DEXTROMETHORPHAN ABUSE AMONG ADOLESCENTS

By

LISA ANN DUNHAM, RN, BSN

A clinical project paper submitted in partial fulfillment of the requirements for the degree of

MASTER OF NURSING

WASHINGTON STATE UNIVERSITY - SPOKANE, WA College ofNursing

MAY 2012 To the Faculty ofWashington State University:

The members ofthe Committee appointed to examine the master's project of

LISA ANN DUNHAM fmd it satisfactory and recommend that it be accepted.

John Roll, Ph.D., Chair

Ruth Bindler, Ph.D., RNC

Mel Habennan, Ph.D., RN, FAAN

ii DEXTROMETHORPHAN ABUSE AMONG ADOLESCENTS

Abstract

by Lisa Ann Dunham, RN, BSN Washington State University May 2012

Chair: John Roll

Dextromethorphan abuse has been increasing among adolescents over the past several years. This medication is readily available and socially accepted among peers.

The euphoric state that is reached with high doses ofthe medication motivates adolescents to abuse this medication. Biological, psychological and social factors all play a role in the initiation and continued misuse ofthe medication. Abuse has an overall negative impact on the individual's health. Medical providers and care givers can implement interventions to prevent and treat dextromethorphan abuse among adolescents.

Key Words: Dextromethorphan, adolescents, over the counter, drug abuse, cough syrup abuse

iii TABLE OF CONTENTS

Page

ABSTRACT "'...... iii

LIST OF FIGURES...... v

LIST OF TABLES...... vi

INTRODUCTION. II "'...... 1

~()RE1fI~~ lP~~~()~ ", ,.... 2

LITERATURE REVIEW

~~)\Jl~1I S;TRATE(J~~...... 2

DEXTROMETHORPHAN ABUSE IN THE U.S...... 3

ADOLESCENT DEXTROMETHORPHAN ABUSE...... 6

~~~S<:~~ )\lJlJS;~ 1lIS;1C...... 7

~~TH 1lIS;1(s. lPFt()~ lJS~...... 8

PREVENTION OF ABUSE...... 9

SIGNIFICANCE FOR NURSE PRACTITIONER PRACTICE...... 11

SUMMARY "' "' "'...... 12

REFERENCES...... 14

iv LIST OF FIGURES

1. Figure 1; The Biopsychosocial Model 17

v LIST OF TABLES

1. Search S1:l'a:tegies 18

vi Dextromethorphan Abuse among AdoleseeDts

"Today, about 8,000 persons older than 12 years will use an illicit drug or misuse a prescription drug for the first time" (O'Malley, 2010, p. 286). The majority will use marijuana, but one-third ofthe people will opt for over-the-counter pain relievers, cough suppressants, tranquilizers, stimulants, and sedatives. According to Williams and

Kokotailo (2006), over-the-counter drug abuse is defined as the use ofa commercially available agent to experience psychoactive effects rather than the intended purpose ofthe agent. Dextromethorphan, a cough suppressant is one ofthese readily available medications that is being misused and abused by adolescents. Dextromethorphan is chemically known as dextromethorphan hydrobromide and is a semisynthetic morphine derivative and opiate analgesic (O~Malley, 2010). Dextromethorphan is sold overtbe counter in products such as Coricidin®, Robitussin®, and Nyquil® (Banken & Foster,

2008).

In 2006 approximately four to six percent ofadolescents in the eighth, tenth, and twelfth grades in the United States reported using dextromethorphan, to create a euphoric state ofmind (Miller, 2011). This medication appeals to youth based on the availability, cost, and social acceptance ofits use, compared to street drugs like heroin, cocaine, or methamphetamine .. Dextromethorphan creates a dissociative state similar to those created by phencyclidine (PCP), lysergic acid diethylamide (LSD) and ketamine since they share a similar pharmacodynamic profile. There are currently over 140 versions of dextromethorphan available for sale over the counter in the United States (Miller, 2011).

The purpose ofthis paper is to examine the adolescent population's abuse ofthe drug dextromethorphan. Biological, psychological and social factors that impact this

1 growing problem will be discussed. The population ofinterest is adolescents ofboth genders from 12·18 years of age.

Tbeoretieal Framework.

The biopsychosocial model has been used as the theoretical framework for this review. This model was created in 1977 by George Engel, a psychiatrist. It views the systems ofbiology, psychology and sociology as being interconnected. These three systems all independently and collectively influence health and behaviors related to wellness (Lakhan, 2006). The biological component relates to the vulnerability of adolescent drug abuse and misuse. Multiple factors can predispose a person to drug abuse, including but not limited to genetic inheritance, in-utero damage resulting in central or autonomic system problems, or physiological differences that occur at any period after birth. The psychosocial factors include family, community, school, peer groups, and social groups; see Figure 1. When all three components are evaluated together the impact on the health ofthe individual is affected greatly in either a positive or negative manner (Lakhan, 2006). For example, ifan adolescent has an alcoholic parent, lacks a social support group, or has a peer group that is using drugs, then according to Engel's model, a negative impact on the individual's health is likely to result.

Seareh Strategies

The Washington State University Library search engine was utilized for the searches in health-based scholarly journals found through CINAHL, PubMED, Web of

Science, and Google Scholar internet search engine. The search terms were

"dextromethorphan," "abuse," "adolescent," and ~'cough syrup abuse." Over 60 articles

2 were identified with a wide range ofinfonnation and the number chosen for the paper was 21. These 21 articles that specifically addressed dextromethorphan abuse and adolescents were then sorted into the categories ofthe paper; see Table 1. These categories were chosen to outline the broader topic ofdextromethorphan in the United

States and then to narrow the focus to adolescents. The articles chosen for these categories specifically addressed dextromethorpban abuse in the United States or adolescents involved in abuse ofthe medication. Articles published no later than six years ago were selected for this paper.

Literature Review

Dextromethorphan Abuse in the United States

Dextromethorphan is a drug that has been used over 40 years for cough and pain relieffrom minor viral upper respiratory tract infections. It is widely accepted and prescribed by the medical community for all ages above two years old.

Dextromethorphan is prescribed more often than codeine. It is available over-the-counter in a variety of fonnulations~brands~ flavors and with different additives such as antihistamines, decongestants, and analgesics. Dextromethorpban works centrally on the medullary cough center to suppress the cough (Banken & Foster, 2008).

"Dextromethorphan is the dextro isomer oflevomethorphan, a semisynthetic morphine derivative. Although structwally similar to other narcotics, dextromethorphan does not act as an opioid receptor agonist (e.g. morphine, heroin). Dextromethorpban and its metabolite, dextrophan, act as potent blockers ofthe N-methyl..d-aspartate receptor

(NMDA). At high doses, the pharmacology ofdextromethorpban is similar to those of the controlled substance phencyclidine (PCP) and ketamine that also antagonize the

3 NMDA receptor" (U.S. Department ofJustice Drug Enforcement Administration Office ofDiversion Control, 2008, p. 1).

In 2008, the American Association ofPoison Control Centers reported "...52,991 case mentions and 40,229 single exposures related to DXM." These statistics were obtained through phone calls to Poison Control Center and emergency department visits

(U.S. Department ofJustice Drug Enforcement Administration Office ofDiversion

Control, 2008, p. 1). Trends in over-the-counter cough and cold medication misuse by eighth, tenth, and twelfth graders from the 2010 Monitoring the Future report showed

3.2%, 5.1 %, and 6.6% usage rates respectively (Johnston et al., 2011).

The recommended dosage ofdextromethorphan in a product for children over 12 years is 10·20 mg every 4 hours or 30 mg every 6 to 8 hours for the immediate-release formulations, and 30 mg every 12 hours for the extended-release fonnulations, with a maximum amount of 120 mg per day (Epocrates, 2011). The range ofdextromethorphan needed to induce physiologic effects ofexcitation, euphori~ and dissociative hallucinations is 8 to SO times the recommended dose. Most users experience decreased excitability ofthe human motor cortex starting at 150 mg. At high doses, vivid dissociative hallucinations and complete body analgesia can develop (Banken & Foster,

2008). There are four plateaus reported with dextromethorphan use, each level causing an added effect. The first plateau includes doses 100-200 mg creating a mild stimulation effect, while the second plateau occurs with doses 200400 mg causing euphoria and hallucinations. The third plateau includes dosages 300-600 mg and result in distorted visual perceptions and loss ofmotor coordination. The final stage is plateau four with

4 doses 500-1500 mg causing dissociative sedation (U.S. Department ofJustice Drug

Enforcement Administration Office of Diversion Control, 2010).

Dextromethorphan intoxication presents with common signs ofdrug ingestion as seen with any medication overdose. Physical signs include tachycardia, nystagmus, pupillary responses, ataxia, clumsiness, restlessness, and hyperexcitability. Each patient presents differently based on specific tolerance and amount taken but at high doses hypertension, nausea, vomiting, stupor, seizure, coma, and respiratory depression may occur (Banken & Foster, 2008).

Dextrometborphan is a psychotropic substance that carries a potential for abuse and psychological dependence. (Mutschler et al., 2010). There are mild withdrawal symptoms and no apparent physical dependence associated with the misuse of dextromethorphan, but additional serious medical complications can develop based on the additional ingredients in the product (Banken & Foster, 2008). The literature reports few cases ofpsychological dependency to dextromethorphan. Dependency criteria includes a strong desire or compulsion to take the medicatio~ reduced ability to control the onset, dose termination and amount consumed ofthe medicatio~ physical withdrawal symptoms upon termination or reduction oftaking the medication, the development of tolerance, and neglect to activities ofdaily living during consumption ofthe medication.

To be diagnosed with dependency three ofthe six criteria must be met within the course ofa year. There are no specific symptoms for psychological dextromethorphan dependency, contributing to difficulty in diagnosis for the primary care provider without open communication between provider and patient (Mutschler et al., 2010).

5 Adoleseent Dextromethorphan Abuse

Abuse and misuse ofdextromethorphan is common among adolescents ages 12 to

18 years. An estimated 3.1 million Americans ages 12 to 25 years have abused an over­ the-counter cough medicine in their lifetime, and close to one million have abused in the past year. Those aged 18 to 25 years are more likely to abuse cough medicine than younger adolescents ages 12 to 17 years. Females have higher documented cough medicine abuse rate than males during ages 12 to 17, however in the age group of 18 to

25 years old, males are more likely to abuse cough medicine (Substance Abuse and

Mental Health Administration, 2008).

Adolescents misuse this medication for a variety ofreasons. Unlike street drugs there is minimal stigma associated with its use, little money is required to attain the product, it is readily accessible over-the-counter or already in the home medicine cabinet, there are few risks ofconsumption perceived by the users, and it is not routinely tested for in urine drug screening (Miller, 2011). The typical abusers ofdextromethorphan are

16 year old adolescents, male and female, and the route is usually oral. It can also be inhaled nasally when obtained in a powder form (Banken & Foster, 2008). Common street names for dextromethorphan include DXM, Dex, CCC, Triple C, Skittles, Robo, and Poor Man's PCP (U.S. Department ofJustice Drug Enforcement Administration

Office ofDiversion Control, 2010). The most popular abused product containing dextromethorphan is Coricidin HBP Cough & Cold Tablets® followed by dextromethorphan containing Robitussin® products (Bryner et al., 2006).

Polysubstance abuse was reported by the California Poison Control System survey ofadolescents complied by Bryner et al., in 2006. Ofthose surveyed 20010

6 reported co-use of dextromethorphan with ethanol, marijuana, opiates, acetaminophen, amphetamines, selective serotonin reuptake inhibitors, pseudoephedrine, and benzodiazepines.

Adolescent Abuse Risk

A qualitative study from Hong Kong by Lam and Shek (2006) found five major reasons for cough medication abuse in a sample of 14 adolescents and five parents. Social pressure, personal problems, family relationships, availability, and ignorance were the most common reasons provided. Peer influence was the most common reason for the flrSt time use ofcough medicine, but the continued use ofthe medication was related to unhappy experiences, failures, desires to escape reality, and low selfesteem. The study participants described themselves as ''useless'', ''worthless'', and "failures" and reported their lives were "upsetting" and they wanted to "avoid" life. A common factor in these individuals was poor family relationships including martial conflicts, family violence, pressure related to family expectations, and inter-family problems (Lam & Shek, 2006).

Availability was another listed key factor for abuse and misuse ofcough medicine

(Lam & Shek, 2006). It was reported that it was easy to access from pharmacies, family and friends. The adolescents stated it was a low risk medication to take, affordable and easy to access and these reasons aided in the medication abuse. Many ofthe study participants reported not knowing the risks ofcough medicine abuse (Lam & Shek,

2006). As little as one package ofdextromethorphan (200 mg) is needed to produce euphoric and hallucinatory effects. This makes it affordable to obtain, and information is readily available on the Internet on how to abuse this medication (Bryner et al., 2006).

7 The abuse ofcough medicine containing dextromethorphan has effects on social and psychological aspects ofthe user's life. In the Lam and Shek (2006) study, participants reported an increase in intra-family relationship difficulties and feeling absent-minded, short tempe~ experiencing hallucinations, an inability to concentrate, lack ofconfidence, sense ofdrug dependency, over-alertness, and suspicion after consuming cough medicine. A report ofdifficulty relating to others including family and friends resulted in feeling socially isolated and withdrawn (Lam & Shek, 2006).

"Adolescence is an important period ofphysical, social, psychological, and cognitive growth" (Stagman et al., 2011, p. 1). Substance abuse during adolescence can impede the attainment ofimportant life skills such as interpersonal relationships, the development ofautonomy, and integration into adult society. The use ofdrugs during adolescence places teens at increased risk for dependency and addiction, and the more risk an adolescent is exposed to such as peer influence; the more likely they are to abuse substances (Stagman et al., 2011).

Health Risks from Use

Each preparation ofdextromethorphan contains different additives based on the marketing aim ofthe product. Acetaminophen (Tylenol®) and diphenhydramine

(Benadryl®) are two ofthe most common additives. These additives to the products that contain dextromethorphan can place the adolescent at risk for further health problems when consumed in large quantities.

Acetaminophen is a common additive to cough and cold preparations. In excess amounts gastrointestinal upset may occur and in high enough amounts hepatotoxicity can occur within 10 hours resulting in liver failure (Bryner et a1., 2006). After ingestion ofa

xiii large amount of acetaminophen transient rises in hepatic transaminases, fulminant hepatic failure, metabolic acidosis, renal failure, cerebral edema, and death may occur. The antidote for acetaminophen toxicity is N-acetylcysteine (Mucomyst®) given orally or intravenously. This medication can be given once blood levels ofacetaminophen are determined to be above 150 meg/roL (McKay, 2011). With chronic abuse of dextromethorphan containing products long term damage may be done to the liver due to acetaminophen. Patients may not present for care until they already are in liver failure.

Diphenhydramine is another medication commonly found as an additive in dextromethorphan cough and cold preparations. Common side effects oftoxic ingestion include, sedation, hallucinations, seizures, wide QRS complex on electrocardiogram, conduction blocks, hypotension, hypertension, respiratory depression, coma, and death

(Bebarta et al., 2010).

Prevention of Abuse

Dextromethorphan has been approved for use by the United States Food and Drug

Administration since 1958 for cough suppression. The United States Drug Enforcement

Agency excluded dextromethorphan from the Controlled Substance Act since 1970 even though there has been reported drug abuse and misuse for greater than 30 years. There have been United States legislative attempts to restrict access to dextromethorphan by

"...restricting the sale ofdextromethorphan-eontaining products to minors, increasing the penalties for misbranded use, requiring registration and cataloguing ofmail orders and internet-based sales, and reclassifying bulk dextromethorphan as a controlled substance"

(Banken & Foster, 2008, p. 403).

9 On September 14,2010, the United States Food and Drog Administration advisory committee chose to not recommend scheduling over-the-counter cough medicines containing dextromethorphan as a controlled substance. This decision was based on the fact that many consumers use dextromethorphan containing products for symptom reliefofcough and because viruses' spread rapidly the public needs to have over-the-counter access for safe and effective self-treatment (Consumer Healthcare

Products Association, 2010). Ifthe United States Food and Drog Administration placed dextromethorphan in Schedule V, then it would have permitted non-prescription use ofit under the federal Controlled Substances Act. This would allow only facilities that are registered with the state boards ofpharmacy to dispense the medication. Some states already have laws that are more restrictive than federal statute and require a minimum age requirement for purchase, and a prescription for Schedule V medications which would make it more difficult for consumers to access the medication (Traynor~ 2010).

In 2005 the United States Food and Drug Administration issued a warning against the abuse potential ofthis drug after five adolescents died from ingestio~ and there have been increased efforts by the American Medical Association to increase control and regulation ofdextromethorphan (Banken & Foster, 2008).

It has been noted that targeted interventions focusing on increased parental awareness and increased perceptions ofthe risks and social disapproval are the most effective abuse reduction strategies (Consumer Healthcare Products Association, 2010).

Along with the United States Food and Drug Administration regulations, caregiver education can help in the reduction ofadolescent misuse ofdextromethorphan.

Adolescents who learn about the risks ofdrug use at home with a parent are up to SO

10 percent less likely to use drugs (Huetteneder, 2006). Office visits by adolescents and/or parents can lead to a discussion regarding drug abuse (prescription, street, and over-the­ counter), alcohol, and tobacco abuse. Parents should be instructed to inventory their medicine cabinets and keep high abuse potential medications, such as cough syrups in a secure place or purchase in limited quantities during an illness then discard the remainder once the illness has resolved. They should also be aware oftheir adolescent's internet use and the websites frequented since many teens learn methods to misuse medications and order medications from the internet Ifan adolescent is noted to have a substance abuse problem encourage parents to seek professional help (Consumer Healthcare

Products Association, 2010).

Signifieanee or ImpHeatioDs for Nune Pnetitioner Practiee

Nurse practitioners and other medical providers playa key role in the prevention and education ofadolescents and care givers regarding over-the-counter medication abuse, such as can occur with dextromethorphan. The provider needs to be aware and educated regarding the abuse potential ofmedications, but not limit the patient's access to the necessary treatment ifdeemed appropriate. During each office visit the patient should be asked about use ofalcoho4 tobacco, drugs, prescription drugs, and over the counter medications. A discussion should take place with the care giver about medications in the home that may be at risk for abuse, and how to talk with the adolescent about drug use

(Joffe, 2008). Parents can have a positive influence in the adolescent's life by encouraging a strong sense of school belonging, and being a positive and present role model in the child's life throughout adolescence (Stagman et al., 2011).

11 Medical providers should become involved in legislation to raise awareness of adolescent misuse ofdextromethorphan. Providers may wish to lobby for cough medications containing dex1romethorphan to be obtained only from behind the pharmacy counter, an age requirement for purchase, and increased public awareness ofthe issue.

According to the biopsychosocial model medical providers and parents have a direct impact on the health habits ofadolescents. The influence ofmedical providers and parental involvement aids in the preventio~ detection, and treatment ofover-the~unter medication abuse. For instance, parents can set good examples ofhealth in the home by not using tobacco or alcohol products. Parents can also be involved in their child's life psychologically by encouraging healthy coping mechanisms and ways to deal with stress.

Additionally, parents can evaluate the stress factors in the home such as sibling rivalry, parental disagreements, etc. and make an effort to eliminate the stressor or reduce it

Medical providers can influence the health habits ofadolescents during each visit

Providers can be involved socially by asking about peers, groups, and activities as part of their social history obtained during the visit, and discuss concerns. They should evaluate health habits such as abuse ofover·the.-counter medications and educate adolescents about the health risks and impact this can have on them psychologically and socially.

Summary

Dextromethorphan is a medication that is currently being abused by adolescents.

It is readily available and socially accepted by peer groups. The biological, psychological, and social factors ofadolescents are all interconnected and playa role in the risk ofthe adolescent abusing medications including dextromethorphan.

12 Medical providers and caregivers playa role in prevention and identification of dextromethorphan abuse. This is done by being involved in legislation and the lives of adolescents. Asking and being infonned about the abuse potential ofdextromethorphan can aid in the prevention ofadolescent misuse ofthe medication.

There is a wide variety ofresearch and infonnation available regarding dextromethorphan abuse. More infonnation about the long term health risks and the development ofpsychological dependence is needed and will help in the establishment of effective prevention programs.

13 Referenees

Bankent J. A., & Foster, H. (2008). Dextromethorphan: An emerging drug ofabuse.

Annals ofthe New York Academy ofSciences, 1139, 402-411.

doi: 10.1196/annals.1432.00

Bebart&, V.S., Blair, H.W., Morgan, D.L., Maddry, J., & Borys, 0.1. (2010). Validation

ofthe American Association ofPoison Control Centers out ofhospital guideline

for pediatric diphenhydramine ingestions. Clinical Toxicology, 48, 559-562.

Bryner, J.K., Wang, U.K., Hui, J.W., Bedodo, M., MacDougall, C., & Anderso~ I.B.

(2006). Dextromethorphan abuse in adolescence: An increasing trend: 1999..

2004. Archives ofPediatrics & Adolescent Medicine, 160, 1217-1222.

Consumer Healthcare Products Association. 2010. FAQs about dextromethorphan.

Retrieved from http://chpa-info/printer.aspx?id=105

Consumer Healthcare Products Association, 2010. Statement from CHPA on the

September 14 FDA Advisory Committee on dextromethorphan. Retrieved from

http://www.chpa-info.orglprinter.aspx?id=685

Dextropmethorphan. (2011). Epocrates Rx Pro Version 4. Retrieved from

http://www.epocrates.com

Huetteneder, V. (2006). Generation Rx: National study confirms abuse ofprescription

and over-the-counter drugs "normalized" among teens. Retrieved from

http://www.drugfree.orglnewsroom/generation-rx-national-study-eonfinns-abuse­

of-prescription-and-over-the-counter-drugs...

%E2%800I09Cnormalized%E2%80%9D-among-teens

Joffe, A., (2008). Your role in curbing prescription and OTC drug abuse by adolescents.

14 Contemporary Pediatrics, 23(10), 97-101.

Johnston, L.D., O'Malley, P.M., Bachman, J.G., & Schulenberg, I.E. (2011). Monitoring

the Future national results on adolescent drug use: Overview ofkeyfindings,

2010. Ann Arbor: Institute for Social Research, University ofMichigan

Kumpfer, K.L., Trunnell, E.P., & Whiteside, H.O. (1990). The biopsychosocial model:

Application to the addiction field. In Enges, R.C. (Ed.), Controversies in the

addictionsfield, 55-68. Retrieved from

http://www.indianaedul..-.engslcbook/cbap7.html

Lakhan, s. (2006, August). The Biopsychosocial Model ofHealth andOlness. Retrieved

from the Connexions Web site: http://cnx.orglcoDtentlm13589/1.2/

Lam, C.M., & Shek, D.T. (2006) A qualitative study ofcough medicine abuse among

Chinese young people in Hong Kong. Journal ofSubstance Abuse 11(14),233­

244.

McKay, C. (2011). Acetaminophen: Hidden complexities ofa simple overdose. Medical

Laboratory Observer, 43(8), 12-16.

Miller~ s. C. (2011). Dextromethorphan to dextrorphan: A pathway towards abuse

liability. Human Psychopharmacology: Clinical and Experimental, 26, 89-90.

doi:l0.1002/hup.1164

Mutsebler~ J., Koopman A., Grosshans, M., Hermann, D., Mann, K., & Kiefer, F. (2010).

Dextrometborphan withdrawal and dependence syndrome. Deutsches Arzteblatt

Internattonal107(30), 537·540.

O'Malley~ P. (2010). Prescription and over-the-counter drug and substance abuse:

Something available for every age, anytime and anywhere. Clinical Nurse

15 Specialist 24(6),286-288.

Substance Abuse and Mental Health Services Administration. (2008). The NSDUH

report: Misuse ofover-the-counter cough and cold medications among persons

aged 12 to 25. The NSDUH Report. Retrieved from

http://oas"samhsa.gov12k8/cough/cough.efm

Stagman, S., Schwarz, S.W., & Powers, D. (2011). Adolescent substance use in the u.s.:

Facts for policy makers. National Centerfor Children in Poverty. Retrieved from

http://nccp.org

Traynor, K. (2010). Advisers vote against declaring dextromethorphan a controlled

substance. American Journal ofHealth-System Pharmacy, 67, 1788, 1790, 1793.

doi: 1O.2146/news100071

U.S. Department ofJustice Dro.g Enforcement Administration Office ofDiversion

Control. (2010). Drugs and chemicals ofconcem: Dextromethorphan. Retrieved

from http://www.deadiversion.usdoj.gov/dmgs_concem/dextro_m/dextro_m.htm

Williams, J.F. & Kokotailo, P.K. (2006). Abuse ofproprietary (over-the-counter) drogs.

Adolescent Medicine, 17, 733-750. doi:lO.l016/j.admecli.2006.06.006

16 Figure 1. The Biopsyehosoeial Model

Psychological Factors: Biological Factors: Stress Environmental agents Home life Physiological reactivity Coping ability Infectious agents Personality Genetics Health habits Prenatal history Reaction to health Substance abuse T .....~.. N ...... tinn

Social Factors: Social support group Health Education Access to health care Peer group School Religion

Figure 1. The biopsychosocial model showing how psychological, biological, and social factors are interconnected with an individual's physical health and illness. Adapted from Behavioral Healthcare Associates (2009). Retrieved from http://www.ashburnpsychologist.com/about_evidence_based-practice.html. Copyright 2009.

17 Table 1. Search Strategies

Author, Title, Year Type of Major Findings Categoryl Article and Conclusions Section of Paper

Banken & Foster Retrospective Concluded trends of Dextromethorphan Dextromethorphan: An Database dextromethorphan abuse in the United emerging drug ofabuse. review, sample abuse, also provided States, Prevention 2008 of280 calls to facts about ofAbuse, the Arkansas dextromethorphan Adolescent Poison Control Dextromethorphan Center Abuse Bebarta et ale Retrospective Findings determined Health Risks from Validation ofthe Study, sample common side effects Use American Association of of928 cases of from ingestion and Poison Control Centers diphenhydrami what level of out ofhospital guideline ne ingestion in ingestion cause for pediatric ages under 6 serious side effects diphenhydramine years old ingestions. 2010 Bryner et ale Retrospective Revealed trends in Adolescent Dextromethorphan Review, sample dextromethorphan Dextromethorphan abuse in adolescence: 1382 California abuse, commonly Abuse, Adolescent An increasing trend: Poison Control abused products, Abuse Risk, 1999-2004. 2006 System cases of and patient Adolescent Abuse dextromethorph outcomes after Risk, Health Risks an abuse ingestion from Use Consumer Health Infonnative Provided Prevention ofAbuse Products Association information on the FAQsabout Food and Drug dextromethorphan. 2010 Administration ruling to deny dextromethorphan as a controlled drug and ways to prevent abuse Consumer Health Informative Provided Prevention ofAbuse Products Association information on the Statement from ClIPA Food and Drug on the September 14 Administration FDA Advisory ruling to deny Committee on dextromethorphan dextromethorphan. 2010 as a controlled drug Epocrates Informative Provided Dextromethorphan Dextromethorphan. dextromethorphan Abuse in the United

18 2011 dosing for States prescribed use Huetteneder Review of Provided statistical Prevention ofAbuse Generation Rx: National Study, results from the study confirms abuse of Partnership for study and prescription and over­ a Drug-Free prevention methods the-counter drugs America "normalized" among teens. 2006 Joffe Informative Provided methods Significance or Your role in curbing the medical provider Implications for prescription and OTe can use to decrease Nurse Practitioner drug abuse by medication abuse Practice adolescents. 2008 Johnston et ale Statistical Statistics on Dextromethorphan Monitoring the Future Results from dextromethorphan Abuse in the United tb national results on the Monitoring abuse amonlS , States th adolescent drug use: the Future study 10 , and 12 grade Overview ofkey students findings. 2010 Kumpfer et ale Informative Provided the Theoretical The biopsychosocial biopsychosocial Framework model: Application to models relevancy to the addiction field. 1990 healthcare Lakhan Informative Defines the Theoretical The biopsychosocial biopsychosocial Framework model ofhealth and model and the illness. 2006 implications on healthcare Lam & Shek Qualitative Concluded 5 major Adolescent Abuse A qualitative study of Study, sample reasons for cough Risk cough medicine abuse of14 medicine abuse to among Chinese yOWlg adolescents and be: social pressure, people in Hong Kong. 5 parents personal problems, 2006 family relationships, availability, and ignorance McKay Infonnative Provided Health Risks from Acetaminophen: Hidden acetaminophen Use complexities ofa simple ingestion effects and overdose. 2011 risks Miller Informative Provided reasons for Introduction, Dextromethorphan to dextromethorphan Adolescent dextrorphan. 2011 abuse among Dextromethorphan adolescents Abuse

19 Mutschler et ale Case Study, Provided abuse Dextromethorphan Dextromethorphan sample 44 year potential Abuse in the United withdrawl and old male infonnation States dependence syndrome. dependant on 2010 dextromethorph an O'Malley Informative Provided facts of Introduction Prescription and over­ drug abuse and the-counter drug and definition of substance abuse: dextromethorphan Something available for every age, anytime, and anywhere. 2010 Stagman et ale Informative Provided facts of Adolescent Abuse Adolescent substance results from drug Risk, Significance use in the u.s.: Facts for abuse or Implications for policy makers. 2011 Nurse Practitioner Practice Substance Abuse and Quantitative Provided statistics Adolescent Mental Health Services Study, ofpercent of Dextromethorphan Administration completed in adolescent Abuse The NSDUH Report: 2006 with population cough Misuse ofover-the­ 44,819 persons medicine abuse and counter cough and cold aged 12 to 25 gender prevalence medications among by interviews ofabuse persons aged 12 to 25. including 2008 questionnaires Traynor Informative Provided the results Prevention ofAbuse Advisers vote against ofthe Food and declaring Drug Administration dextromethorphan a committee meeting controlled substance. denying 2010 dextromethorphan to be a scheduled drug U.S. Department of Informative Provided the dose Dextromethorphan Justice Drug dependant plateaus Abuse in the United Enforcement associated with States, Adolescent Administration Office of dextromethorphan Dextromethorphan Diversion Control abuse Abuse Drugs and Chemicals of concern: Dextromethorphan. 2010 Williams & Kokotailo Informative Dermes over-the­ Dextromethorphan Abuse ofproprietary counter drug abuse Abuse among (over-the-counter) Adolescents

20 Idrugs. 2006 I

21