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DEXTROMETHORPHAN ABUSE AMONG ADOLESCENTS by LISA

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DEXTROMETHORPHAN ABUSE AMONG ADOLESCENTS by LISA 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
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