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tech talk ce
the national continuing education program for pharmacy technicians
Answer online for instant results www.pharmacygateway.ca
CE just for technicians
Tech Talk CE is the only national
continuing education program for
Canadian pharmacy technicians.
It is independently accredited by the
CE division at Rogers Publishing Ltd.,
publisher of Pharmacy Practice, which
has been producing CE lessons for
pharmacists for more than 10 years.
As the role of the technician expands,
use Tech Talk CE as a regular part of
your learning portfolio. Note that a
passing grade of 70% is required to earn
the CE credit. Technicians certified by the
Pharmacy Technician Certification Board
of Alberta can submit CE units earned
through Tech Talk CE to their certification board.
Tech Talk CE is generously sponsored
by Novopharm Limited. Download back
issues at www.pharmacygateway.ca or
www.novopharm.com.
Answering Options
1. Answer the lesson online and
get your results instantly at
www.pharmacygateway.ca.
2. Use the reply card inserted with this
CE lesson. Circle the answers on
the card and mail in the
pre-paid, self-addressed card or fax to
Mayra Ramos, 416-764-3937.
To pass this lesson, a grade of 70%
(7 out of 10) is required. If you pass,
you will receive 1 CEU. You will be
advised of your results in a letter
from Tech Talk. Please allow
8 to 12 weeks.
Please note: Tech Talk CE is not
accredited by the Canadian Council
for Continuing Education in Pharmacy
(CCCEP).
CE Faculty
CE Coordinator:
Margaret Woodruff, R.Ph, B.Sc.
Phm., MBA
Humber College
Clinical Editor:
Lu-Ann Murdoch, B.Sc.Phm.
Author:
Susan Halasi, M.Sr.Phm,
RPh MPH
Reviewer:
Stephanie Bradley, CPhT
1 CEU
free
april/may
2007
Misuse of OTC products
By Susan Halasi, M.Sc.Phm.
Statement of objectives
Upon completion of this lesson, the pharmacy technician
should be able to:
1. Identify patients who are prone to abusing over-thecounter products.
2. Understand the consequences of abusing specific
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over-the-counter products.
3. Recognize why people may misuse over-the-counter products and
properly direct them to the appropriate healthcare professional.
Introduction
The abuse of over-the-counter (OTC) products is a
growing concern for legislators and professionals alike.
The pharmacist or pharmacy technician often detects
prescription drug abuse when a medication is dispensed.
OTC products, however, have an element of self-selection,
so abuse is more difficult to recognize.
The Canadian Parliamentary Research Branch, Political
and Social Affairs Division, has investigated the costs associated with substance abuse and published a policy paper
about it. Beyond the obvious costs associated with OTC
misuse, the paper cites several indirect costs resulting from
the long-term health problems in users, the breakdown
of family relationships, an increase in violent or abusive
behaviour in the user, and the absence or inability to
be productive in the workplace, which must also be
considered when calculating the real costs associated with
substance abuse.1
The federal government of Canada created the
Precursor Control Regulations in 2002 in an attempt
to curb the misuse of OTC products. The regulations are
designed to limit, or control, specific OTC products that
are readily available in a pharmacy, including pseudoephedrine and other chemicals such as iodine crystals,
isopropyl and rubbing alcohol, lye, lithium batteries and
rock salt, which are commonly used to manufacture the
street drug crystal methamphetamine.2
The MethWatch initiative strives to educate and help
front-line staff recognize and deal with dubious purchases
of certain self-selected products. The program instructs
employees on how to deal with unusually large purchases
of targeted products without confronting the customer
and endangering themselves. The pharmacy technician
could comply with this legislation simply by placing an
anonymous call to the RCMP toll-free hotline that is listed
on the MethWatch website.3
This lesson is intended to help pharmacy technicians
identify those individuals who may be abusing OTCs,
so they do not become unwitting accomplices. As well,
it will acquaint them with consequences of such abuse,
assist them in understanding what drives people to overuse products, and provide guidance on when technicians
should direct patients to the pharmacist for help.
Population-specific indicators
Adolescents (under 20 years of age) A recent survey of
high school students was conducted in an Ohio suburb
to investigate misuse of OTC products by adolescents.4
A total of 39,345 students were asked how often they used
OTC drugs to get “high.” The study didn’t differentiate or
inquire as to which substances were misused. The survey also asked about their home situation (two parents,
joint custody, or single-parent structure). OTC abuse by
students from a traditional family unit was lower, but
misuse did not vary significantly by family structure.
Overall, 4.7% of students indicated they misused OTC
An educational service for Canadian pharmacy technicians,
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tech talk ce
Continuing Education
drugs, with females abusing these products
more often than males. Misuse of medications
increased with grade level. Aboriginal youth
reported the highest levels of OTC misuse, followed by Caucasian and Asian populations, while
African American students indicated they rarely
used OTC products to get “high.” Students
abusing OTC products were more likely to use
alcohol and illicit drugs to cope with depression
brought on by “stress” in their lives.4
Addiction specialist Dr. Shannon Miller suggests this age group thinks OTC drugs are a
“smart choice” because they’re relatively cheap
(especially the generic/house brand products),
readily accessible (the family medicine cupboard/by shoplifting), carry no stigma for abuse
(compared to heroin or cocaine), and carry
minimal risk for detection (home or job test
kits).5,6 In this report, adolescents sought escape
from boredom, by intoxicating themselves at
parties, before, during, or after school.6
Female adolescents also revealed they may
abuse laxatives in an attempt to achieve the
“ideal” body image. Individuals with anorexia
try to use techniques such as restrained eating,
self-induced vomiting, and bowel purging with
stimulant laxatives, to continually lower their
weight.7 Bulimics will eat normally, then induce
vomiting using their fingers, utensils or purgatives to achieve weight control.8
Adults (21 to 50 years of age) Adults abuse
various OTC products for a number of reasons.
Antihistamines and cough suppressants provide
“cheap thrills” for this age group, if money is
a factor. Furthermore, extracting opioids and
decongestants from certain OTC drugs is part
of manufacturing illicit street drugs, which are
then sold to others for a huge profit.9,10
Females who feel pressure to maintain an
“ideal” body image are more likely to abuse
laxative products than males. Diarrhea resulting
from laxative abuse may lead to an electrolyte
imbalance, and the potential for kidney damage.8
The recent phenomenon of achieving a
“sculpted” body has led millions of people to
abuse OTC products sold as dietary supplements. Such products (many of which contain
ephedrine-like derivatives) have the potential
to cause anxiety, insomnia, psychosis and even
fatal cardiovascular problems.11
Seniors (over 55 years of age) A study conducted
in the south of Italy utilized a questionnaire to
determine the extent of overuse of laxatives. The
survey showed that over 40% of respondents
took laxatives when they didn’t need them. The
most common self-prescribers were elderly and
female. The authors suggested that laxative abuse
in those who suffer from anorexia or bulimia
can lead to colon cancer or laxative poisoning.
Such behaviour in the elderly may affect drugs
with narrow therapeutic windows, such as
warfarin or digoxin. Laxatives can cause severe
water and electrolyte loss, and affect levels of
vitamin K.12
OTC abuse categories
The patterns of OTC drug abuse are not static.
They continually evolve as professionals and
legislators observe these trends in illegal use or
diversion of products, and try to counter such
activities.9 Technicians and pharmacists can work
together to note these trends, report them and
avoid being unwitting accomplices in drug abuse.
Since the abused medications are constantly
changing and no organization systematically
researches and records information in this area,
most of the information available is from case
reports, making the information anecdotal and
incomplete. The following examples provide
insight into selected drug categories with reported
abuse potential and some of the dangers or issues
associated with this abuse/misuse. They do not
imply that other OTCs are not abused and technicians need to stay vigilant about all OTC sales to
see emerging patterns of inappropriate use.
Documented abuse of OTCs
Ant i h i s t am i n e s Dimenhydrinate is a
common medication that is normally used for
nausea and vomiting. Abusers have been characterized as adolescents, and individuals with a psychiatric history (schizophrenia, depression, substance abuse, personality disorders). These individuals are reported to become intoxicated (“high”)
when they consume anywhere between 7501,250 mg (about 15-25 tablets).9 Chronic abusers
have been reported to take doses as large as 5,000
mg, or 100 tablets, daily.13,14 If the individual
becomes addicted, then withdrawal or abstinence
symptoms will occur when they are unable to get a
supply of the medication. Withdrawal symptoms
include lethargy, agitation, hostility, clumsiness,
nausea, vomiting, hallucinations, confusion
and aggression. Technicians may attribute these
symptoms to a psychiatric disorder, rather than
realize it’s a drug-related problem.13,14
Diphenhydramine is normally used as an antihistamine for allergic reactions and as a sleeping
aid for insomnia (due to its drowsiness adverse
effect). The profile of a typical abuser includes
patients with schizophrenia and individuals with
chronic insomnia. Reported cases of chronic
abuse include daily consumption of 1,250-2,500
mg (50-100 tablets).9 Withdrawal symptoms
tech talk
have also been reported and are associated with
diarrhea, sweating, salivation, insomnia, anxiety
and aggression.
Cough and cold Dextromethorphan, a cough
suppressant, is reported to have been abused by
a 23-year-old man who used 26-48 ounces daily for five years (he purchased this item by the
case).9 The effects of abusing this OTC have been
likened to using LSD, producing euphoria, hallucinations and altered time perception. Adverse
effects of high taking doses include nausea,
vomiting, psychosis, mania, seizures and
respiratory depression.9 Increased abuse of this
product has led many physicians to recommend that dextromethorphan be rescheduled to
prescription-only status.6
Pseudoephedrine, a decongestant, is misused
for its stimulant and hallucinatory effects. As
previously noted, the active ingredient in this
OTC can be extracted for the manufacture of
crystal meth and the Meth Watch program has
been established to help front-line staff deal with
issues surrounding its sale.4,9
Laxatives and Purgatives As previously
explained, stimulant-type laxatives (bisacodyl,
castor oil, senna) have been abused in an
attempt to control weight in patients who
are bulimic or anorexic. 7,8,12 Abuse of laxatives is associated with chronic diarrhea,
electrolyte and acid-base disturbances, which
can become life-threatening. 8,12 Chronic use
may mask cancer or create absorption difficulties for drugs with a narrow therapeutic
window, such as warfarin or digoxin.12 These
patients may also abuse ipecac syrup, which is
normally intended to induce vomiting in situations where a patient has ingested something
poisonous. Heartbeat irregularity resulting
from ipecac abuse can cause death.8
Pain Relievers Codeine is a narcotic and
is available over-the-counter in combination products only. It is usually combined
with ASA or acetaminophen and caffeine.
Abusers who are seeking its euphoric effects
may attempt to extract the codeine from these
combination analgesics by dissolving tablets in water and passing them through coffee
filters. 10,17 However, this pattern of codeine
extraction has declined since pharmacies have made the product less available to
consumers by placing it behind the counter.
Nevertheless, codeine remains readily available
from illicit sources.9,17 Patients with liver, kidney or heart disease or the elderly are at greatest
risk for developing acute kidney failure due to
abuse of non-steroidal anti-inflammatory drugs
including ibuprofen.18
April/may 2007
The technician’s role
The above examples provide some insight into
the variety of over-the-counter medications that
have the potential for misuse or abuse. However,
since patterns of abuse constantly change, it can
be challenging to distinguish appropriate and
inappropriate use of OTC medications.
Often education is all that is needed to
address the problem within the pharmacy
environment. For example, if a pharmacy technician notices an individual purchasing topical
hydrocortisone, the technician should ensure
the patient speaks to the pharmacist to receive
proper instructions for using the product.
However, in some situations there are no
obvious reasons to suspect a problem. Therefore
the pharmacy technician needs to watch out for
some general indicators of misuse and abuse.
To help technicians identify a situation
of misuse or abuse, the following checklist
details some of the behaviours that could
indicate a problem:
1.Be aware of patients who purchase an
unusually large quantity of one product.
What defines a large quantity is sometimes difficult to measure, but purchasing
several bottles when the norm is one
could indicate a problem.
2.Another indicator to watch out for is
if the patient buys the same quantity, but
does so frequently (possibly every few
days), when the medication would last
for weeks under normal circumstances.
3.When a patient buys a product in a drug
category that is known to be misused, this
may also indicate a problem, although as
previously stated this is a changing target.
4.The patient fits the profile discussed above
of a potential abuser.
Keep in mind, there are often very legitimate
reasons for a patient to purchase large quantities
or purchase frequently so it is important for the
technician to never confront or accuse a patient.
Simply be vigilant and try to refer them in a
non-confrontational manner to the pharmacist.
Common sense should also be used.
As explained above, it is quite often the
pharmacy team that first notices when a medication is starting to be abused so if the pharmacy
technician suddenly notices a large increase in
sales of a certain OTC product to a specific
group of patients, a “red flag” should go up and
the technician should report this to the pharmacist, who can then pass it on to the other
healthcare professionals and/or the authorities
as appropriate.
Since many pharmacies keep track of OTC
purchases in the patient’s computer medication
profile, the pharmacy technician could assist
the pharmacist by ensuring appropriate entries
are entered into the system.
Summary
The challenge for pharmacy technicians and
pharmacists alike is to control the problem
of abuse, yet make over-the-counter products
accessible to the majority of the population
who use them appropriately. Through awareness, vigilant monitoring and education,
pharmacy technicians and pharmacists can
promote the safe and effective use of such
products.9,20
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Up for grabs: 2 Sony Playstation Portable prize packages (approx. retail value $430)
1 Apple iPod Nano (approx. retail value $170)
Click on www.pharmacygateway.ca to access over 20 Tech Talk CE lessons written especially for
pharmacy technicians like you.
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at the number below.
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Go online or fill out this form and fax to 416-764-3931.
Referral name ______________________________________
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Referral email or phone # _____________________________
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Name of lesson completed _____________________________
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Contest Closes September 30, 2007. To enter, you must be employed as a pharmacy technician and be a Canadian resident over age
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received. Mathematical skill-testing question to be correctly answered to win. No Purchase Necessary.
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Dietary Supplements Ephedrine/creatine is
used by more than one million people to gain
muscle and lose fat, according to an American
survey, despite lack of proof that it is effective. Ephedrine may cause anxiety, insomnia,
psychosis, mania and fatal cardiovascular complications so its use should be monitored even
in usual doses.11
Topical products Hydrocortisone can be used
topically for skin inflammation and rashes.
Inappropriate application to the face for extended
periods of time has led to the development of
rosacea accompanied by burning, itching, red
papules and nodules.19
tech talk ce
References:
1.Chenier NM. Substance abuse and public policy.
Parliamentary Research Branch, Political and Social
Affairs Division. 2001 January. [accessed December
12, 2006].
Available from : www.parl.gc.ca/information/
library/prbpubs/942-e.html
2.Anon. Crystal meth advisory. Pharm Connection
Sep/Oct 2005; 18-9.
3.Meth Watch Coalition. Meth Watch: A Toolkit for
Head Offices, Store Managers and Employees of
Participating Organizations. 2005 April. [accessed
Continuing Education
December 15, 2006]. Available from: www.methwatch.ca
4.Steinman KJ. High school students’ misuse of overthe-counter drugs: a population-based study in an
urban county. J Adolesc Health 2006;38:445-7.
5.Miller SC. Coricidin® HBP Cough and Cold
Addiction. J Am Acad Child Adolesc Psychiatry
2005;44(6):509-10.
6.Schwartz RH. Adolescent abuse of dextromethorphan. Clin Pediatr 2005;44:565-8.
7.Gwadry-Sridhar F. OTC Counsellor: Counselling
Patients on Constipation and Laxatives. Pharmacy
Pract, December 1997.
8.Pray WS, editor. Nonprescription Product
Therapeutics.1st ed. Lippincott Williams & Wilkins,
1999.
9.Webb J. Over-the-counter or underground, don’t
be an accomplice to OTC abuse. Pharm Pract
2003;19(2):33-6.
10.Hughes GR, McElnay JC, Hughes CM, et al.
Abuse/Misuse of Non-Prescription Drugs. Pharm
World Sci 1999;21(6):251-5.
11.Kanayama G, Gruber AJ, Pope Jr HG, et al.
Over-the-Counter Drug Use in Gymnasiums:
An Underrecognized Substance Abuse Problem?
Psychother Psychosom 2001;70:137-40.
12.Motola G, Mazzeo R, Rinaldi B, et al. Self-prescribed laxative use: a drug-utilization review.
Adv Therapy 2002;19(5):203-8.
13.Halpert AG, Olmstead MC, Beninger RJ.
Mechanisms and Abuse Liability of the Antihistamine dimenhydrinate. Neurosci Biobehav Rev
2002;26:61-7.
14.Rowe C, Verjee Z, Koren G. Adolescent
Dimenhydrinate Abuse: Resurgence of an Old
Problem. J Adolesc Health 1997;21:47-9.
15.Marinetti L, Lehman L, Casto B, et al. Over-theCounter Cold Medications—Postmortem Findings
in Infants and the Relationship to Cause of Death.
J Anal Tox 2005;29:738-43.
16.Ujiye G. Precursors to Illicit Drugs. Pharm
Connection Jul/Aug 2003;10-5.
17.Fleming GF, McElnay JC, Hughes CM. The separation of codeine from nonprescription combination
analgesic products. Substance Use & Misuse
2003;38(9):1217-26.
18.Whelton A. Renal Effects of Over-the-Counter
Analgesics. J Clin Pharmacol 1995;35:454-63.
19.Tackett BN, Smith MC, Nedorost ST, et al.
➤ Questions
Please select the best answer for each question or answer
online at www.pharmacygateway.ca for instant results.
1.Substance abuse has been
associated with:
a) Violent and abusive behaviour.
b) Improved productivity at work.
c)No real change in the abuser’s health.
d) None of the above.
2. One of the following statements is
TRUE about adolescent abusers:
a)Adolescents in a single-parent family significantly abuse OTC products
compared to individuals coming from a
traditional family setting.
b)Male adolescents are the most frequent
abusers of laxative OTC drugs.
c)Adolescents consider OTC drugs
cheap, easily accessible, and often
overlooked as a way to get “high.”
d)It is the group in Grades 7 through
9 who are more likely to abuse OTC
drugs than high school seniors.
3. Regarding OTC abuse by adults:
a)Cough and cold products are not
abused since they cause sleepiness.
b)The abuse of laxatives by women is
common, but presents no real danger.
c)The abuse of dietary supplements,
particularly those containing ephedrine
may cause cardiovascular disorders.
d)None of the above.
4. One of the following statements is
TRUE about dimenhydrinate abuse.
a)Chronic abusers of dimenhydrinate may
take up to 10 tablets daily.
b)Adolescents have not been known
to abuse dimenhydrinate, usually it
is someone with a psychiatric history
(schizophrenia, personality disorder).
c)No abstinence or withdrawal symptoms
are associated with the discontinuation
of large quantities of dimenhydrinate.
d)Withdrawal symptoms would include
lethargy, agitation, hostility, clumsiness,
nausea, vomiting, hallucinations, confusion and aggression.
5. Abuse of dextromethorphan:
a)Has led emergency physicians to
recommend that it be changed to a
prescription-status drug.
b)Will cause euphoria, hallucinations and
altered time perception.
c)Was purchased by the case by an individual taking excessive quantities daily.
d)A, B and C are correct.
6. Abusers purchasing large quantities
of pseudoephedrine:
a)Use it for its hallucinatory effects.
b)May extract the chemical for the manufacture of an illicit product.
c)Should not be stopped, but reported
to RCMP Diversion Program.
d)A, B and C are correct.
7. Stimulant laxative abuse:
a)Can be seen in the adolescent, adult
and senior population.
b)Normalizes electrolytes, but does cause
loss of water.
c)Speeds up absorption, increasing the
benefit of drugs with narrow therapeutic index.
d)Is not seen in the bulimic patient.
8.Abuse of OTC analgesics:
a)Is common because codeine is very
difficult to obtain on the street.
b)Is infrequent because it is impossible to
extract codeine from tablets.
c)Such as non-steroidal anti-inflammatory
drugs can result in acute kidney failure.
d)Abuse of OTC analgesics has not been
reported.
9. When it comes to OTC abuse, healthcare professionals:
a)Should not get involved with their
customers OTC use; it is not their
business.
b)Should not be unwitting accomplices to
OTC abuse.
c)Should monitor OTC use in order
to provide optimal patient care and
ensure patient safety.
d)B and C are correct.
10. Increased awareness by healthcare
professionals about the abuse of
OTC products:
a) Involves education and vigilant monitoring of certain product categories.
b) Won’t really affect accessibility and
location of OTC products of abuse.
c) A and B are correct.
d) None of the above.
Morbidity of Over-the-Counter Topical
Steroids. J Am Acad Dermatol 2006;55(1):182.
20.Wazaify M, Shields E, Hughes CM, et al. Societal
Perspectives on Over-the-counter (OTC)
Medicines. Fam Pract 2005;22:170-76.
tech talk
For information about CE marking, please contact Mayra Ramos at (416) 764-3879
or fax (416) 764-3937 or email [email protected].
All other inquiries about Tech Talk CE should be directed to Laurie Jennings at
(416) 764-3917 or [email protected]
april/may 2007