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Episode 57

Which over-the-counter medications are used most often recreationally?

Which over-the-counter medications pose a risk to a person’s health?


Over-the counter medications are incredibly numerous in type and treatment provided. They are a huge part of our lives and something that provide relief for many uncomfortable symptoms. These medications are considered to be relatively safe and so don’t need a prescription. In the last couple of decades there have been more restrictions placed on OTC meds. There are some medications that are pretty commonly misused in a recreational way. People use them to get high and often it’s the first drug used by many adolescents.

Transcript

You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective.  I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor.  It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice.   So join me each week as we talk about All Things Substance.

Welcome back to the All Things Substance podcast. This is episode 57. It seems as though we may finally have fall up here in the North. The colors are beautiful and the leaves are falling, but the temperature has been in the sixties and that is really weird. Normally we have cooler temperatures like in the sixties in September, but we’ve had days up into the seventies and even eighties all the way through the end of the month. This morning as I’m recording, it’s about 48 degrees outside with a good breeze. I love this weather. It is definitely my favorite. 

We’re getting towards the end of our series about drugs of abuse.  We have just a few more left. In future episodes, I’m going to be talking about Delta-8, which is a marijuana derivative that you may just be starting to hear about. 

We’re also going to cover CBD. CBD is everywhere and I figured that I should probably do an episode on it even though it’s not a drug of abuse. I thought that listeners might be interested in hearing information about CBD from a more unbiased source than you tend to find on the internet. That’ll be coming next month. 

Today, we’re going to be covering over-the-counter medications that tend to be misused as recreational drugs. I’m not sure what it’s like in other countries, but I know in America we all tend to have extra medications in our medicine cabinets or in our linen closets. I recall having a shoe box full of old medication in our closet growing up. Prescription medications, along with over-the-counter medications. 

Most of us don’t think much about what’s in our medicine cabinets and just have it there as a “ just in case”. However research has told us that a number of these medications  do get misused and tend to get misused by adolescents and adults alike.

There are a couple that are considered behind the counter medications because you have to ask the pharmacist for them, even though they don’t require a prescription. We didn’t really have medications like that until around 2005.

The first medication we’re going to talk about today is the most commonly abused one:  dextromethorphan. We’ve talked about dextromethorphan before, when we talked about dissociative hallucinogens. If you haven’t checked out the hallucinogen episodes, you can head over to betsy byler.com/podcast and there are a couple of episodes talking about hallucinogens. 

Dissociative  hallucinogens are what they sound like.  They are drugs with hallucinogenic properties that cause a feeling of dissociation from one’s body and time. 

Dextromethorphan received its FDA approval in 1958 for use as a cough suppressant. It’s one of the most common compounds found in most over-the-counter cough medications for the last 60 years.  It’s packaging  usually includes the label extra strength. When taken as directed, it’s safe and effective.

However, dextromethorphan is the most highly abused over-the-counter medication. That’s because of its stimulant and hallucinogenic effects in higher doses. Low doses of it produce a mild stimulant effect and possibly some distorted visual perception. When you take high enough doses of DXM, the drug causes similar effects to PCP and ketamine.

There’s a complete detachment from the body, like other dissociative drugs. Some of this is done in liquid form and some of it in tablet form. The effects of dextromethorphan really depend on dosing. When you take TXM  like, you’re supposed to, you’re not going to get high. Most of us have actually had this in a cold medication and  may not have realized that that’s what it’s from. 

I’ve known people who have taken dextromethorphan in things like say NyQuil or some other kind of cold medication and they don’t like how it makes them. What they’re responding to is the effect that people are after, when they abused this medication.  The effects of this medication increase  as the dose increases. There are said to be different stages of intoxication often called plateaus.

So the first plateau was at 100 to 200 milligrams. Producing effects, similar to ecstasy, which causes mild stimulation and has an uplifting effect. People describe feeling more energetic, social and talkative. This is not to say that it’s the same as ecstasy, it’s reminiscent of ecstasy.

For perspective here, we’re talking about 25 milligrams when you take it as a cold medication versus taking a hundred to 200 milligrams, when you’re using it to get a level of intoxication. The second stage happens when you’re at about 200 to 400 milligrams.  That’s compared with more alcohol intoxication with more noticeable decline in motor skills and cognitive functioning. Euphoria and hallucinations are also likely with this dose. 

This tends to be what people call robo tripping. I’ve known about robo tripping since high school.  While I haven’t personally done it, I knew a lot of people who had tried it. It wasn’t something that people did on a real regular basis. It was sort of a stop gap since they couldn’t find what they really wanted to get high on. So they use this instead.  The person who told me about it I recall him saying that you either trip or you puke red. The name of course comes from Robitussin, which has been one of the more popular cough medications.

The third plateau can get pretty intense. This is where the effects are similar to those of ketamine. This happens around 400 to 600 milligrams of dextromethorphan. Remember that 25 milligrams is a standard dose when you have a cold. At 400 to 600 milligrams, that’s enough to leave you almost incapacitated. The person would be strongly dissociated from their body and the world around them. There will be intense hallucinations and a loss of motor coordination. 

The last plateau that’s talked about in the literature is extremely high. This is dextromethorphan  anywhere from 500 to 1500 milligrams. At this stage, the effects are similar to PCP.. It can cause a trance-like state and a sensation similar to an out of body experience. The effects of this are pretty hard to shake off as compared with other stages. Some people have experienced effects  for up to two weeks after the last time they took dextromethorphan.

The physical side effects are intense and can be dangerous. It could be things like increased body temperature, hot flashes, sweating, nausea, dizziness, slurred speech, lethargy, hyperactivity, high blood pressure, slow breathing, irregular heartbeat, itching, rash, involuntary eye movements,  unconsciousness, seizures and a rare side effect would be respiratory depression. Dextromethorphan has been thought to cause Olney’s lesions when administered intravenously. 

Long-term use can cause some really serious problems. Typically those end up being liver injury and cardiovascular problems. Dextromethorphan is in a lot of different medications and so to cover all of the brand names, isn’t really feasible. Anytime you have something that’s listed as being for cold and decongestant, you need to take a look for dextromethorphan. This typically isn’t someone’s drug of choice. Although I have worked with people who have chosen it as their drug of choice.

I worked with a young man many years ago who chose Coricidin Cough and Cold or triple C’s as his drug of choice. He was taking 30 to 40 tablets a day of the medication and ended up having some cardiovascular issues and damage to his heart due to the consistent use of dextromethorphan.

There are case studies of people getting addicted to dextromethorphan. One of them I saw was a man in his forties who was using 1800 milligrams a day. There is a tolerance effect and or withdrawal effect. The withdrawal effect is as you would expect agitation cravings, nausea and jitteriness.

Dextromethorphan is not currently a scheduled drug. It’s been brought up a lot in different conversations about whether or not it should be included in the schedule system. There are a number of states who have banned sale of anything with dextromethorphan in it to minors. For the most part, though, it’s not heavily regulated.

The other quote behind the counter medication that is fairly heavily regulated is pseudoephedrine. Pseudoephedrine  was the main active ingredient in the medication brand name Sudafed. When I was a kid and all the way through school pseudoephedrine or Sudafed was readily available.

I don’t actually remember anyone really abusing it. It wasn’t until methamphetamine really hit the scene that we started hearing about it. And that’s because pseudoephedrine is one of the main ingredients in mainstream meth. 

So I’m not giving you an actual recipe for making meth just talking about the steps and how pseudoephedrine is involved.  The first step is to take the ephedrine or the pseudoephedrine and mix it  with ammonia and lithium or iodine and phosphorus. Later it’s mixed with water and usually some kind of solvent like gasoline that can help extract the methamphetamine from the mixture.

Pseudoephedrine is the thing that’s the main part of methamphetamine. Certainly there are other ways of making meth as recipes for it, abound on the internet, as well as having to find a way around the need to get massive amounts of pseudoephedrine.

This all changed in 2005 with  the Combat Methamphetamine Epidemic Act of 2005. This was actually part of the overall Patriot Act signed by President Bush. The Act put pseudoephedrine behind the counter and put a limit on how many boxes or tablets someone could buy at a time.

It also required that they have a log of who has been buying these medications. The log would then be turned over to law enforcement upon request so that they could try to track down who exactly has been making meth in the area. 

Pseudoephedrine has a long history of medical uses. It’s helpful in treating the symptoms of the common cold and flu sinusitis, asthma and bronchitis. Pseudoephedrine is a decongestant that shrinks blood vessels  in the nasal passages.  Due to its central nervous system, stimulant properties and structural similarity to amphetamine it’s also used for non-medical purposes. The substance has been taken as an appetite reducer, something to eliminate drowsiness and fatigue and to improve concentration. 

The ephedrine and pseudoephedrine  is also ephedra,  which has been the core of a lot of appetite reduction medications in the past. Those medications aren’t available anymore, at least in the United States. Pseudoephedrine is, as long as you get the person behind the counter at the pharmacy, to sell it to you. 

Pseudoephedrine stimulates the sympathetic system to flight or flight reactions, speeds up breathing, increases blood pressure, accelerates heart rate, narrows peripheral blood vessels, causes bronchodilation, increases the blood glucose levels, stimulates the central nervous system, as well as giving a sense of an energy surge and improving mood.

In general dosages range from about 30 milligrams to upwards of 120 milligrams. It’s most often compounded with antihistamines, pain medications and cough medications. The maximum possible dose for pseudoephedrine and adults is 240 milligrams. When someone is abusing pseudoephedrine though, those dosages get a lot higher, just like with dextromethorphan.

There are reports of massive doses of upwards of 3000 to 4,500 milligrams of pseudoephedrine. Sometimes that’s in pill form but often that can be also done intravenously. Physical symptoms associated with a high dosage of pseudoephedrine include stimulating effects like decreased appetite, dry mouth, heart palpitations, and motor issues with gait and balance, postural instability, generalized dystonia and psychomotor retardation. 

Pseudoephedrine effects are dose dependent and range from euphoria to insomnia, diminished sense of fatigue and accelerated thinking. There’s also  psychotic symptoms with auditory and visual hallucinations, delusions, fear and disorganized behavior.

Withdrawal symptoms have been recorded after the abrupt stopping of long-term use. Some cases have required hospitalization and treatment with antipsychotics like Haldol, or  benzodiazepines, antidepressants like amitriptyline.

In extreme cases, death may occur due to overdose. Symptoms of overdose include headache, dizziness, anxiety,tinnitus, blurred vision, ataxia, chest pain, tachycardia, increased or decreased blood pressure, increased thirst, sweating, difficulty urinating, nausea, and vomiting.

There are a number of medications adjacent to pseudoephedrine and dextromethorphan  that are often misused and go under different trade names. We won’t cover them in depth, but I will mention them so that we’re aware of what those names might be. 

A drug called phenylpropanolamine  is also used for nasal decongestant due to cold, hay fever and upper respiratory allergies. Many of the drugs containing this particular compound have been taken off the market “voluntarily” due to issues related to potential for stroke.

Some of these brand names are Tavist-D, Dimetapp, Vicks and Alka-Seltzer plus. Now I know we’ve seen some of these on the market. What we have now  is a different derivative of pseudoephedrine that doesn’t get you high and doesn’t act the same way. A lot of times it’s marketed as being high blood pressure friendly. And I remember when that came out, it didn’t feel as effective as pseudoephedrine to handle congestion. Phenylpropanolamine has also been used as an appetite suppressant as well as a decongestant.

Another medication Chlorpheniramine is used to relieve symptoms related to allergies like red itchy, watery eyes, sneezing, itchy nose, or throat. The brand name being  and other derivatives like Chlor Tabs or Alle Chlor. This drug is an antihistamine as you’ll find a lot of these drugs are labeled as antihistamines, but function a little bit differently. 

The most popular antihistamine of course is diphenhydramine, which is generally known as Benadryl.  The over the counter allergy drug has hallucinogenic effects when taken in large amounts. Typical doses of diphenhydramine  is about 25 milligrams. If you look at things like NyQuil, you’ll find diphenhydramine in it. This is often used to help induce sleep when someone is sick, but also helps to work on some of the symptoms of a common cold or sinusitis.

According to clinical studies and manufacturer labeling the maximum dose for Benadryl is 300 milligrams. Diphenhydramine acts on the peripheral and central histamine receptors causing a reduction in allergic symptoms and causing sedation. Common side effects are drowsiness, of course, dizziness, impaired coordination, headache, dry mouth, urinary retention, hypotension, blurred vision, tachycardia, photosensitivity and sometimes erectile dysfunction. There can be serious reactions such as seizures and psychosis.

Diphenhydramine overdose can cause toxicity ranging from agitation to cardiac arrhythmia. The greater the level of diphenhydramine in the system, the worse the symptoms of course, and that can get pretty serious. You can imagine why people would take it though. When they want to get high they’re looking for that sort of detached feeling along with hallucinogenic effects and feeling relaxed.

How much you have to take to have that happen kind of varies. The max dose is 300 milligrams and so for some people, that’s going to be enough to cause those side effects and for others, they’re going to be taking upwards of 600 to a thousand milligrams.

There are reports of “ bad trip” where the hallucinations were fairly scary and the delusions also negative in general. There is a tolerance effect and a withdrawal effect. Typically when people are using diphenhydramine for sleep, they find that they end up having to take more. If you haven’t heard the episode on sleep medications, I do talk about diphenhydramine as being used for a sleep medication. 

There are some contra-indications to taking it long-term even at regular doses. There were reports in late 2020 about people doing a quote Benadryl challenge on Tik-Tok, where people were taking this and having some really severe side effects and the risk of seizures, stroke, and death. 

Also in the antihistamine category is a medication called dimenhydrinate which is Dramamine. Dramamine is typically used to treat nausea, vomiting, and dizziness due to motion sickness. Symptoms of over-taking this can be a stimulating effect, emotional lability. 

Someone’s going to be taking this in order to get high  and get a somewhat stimulating effect from it. Along with some delirium that unfortunately also can come with paranoia and incoherence, visual and auditory hallucinations at higher doses along with agitation, and anxiety. Those aren’t necessarily the desired effects for this, but just like the other medications, people seem to be willing to risk the bad side effects hoping for a good trip or a good experience. 

Physical effects were mild and included tachycardia, hypertension, flushing, restlessness, dystonic reactions, and ataxia.  Withdrawal symptoms were recorded in those who had chronic use and included irritability, anxiety, and craving.

In addition to the Dramamine conversation there’s another type of medication that’s used for motion sickness called promethazine. Common brand names are Phenadoz and Promethegan.  

Promethazine is going to have a similar profile to Dramamine. And I don’t know that these are super commonly abused, but they are abusable. You have to take quite a bit of them in order to have an effect. People are typically trying to get some sort of high euphoria, relaxed state and some hallucinations.

There are warnings about things like Dramamine, even in the drug using community. On Reddit, which is a popular site for a number of different things, there are accounts of people using Dramamine and what happens at each stage. They talk about seeing spiders specifically when they’re hallucinating and feeling really brain dead or foggy for a while after they come down.

In the nasal decongestant category there’s a medication called propylhexedrine that’s available over the counter as an inhaler . The brand name is Benzedrex in the United States, and  Obesin in the UK. In addition to being a nasal decongestant, it can be used as an appetite suppressant and a psychostimulant.

Users report a high, similar to amphetamines, but they say that it’s more euphoric. Generally. It has a much shorter duration of action, which is to be expected for an over-the-counter inhaler. Long-term use does create problems and seems to have a heavier strain on the cardiovascular system  and there’s a risk of heart damage  when used daily. As to be expected with amphetamine type medications there are complications like faster abnormal heart rhythm, high blood pressure and paranoia.

The FDA put out a warning about this particular medication in March of 2021. Additionally, there was a presentation done at the Academy of Addiction Psychiatry meeting about the increasing incidents of propylhexedrine abuse. 

There were some articles about nasal spray abuse. This isn’t as much used as a high, but some people will report that you can have some delirium and psychosis if you use it in high doses. What tends to happen though, is that when people are using nasal sprays on a regular basis, they get rebound congestion leading to further use. This can be seen as an addiction, but it doesn’t necessarily have the right markers according to the literature.

There’s a term that I ran across a few different times: nootropic,  in terms of a nootropic medication. Colloquially, this is known as a smart drug or a cognitive enhancer. They’re supposed to improve cognitive function, particularly executive functions, memory, creativity, or motivation. Nootropic medications could be any kind of supplement  and there happened to be quite a lot of them. Their medical efficacy hasn’t been tested and so there’s a lot of claims being made, but people still take them. One of those supplements that’s being abused it’s called phenibut with one T. Phenibut is sold under different brand names, like Anvifen and Noofen among others.

It’s a central nervous system depressant and is used to treat anxiety, insomnia and for a variety of other indications, it’s usually taken by mouth as a tablet, but could be given intravenously. Side effects include sedation, sleepiness, nausea, irritability, agitation, dizziness, and headache among others. It has a delayed onset, which often leads people to take more thinking that the first dose wasn’t going to work. 

Overdose is possible creating central nervous system depression, including unconsciousness. Phenibut was developed in the Soviet Union and was introduced for medical use  in the 1960s. Today, it’s marketed for medical use in Russia, Ukraine, Belarus, Kazakhstan, and Latvia. The medication is not approved for clinical use in the United States and most of Europe. In Australia it’s a controlled substance. 

It is sold on the internet though, as a supplement and supposed to be a nootropic medication. Phenibut has been used recreationally and  can produce euphoria and is known to have a tolerance and withdrawal effect. 

This drug is sure to be coming up in the news in the future, as it’s being discussed all over the world, in terms of what regulations should be. Different countries are proposing certain laws for tracking and for limiting quantities. In the U S though, it’s considered a”new drug” and no regulation really exists yet. 

Research says that Phenibut poses a high risk for potential abuse. Withdrawal from phenibut mimics benzodiazepine and alcohol withdrawal.  The withdrawal is said to be potentially equally as dangerous as benzodiazepine and alcohol withdrawal.

I think as the substance becomes more popular, we’re going to hear about it more. It’s being touted online as helping anxiety. We know that a lot of people are trying to manage their anxiety and trying to find natural ways to do so, rather than taking an SSRI  or other type of psychotropic prescription medication.

If you were to do a search on over the counter drug medication abuse, you’re going to come up with a few things specifically, dextromethorphan (the cough suppressant we talked about earlier) pseudoephedrine and Loperamide. 

Loperimide is something that I think that people haven’t necessarily heard of unless they have specific symptoms. One of the main brand names for Loperamide is Imodium A-D.

Loperamide is a medication used to treat diarrhea. Was first made in 1969 and used medically in 1976. It became available without a prescription in 1988. Initially it was categorized as a schedule five drug by the FDA. The FDA approval is to treat various forms of diarrhea, but also has been used off-label to treat adverse effects of chemotherapy.

So what is an anti-diarrheal drug doing in a drug of abuse conversation? Well, it’s because it has an opioid-like impact on the body. It’s the opioid-like abuse potential that made it that schedule five drug. 

The first time I ran into this in practice was a number of years ago, we were running an opioid use disorder program with medication assisted treatment and had a client  who had been using  Loperamide consistently. When I say using, I don’t mean using in the sense of an average dose. I’m talking about 100 to 200 pills a day on a daily basis.

At the time, I hadn’t even heard of it,  but a quick Google search of some forums where people who are using it tend to congregate, found reference to it. In the using community loperamide is suggested for use with opioid withdrawal in order to manage symptoms. And sometimes as a bridge, when you can’t find an opioid to use. 

There are a lot of different dosage levels suggested by the community in terms of managing withdrawal. All of them refer to using at least 40, 50 or 60 pills at a time and supplementing that with other types of medication to help manage withdrawals or to bridge until they can find  their opiate of choice. 

There are significant consequences to using  this much of a medication. One of the issues here is that opiates in general cause issues in the gastrointestinal system with constipation. We’re adding Imodium A-D on top of that, which is supposed to stop you from having diarrhea. That is going to complicate things immensely. However, opiate withdrawal is so much worse than I think people even imagine that even deliberately causing this type of gastrointestinal issue is worth it in most cases, for people going through withdrawal. 

Loperamide can also be used to get a euphoric feeling. Typically it doesn’t cross the blood-brain barrier, which is needed in order to feel high. However, apparently if you throw enough at it, some of it’s going to slip through, but also its action on the central nervous system can create specific feelings and sometimes people are using it just to get high. Those are the levels that we’re talking about between 100 and 200 pills a day. 

When we’re at that level and even at lower levels, there is some significant risk in terms of what’s called Loperamide induced cardiotoxicity. It said that patients present with potentially life-threatening forms of dysrhythmia when using Loperamide in these toxic doses. In addition to lethal cardiac conduction abnormalities there’s also a risk for respiratory depression because of its opioid-like effect. 

The common adverse effects are dry mouth, abdominal cramps, nausea, constipation, urinary retention, dizziness and drowsiness. Other severe effects are listed as necrotizing enterocolitis, toxic epidermal necrolysis and cardiac arrest.

There are some studies being done to see  what high doses of Loperamide could do for helping the tapering process of opiates. Right now, we don’t really have much restriction in the United States on Loperamide. There has been some conversation between the FDA and the manufacturers of Loperamide to voluntarily limit the number of pills in a box, as well as using blister packs, which they feel like reduce the ability of somebody to just have bottles and bottles of it.

The withdrawal and the recovery from Loperamide is pretty risky at times the cardiovascular issues alone make it difficult. And when someone’s going to be going on a medication like Suboxone, this has to be taken into effect. The person will have to go off of Loperamide for a number of days in order to be put on something like Suboxone. This is especially difficult and hard to get someone to agree to. But it’s super important that it’s adhered to because of all of the risks associated with it.

I think sometimes people have a hard time understanding why someone would do something like this to their body. That someone would drop a hundred to 200 times the amount they’re supposed to take onto their body, knowing how bad it’s going to make them feel. 

What I think we need to understand is that opiate withdrawal feels infinitely worse than that. Opiate withdrawal is incredibly motivating in terms of getting you to use something or anything. I’ve talked about this and the opiate episodes and tried to convey why people use pills or heroin, because it can seem really confusing as to why someone would do that.This is why. 

Remembering that all the way back. When we talked about addiction, not being a choice, this is where it comes in. This person did not choose to get addicted. They chose to use as most humans do, whether they choose to use some kind of substance, whether it’s alcohol or a plant  or something else like caffeine. No one plans on getting hooked on something. As we all feel like we have better quote control than that. 

Opiate withdrawal is a terrible place to be in and there is a ton of information online about how to manage the symptoms of withdrawal. I found a lot of information about Loperamide on a site called bluelight.com. It’s a site that promotes harm reduction and doesn’t condone nor condemn drug use. There’s a lot of conversation about how to use specific drugs and ways to potentially manage any adverse side effects.

The last substance I’m going to talk about today is the most commonly used psychoactive substance in the world and that’s caffeine.  Caffeine was first extracted from cocoa beans in its purest form, a white powder in the 1820s by a German scientist. Coffee seems to be  the most widely consumed caffeinated product in the world, coffee on its own is supposed to be relatively harmless and generally decently well tolerated. Most adults in the United States use caffeine, whether it’s coffee, pop, energy drinks, or even in chocolate.

Lots of us are familiar with drinking less caffeine all of a sudden when we get the dreaded caffeine headache, which no over the counter medication seems to touch insomnia and other symptoms. We’re talking about this in terms of a dependence, rather than an addiction. Most of the medications we’ve talked about today, we’re talking about a dependency.

Addiction is something specific that makes changes in the brain. If you haven’t listened to the episode on brain science, head over to betsybyler.com/podcast and it’s one of the very first episodes that I did  where I talk about how the brain gets changed when addiction kicks in. 

In this case for caffeine, we’re talking about dependency because there is a withdrawal syndrome attached to it. Like many other substances coat caffeine does signal a dopamine release in the brain. Dopamine of course is the chemical that helps control movement, motivation and emotions. So when there’s more caffeine, a person’s going to feel more alert, their movements may speed up or seem like they’re restless or in general  hopped up on caffeine. 

One of my favorite scenes in a kid’s movie was in the movie Over the Hedge when one of the characters drank an energy drink and was moving so fast that it basically slowed down time. We’re not talking about being able to have so much caffeine that that happen. But an over abundance of caffeine does cause  some unintended consequences.

There’s the drink form of caffeine, especially with the giant number of energy drinks that are on the market today and there’s caffeine in foods. Additionally though, there’s caffeine pills. Those have been available for quite some time.

The advent of caffeine pills is something that isn’t new. It well predated my high school years and I remember taking Vivarin and NoDoz and a bunch of other caffeine pills in high school to try to get some sort of amped up feeling.  There are reports of it being used as well for studying and being in college, trying to pull all-nighters as well as just to try to get high. Typical side effects of caffeine are feeling more awake and alert, feeling restless, anxious, or irritable, increased body temperature, dehydration, headache, faster breathing and fast heart rate. 

It shouldn’t surprise us that there’s wide availability for caffeine pills and caffeine powder online.  You can buy these things in bulk without much regulation. Caffeine powder is pretty potent.  Certainly combining this powder or tablets with other substances can really increase the negative outcomes.

For reference,  we’re talking about the guidelines being a max of 400 milligrams of caffeine per day. In typical pop there’s about 9.7 milligrams per a hundred milliliters. Green tea comes in at 12.1, milk chocolate at 20 milligrams, black coffee at 74.5, cappuccino at 101 and espresso at 194 milligrams. So you can see that  having a couple shots in your latte it’s actually quite a bit of caffeine. 

So when we’re talking about these powders, we’re talking about an incredible amount of milligrams. A teaspoon of this powder can be equivalent to 28 cups of coffee. Two teaspoons is said to be a lethal dose. 

There are reports of people snorting pure caffeine powder, and they’re not able to really control the dose that way. Caffeine overdose is said to typically come from use of these tablets or powder rather than from drinking caffeine.  It’s highly concentrated and therefore can have some pretty serious health consequences, including death from overdose.

The cause of death is typically , from ventricular fibrillation. This happens when the lower chambers of the heart vibrate, rather than contracting regularly. This stops the heart from beating and causes cardiac arrest. Symptoms of caffeine overdose can include a very fast or irregular heartbeat, shaking sickness or vomiting, confusion, and panic attacks among others.

There’s conversation happening right now in the United States about banning this pure concentrated caffeine powder. There’s an organization that’s working on keeping limits off of these products saying that the problem “isn’t with the product, but with how people abuse it”. Further saying “If we start to ban every food product people abuse, we’re going to run out of things to eat pretty quickly. What? I don’t know about that, not suggesting that we need to ban it.

I’m just saying that the conversation’s happening, but the statement about that, we’re going to run out of things to eat. What?  Like, come on now. We’re talking about things that people abuse unto their death, let alone things that they over consume.

The point of today’s podcast was to go over the things that are available, either online, behind the counter or over the counter that are being abused recreationally.  Some of them are more readily available than others, and some of them have more consequences than others. For us, these are just things that I think we need to be aware of, especially in our work with adolescents and with parents.

Oftentimes a lot of these medications are used to start experimenting with substances rather than it’s going to be their drug of choice. There are other things though, like massive amounts of pseudoephedrine, loperamide or dextromethorphan that can be concerning.

Keep your ears out for some of these things and take a look in your own medicine cabinet to see what’s there. I think a lot of us think we don’t have anything that would be useful to anyone or abusable or desirable in any way. However when people are looking to get high, they do get kind of creative.

We’ve talked about a number of over the counter medications today, and I wanted to just recap some of the brand names because it’s kind of a lot of information. So we’re talking about things that have any kind of cough suppressant. So NyQuil, DayQuil, Robitussin, generic cough syrups.

Cough and cold medication like Dimetapp Chlortrimeton,  Sudafed Mucinex, Coricidin Cough and Cold and even things like Alka Seltzer that ended up having medications for cough suppressant, or treating colds and sinusitis. You’re always looking for the active ingredients to see what’s in it.  

In addition the branches of these brands that work for allergies using diphenhydramine or Benadryl. Additionally, the motion sickness or antiemetic drugs like Dramamine and promethazine are also ones that can be abused. And of course the most popular caffeine.

I hope the information on over the counter drugs on over the counter medications has been helpful and interesting. Next week, I’m putting up an interview that I did with a fellow podcaster.  Paul Krauss is the clinical director for Health for Life Counseling and Grand Rapids, which is the home of the Trauma Informed Counseling Center of Grand Rapids. He’s also a private practice psychotherapist, an EMDR consultant, and the host of the Intentional Clinician Podcast. He’s involved in a number of projects, including creating the National Violence Prevention hotline, which is an in progress process, as well as the Intentional Clinician Training Program for Counselors.  I had the privilege of doing an interview with him on his podcast. That interview will be coming out next week. Hope to see you on the next podcast and until then have a great week.

Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist friends and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know.  Just send a message to podcast@betsybyler.com. I’ll see you on next week’s podcast. And until then have a great week.

This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, clinical or any other professional information.

Helpful Links

Pseudoephedrine Uses, Dosage & Side Effects – Drugs.com

Pseudoephedrine: MedlinePlus Drug Information

Pseudoephedrine—Benefits and Risks

The advent of a new pseudoephedrine product to combat methamphetamine abuse

FDA warns that abuse and misuse of the nasal decongestant propylhexedrine causes serious harm | FDA

Legal Requirements for the Sale and Purchase of Drug Products Containing Pseudoephedrine, Ephedrine, and Phenylpropanolamine | FDA

Frontiers | Focus on Over-the-Counter Drugs’ Misuse: A Systematic Review on Antihistamines, Cough Medicines, and Decongestants | Psychiatry

Loperamide – StatPearls – NCBI Bookshelf

Loperamide Uses, Side Effects & Warnings – Drugs.com

Loperamide Oral: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing – WebMD

Consumer Health Group Warns of Loperamide Abuse, Misuse

Loperamide Dependency: A Case Report

Imodium Addiction: Why Are Some People Hooked on the Anti-Diarrheal Medication?

Loperamide – An Unexpected Drug of Abuse – Missouri Poison Center

CDER Conversation: Reducing the Risk of Loperamide Misuse and Abuse | FDA

Dextromethorphan – StatPearls – NCBI BookshelfPhenylpropanolamine – an overview | ScienceDirect Topics

The Delirious Cult of Recreational Benadryl Users

Diphenhydramine – StatPearls – NCBI Bookshelf

Diphenhydramine Toxicity – StatPearls – NCBI Bookshelf

Chronic diphenhydramine abuse and withdrawal

FDA warns about serious problems with high doses of the allergy medicine diphenhydramine (Benadryl) | FDA

“I Want A New Drug:” OTC Inhaler Abuse | Tom Viola

6 of the best caffeine pills for weight loss and studying

4 Tips for Students to Safely Use Caffeine Pills

Caffeine Abuse: Buzz Gone Wrong

Caffeine: How Long it Lasts, How Much & Withdrawals

Caffeine overdose: Symptoms, treatment, and how much is too much?

Caffeine Overdose: Symptoms, Side Effects, and Treatment

Is It Possible to Overdose on Caffeine?

Is Caffeine Really Addictive? | NIDA Archives

Snorting Caffeine Powder? You Could Damage Your Heart – Everyday Health

FDA Hands Tied in Powdered Caffeine Abuse Cases | US News

Abuse of over-the-counter medicines: a pharmacist’s perspective

Abuse of Over-the-Counter Medications Among Teenagers and Young Adults – Editorials – American Family Physician

CONCLUSIONS AND IMPLICATIONS FOR DECISION OR POLICY MAKING – Abuse and Misuse Potential of Dimenhydrinate: A Review of the Clinical Evidence – NCBI Bookshelf

Phenibut (beta-phenyl-GABA): a tranquilizer and nootropic drug – PubMed

Phenibut: The Russian Cosmonaut Drug You Can Buy Online to Reduce Anxiety | Psychiatry | Michigan Medicine | University of Michigan

Phenibut (β-Phenyl-γ-aminobutyric Acid) Dependence and Management of Withdrawal: Emerging Nootropics of Abuse

Dissociative intoxication and prolonged withdrawal associated with phenibut: a case report

Dextromethorphan Abuse in Adolescence

Robotripping on DXM: What You Need to Know

Dextromethorphan (DXM) – Partnership to End Addiction

Dextromethorphan in Cough Syrup: The Poor Man’s Psychosis

Dextromethorphan: a case study on addressing abuse of a safe and effective drug

Cognitive deterioration from long-term abuse of dextromethorphan: a case report.

Dextromethorphan Withdrawal and Dependence Syndrome

Free Treatment Tool https://betsybyler.com/treatment-tool/