematically examined.

AIMS

The purpose of this meta-synthesis is to generate new knowledge and theoretical understanding of adolescents' use of over-the-counter (OTC) analgesics.

DESIGN

Qualitative meta-ethnography using Noblit and Hare's (1988) approach.

SETTINGS

PARTICIPANTS/SUBJECTS: METHODS: We identified qualitative studies in the CINAHL, PubMed, PsycINFO, and ProQuest Dissertation and Thesis databases that addressed OTC analgesic use in adolescents, were published between 2006 and 2018, and were written in English. Themes were extracted from studies meeting inclusion/exclusion criteria and a meta-ethnographic analysis was conducted.

RESULTS

Seven studies met inclusion/exclusion criteria. Four themes were identified that described reasons for adolescent use of OTC analgesics for pain management: 1) survival instinct; 2) placebo for stress and anxiety control; 3) accessibility; and 4) consumer socialization.

CONCLUSIONS

Findings suggest that OTC analgesic use is common among adolescents to treat pain and other non-medically-indicated conditions, such as stress and anxiety.

What Do Young Adults Think about the Safety of Over-the-Counter Analgesics? Findings from a Cross-Sectional Survey

Analgesics are commonly used over-the-counter (OTC) medicines readily available for purchase, sometimes without advice of a health professional. However, analgesics can cause harm even when taken according to dosing recommendations. Young adults may be more vulnerable to harm if they perceive low risk with OTC analgesic use, or struggle to interpret dosing instructions. This study aimed to explore factors affecting how young adults use OTC analgesics and associated perceptions of safety. An online survey was distributed to school-leavers and university students (17 to 25 years), in South-East Queensland, Australia, in the period November-December 2019. Most of the 302 respondents (school-leavers n = 147, university students n = 155) did not use analgesics frequently. School-leavers deferred to parents for analgesic information, while university students preferred the internet. The majority of respondents appeared safety conscious and did not take outside indicated use or instructions. However, a small proportion reported taking analgesics for an inappropriate indication. The difference in preferred source of analgesic information may reflect experience with analgesic use, increasing autonomy or decreased parental influence. Whilst it is encouraging that the majority of young adults appeared safety conscious, greater insight is needed into factors influencing decision making on OTC use, e.g., medicines knowledge, and changes with increasing age.

Medication Education Provided to School-Aged Children: A Systematic Scoping Review

OBJECTIVES

To characterize the educational interventions regarding prescription and nonprescription medication use for school-aged children, we systematically reviewed evidence of programs available for this age group.

METHODS

Searches in PubMed, CINAHL, EMBASE, ERIC, and International Pharmaceutical Abstracts were conducted. Search terms focused on: population education, school-age children, and medications. Studies were excluded if they were specific to a particular disease state or class of medication, drugs of misuse and illicit drugs. Data extraction included study design, location, educational intervention and duration, research methods, and main findings.

RESULTS

We found 14 studies representing 8 separate projects. Six projects were identified in the gray literature. Projects ranged from individual sessions to national programs. Quantitative studies showed improvement in knowledge, medication literacy, and confidence. The adoption of medication education strategies was dependent on the educator's comfort level and beliefs regarding medication safety.

CONCLUSIONS

Credible medication education resources are available and have been shown to improve students' knowledge. There remains a need for multifaceted implementation and evaluation strategies. Strategies and resources are available to implement interventions in communities to address medication education in school-age children. Frameworks should be used to facilitate the implementation of effective health promotion strategies around safe-medication use for school-aged children.