“Purple Drank” (Codeine and Promethazine Cough Syrup): A Systematic Review of a Social Phenomenon with Medical Implications

The roles of vicarious trauma exposure and perceived social support in codeine syrup misuse among Black men living in prisons

Using General Strain Theory, this study investigates the effects of vicarious trauma exposure and perceived social support on nonmedical codeine syrup misuse among Black incarcerated men nearing community re-entry. Data were drawn from the Helping Incarcerated Men project, a study examining mental health, substance misuse, and human immunodeficiency virus (HIV) risk behaviors among Black men living in prisons who were within 180 days of release. A total of 200 Black men self-reported demographics (i.e., age and length of incarceration after age 18), vicarious trauma exposure (e.g., ever witnessing an assault with a weapon and a sudden accidental death), perceived social support, and nonmedical codeine syrup misuse. Findings from the logistic regression analysis showed witnessing an assault with a weapon and a sudden accidental death increased the likelihood of codeine syrup misuse. Perceived social support was not associated with codeine syrup misuse. Implications for practice and future research are discussed.

Milligram scale enantioresolution of promethazine and its main metabolites, determination of their absolute configuration and assessment of enantioselective effects on human SY-SY5Y cells

The misuse of pharmaceuticals has significantly increased in recent decades, becoming a major public health concern. The risks associated with medication misuse are particularly high in cases of overdose, especially when the active substances are chiral, as enantioselectivity plays an important role in toxicity. Promethazine (PMZ) is a chiral antihistamine marketed as a racemate and it is misused in "Purple Drank", a recreational drug beverage, that combines codeine and/or PMZ, with soda or alcohol leading to serious health consequences and fatalities in consumers around the world, particularly among teenagers. Information regarding the enantioselectivity in the toxicity of (R,S)-PMZ and its main metabolites, namely promethazine sulfoxide (PMZSO) and desmonomethyl promethazine (DMPMZ), is unknown. This work reported, for the first time, the enantioseparation, in milligram scale, of (R,S)-PMZ, (R,S)-DMPMZ, (R,S)- PMZSO and the determination of their absolute configurations by electronic circular dichroism (ECD). The enantioseparation of all the six enantiomers was accomplished in a homemade semi-preparative column with amylose tris-3,5-dimethylphenylcarbamate (AD) coated with aminopropyl Nucleosil silica. The enantiomeric purity was evaluated using the analytical Lux® 3 µm i-Amylose-3 column, yielding enantiomeric purity values ranging between 94.4% and 99.7%. The elution order of all the enantiomers was accomplished combining the ECD results with an optical rotation detector. The elution order of the enantiomers was influenced only by the chiral selector, rather than the mobile phase. The cytotoxicity of the racemates and the isolated enantiomers towards differentiated SH-SY5Y cells was evaluated. (R,S)-DMPMZ exhibited a significantly higher cytotoxicity than (R,S)-PMZ, suggesting the metabolic bioactivation of (R,S)-PMZ. Conversely, no significant cytotoxicity was found for (R,S)-PMZSO, underscoring a metabolic detoxification pathway. Remarkably, enantioselectivity was observed for the cytotoxicity of PMZ; (R)-PMZ was significantly more cytotoxic than (S)-PMZ. The results underscore the importance to isolate the enantiomers in their enantiomerically form and their correct identification for toxicity enantioselectivity studies, which are vital to understand the drug's behaviour and safety, especially in case of overdoses.

Binding studies of promethazine and its metabolites with human serum albumin by high-performance affinity chromatography and molecular docking in the presence of codeine

"Purple Drank", a soft drink containing promethazine (PMZ) and codeine (COD), has gained global popularity for its hallucinogenic effects. Consuming large amounts of this combination can lead to potentially fatal events. The binding of these drugs to plasma proteins can exacerbate the issue by increasing the risk of drug interactions, side effects, and/or toxicity. Herein, the binding affinity to human serum albumin (HSA) of PMZ and its primary metabolites [N-desmethyl promethazine (DMPMZ) and promethazine sulphoxide (PMZSO)], along with COD, was investigated by high-performance affinity chromatography (HPAC) though zonal approach. PMZ and its metabolites exhibited a notable binding affinity for HSA (%b values higher than 80%), while COD exhibited a %b value of 65%. To discern the specific sites of HSA to which these compounds were bound, displacement experiments were performed using warfarin and (S)-ibuprofen as probes for sites I and II, respectively, which revealed that all analytes were bound to both sites. Molecular docking studies corroborated the experimental results, reinforcing the insights gained from the empirical data. The in silico data also suggested that competition between PMZ and its metabolites with COD can occur in both sites of HSA, but mainly in site II. As the target compounds are chiral, the enantioselectivity for HSA binding was also explored, showing that the binding for these compounds was not enantioselective.

Codeine and promethazine: Exploratory study on "lean" or "sizzurp" using national survey data and an online forum

BACKGROUND

The concoction known as "lean" containing codeine and promethazine, holds a prominent cultural presence and is often referenced in mass media platforms (e.g., music and social media). Surprisingly, there's a scarcity of national data characterizing the use of lean. Therefore, the current study investigated the use of lean using national survey data and online forum participant input, and focused on identifying concurrent substance use, exploring co-administration with other substances (e.g., alcohol, cannabis), and determining lean-related experiences.

METHODS

We analyzed data from the National Survey on Drug Use and Health (NSDUH) spanning 2007-2019, identifying persons who used lean (weighted N = 42,275). Additionally, we conducted a Reddit-based study to gather insights about lean consumtion (N = 192).

RESULTS

The NSDUH data indicated that lean use was most prevalent among teenagers and young adults (ages 13-21), accounting for 66% of the sample. This trend was more pronounced in male respondents (75%) compared to females. Additionally, the use was predominantly observed among Black/African American (29%), Hispanic (28%), and White (33%) populations, with these groups also reporting higher levels of concurrent alcohol and cannabis use. Similarly, findings from Reddit showed that individuals who used lean were predominantly male (67%) and exhibited elevated concurrent rates of alcohol (83%) and cannabis (46%) use in the past 30 days. Moreover, approximately 66% of respondents met criteria for severe lean use disorder, and 37% acknowledged driving under its influence.

CONCLUSION

The NSDUH data found that mostly young adult males reported consuming lean in the past twelve months, though the racial/ethnic breakdown of persons who used lean was diverse. The Reddit data found that most individuals in the sample met the criteria for a substance use disorder pertaining to their lean consumption. These findings underscore the clinical significance and necessity for further controlled research on lean.

Lean/Sizzurp Ingredients, Use, and Coping With Mental Health Symptoms

The substance combination of codeine and promethazine, commonly termed lean/sizzurp, has been identified as a method that some individuals use to cope with PTSD and other mental health symptomology. A sample of 1423 adults with self-reported past year lean use was recruited from substance-related Reddit pages to complete a survey about lean, including information about using lean to cope with emotions, thoughts, or feelings. To be included in the sample, persons needed to: (1) be ⩾18 years old, (2) report past year lean use, (3) complete lean use screeners, and (4) pass data quality checks (eg, bot detection). As Reddit is an online forum, no geographic restrictions were placed on study participation. Data on demographic characteristics, lean use, and mental health disorder symptomology were captured from participants. Logistic regression models included anxiety, depression, and trauma as independent variables along with covariates to examine using lean to cope with emotions, thoughts, or feelings in the past 30 days. Most participants were male (n = 1102; 77.4%), with an average age of 26.9 (SD = 5.2) years. Most participants used included codeine as an ingredient in lean (n = 1060; 74.5%); promethazine was added as an ingredient by 31.7% of the sample (n = 451), and the combination of codeine and promethazine was included as ingredients by 13.5% (n = 192) of the sample. Participants with anxiety, lifetime trauma exposure, and who were female had increased odds of using lean to cope with emotions, thoughts, or feelings in the past 30 days. Those with depression and unstable housing exhibited decreased odds of using lean to cope with emotions, thoughts, or feelings in the past 30 days. This study recruited persons via social media to learn more about lean use, especially lean use to cope with mental health symptoms; future population-level studies are needed.

Deliberate Self-Poisoning: Real-Time Characterization of Suicidal Habits and Toxidromes in the Food and Drug Administration Adverse Event Reporting System

INTRODUCTION

Deliberate self-poisoning (DSP) using drugs is the preferred method of suicide at a global level. Its investigation is hampered by limited sample sizes and data reliability. We investigate the role of the US FDA Adverse Event Reporting System (FAERS), a consolidated pharmacovigilance database, in outlining DSP habits and toxidromes.

METHODS

We retrieved cases of 'intentional overdose' and 'poisoning deliberate' from the FAERS (January 2004-December 2021). Using descriptive and disproportionality analyses, we estimated temporal trends, potential risk factors, toxidromes, case-fatality rates and lethal doses (LDs) for the most frequently reported drugs.

RESULTS

We retrieved 42,103 DSP cases (17% fatal). Most cases were submitted in winter. Reports of DSP involved younger people, psychiatric conditions, and alcohol use, compared with non-DSP, and fatality was higher in men and older patients. Suspected drugs were mainly antidepressants, analgesics, and antipsychotics. Multiple drug intake was recorded in more than 50% of the reports, especially analgesics, psychotropics, and cardiovascular agents. The most frequently reported drugs were paracetamol, promethazine, amlodipine, quetiapine, and metformin. We estimated LD25 for paracetamol (150 g).

CONCLUSION

Worldwide coverage of the FAERS complements existing knowledge about DSP and may drive tailored prevention measures to timely address the DSP phenomenon and prevent intentional suicides.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pattern of substance use and substance use disorder in adolescent learners at public secondary schools in Gaborone, Botswana

INTRODUCTION

Substance use amongst adolescents remains a global public health challenge. The potential negative health outcomes of substance use suggest the need to understand the pattern of use and the associated factors among adolescents. This study aimed to describe the prevalence of substance use, SUDs, and PD and the associated factors in adolescent learners at public schools in Gaborone, Botswana.

METHODS

A cross-sectional study was conducted at 13 public secondary schools in Gaborone among 742 students. Assessment tools included the World Health Organization drug questionnaire, DSM-5 interview for SUD, and the General Health Questionnaire-12.

RESULTS

The mean age (SD) of the participants was 15.26 (1.57) years, and there were more females (55.5%). Over two-fifths (44.6%) of learners reported psychoactive substance use in the past 12 months, and 31.5% meeting DSM 5 criteria for a SUD. Alcohol was the most used psychoactive substance (25.1%). Male gender (AOR = 1.94; 95% CI: 1.26-2.995), having a friend (AOR = 4.27; 95% CI: 2.68-6.78), or father (AOR = 1.87; 95% CI: 1.14-3.04), who uses substance, and higher levels of PD (AOR = 1.09; 95% CI: 1.03-1.17) remained significantly associated with SUD. Regular participation in religious activities negatively correlated with SUD (AOR = 0.61; 95% CI: 0.38-0.96).

CONCLUSION

The high prevalence of substance use and SUDs among in-school adolescents is concerning. Substance use programs need to include family-focused and religious-based therapy and youth empowerment in developing positive peer relationships. Also, they should be integrated with mental health screening to assess comorbid PD.

The Benzydamine Experience: A Systematic Review of Benzydamine Abuse

BACKGROUND

Both prescription and over-the-counter (OTC) drugs recently emerged among novel psychoactive substances (NPS) being reported as ingested for recreational purposes. Among them, benzydamine (BZY), normally prescribed as an OTC anti-inflammatory drug, is reportedly being diverted and recreationally used.

OBJECTIVE

The aim of this study was to investigate how the misuse of BZY has been reported, illustrating its psychotropic molecular mechanism, and studying its psychopathological effects.

METHODS

We firstly conducted a systematic review of the literature concerning the abuse of BZY and its effects. For data gathering purposes, both PRISMA and PROSPERO guidelines were followed. All research methods were approved by PROSPERO (identification code CRD42020187266). Second, we analysed BZY-related data from the European Monitoring Agency (EMA) Adverse Drug Reactions (ADRs) database recorded during 2005-2020 regarding its abuse.

RESULTS

Eleven articles, published during 1997-2019, were included in our systematic review, including five case reports, four surveys, and two retrospective case series analyses. While nine articles dealt with the recreational use of BZY, two described an oral overdose of the drug. When specified, dosages of BZY consumed ranged from 500 to 1500mg. The EMA dataset contained three cases of BZY abuse.

CONCLUSION

Results from the systematic review showed BZY might be diverted for typical hallucinogenic properties occurring at high dosages. Healthcare professionals should be warned about a possible misuse/abuse of a commonly prescribed anti-inflammatory drug and be vigilant when prescribing it. Physicians working in emergency units should know that psychotic symptoms may be related to BZY abuse.

Medical prescription forms of opioid cough suppressants falsified by the patients before and after they switched from OTC to prescription-only in France

BACKGROUND

The French Ministry of Health scheduled opioid cough suppressants as prescription-only drugs on July 12^th , 2017. The present study assessed the impact of this regulation on the diversion modalities of the concerned drugs and the related drug pholcodine by analysing the national OSIAP (Ordonnances suspectes indicateur d'abus possible) database.

METHODS

Medical prescriptions with at least one mention of codeine, dextromethorphan, ethylmorphine, noscapine or pholcodine for cough suppression recorded in 2013-2019 were extracted from OSIAP. Annual mentioning rates were estimated by dividing numbers of mentions over those of prescriptions recorded the year considered. A descriptive analysis compared the characteristics of prescriptions before and after July 12^th , 2017.

RESULTS

Overall, 832 mentions of the requested drugs were retrieved on 827 prescription forms. Codeine was the most frequent (n=809, 8.7%) with 6 additional mentions of codeine/ethylmorphine combination, followed by dextromethorphan (n=11, 0.1%) and pholcodine (n=6, 0.1%). There was no mention of noscapine. Annual mentioning rates varied between 0 and 0.3% for all drugs except codeine. Codeine mentioning rates ranged between 0.3% (n=2) and 0.7% (n=9) before July 12^th , 2017 and increased to 10.1% (n= 61) thereafter in 2017, 16.1% (n=314) in 2018, and 19.8% (n=414) in 2019. The profile of subjects evolved accordingly with an arisen male/female ratio (10.0 versus 1.5 before), a younger age (23 years versus 40 before, p<0.001).

DISCUSSION

The sharp increase of recourse to falsified prescription forms indicates that codeine diversion continues despite a restricted access, whereas the other drugs studied do not seem to have been impacted.

Clinical Pharmacology, Toxicity, and Abuse Potential of Opioids

Opioids were the most common drug class resulting in overdose deaths in the United States in 2019. Widespread clinical use of prescription opioids for moderate to severe pain contributed to the ongoing opioid epidemic with the subsequent emergence of fentanyl-laced heroin. More potent analogues of fentanyl and structurally diverse opioid receptor agonists such as AH-7921 and MT-45 are fueling an increasingly diverse illicit opioid supply. Overdose from synthetic opioids with high binding affinities may not respond to a typical naloxone dose, thereby rendering autoinjectors less effective, requiring higher antagonist doses or resulting in a confusing clinical picture for health care providers. Nonscheduled opioid drugs such as loperamide and dextromethorphan are associated with dependence and risk of overdose as easier access makes them attractive to opioid users. Despite a common opioid-mediated pathway, several opioids present with unique pharmacodynamic properties leading to acute toxicity and dependence development. Pharmacokinetic considerations involve half-life of the parent opioid and its metabolites as well as resulting toxicity, as is established for tramadol, codeine, and oxycodone. Pharmacokinetic considerations, toxicities, and treatment approaches for notable opioids are reviewed.

Detection of pharmaceuticals in "dirty sprite" using gas chromatography and mass spectrometry

Dirty Sprite, also known as "lean" or "purple drank", is a preparation associated with the presence of codeine and promethazine. These drinks, predominantly used by young people, are mixtures of, for example, soft drinks, prescription medicines, and prescription cough syrups. The use of these illicit preparations started in Texas in the 1960s and become popularized in the 1990s. However, the misuse of these cocktails has become more common in other countries to date, for example, in Thailand. Given the illicit nature of these preparations and the lack of information available on the composition of these products, there is a need to identify and quantify the drugs that may be present. Three samples of Dirty Sprite were analyzed using GC-MS after liquid/liquid-extraction under acidic and basic conditions. Since the acidic extraction did not show the detection of relevant substances, samples were alkalized to pH ≥ 9, followed by extraction with 1-chlorobutane. GC-MS screening revealed the identification of codeine, dihydrocodeine, promethazine and impurities of cocaine. A selected ion monitoring method was developed for the quantification of these compounds using lemonade as a calibration matrix. Quantitative analysis showed concentrations of 130-mg/L codeine, 75-mg/L promethazine, and 3.4-mg/L cocaine in sample 1; 74-mg/L promethazine and 91-mg/L dihydrocodeine in sample 2; and 130-mg/L codeine combined with 68-mg/L promethazine in sample 3. The results also illustrate that the consumption of drugs detected in Dirty Sprite samples could lead to health risks given that these prescription medicines are consumed outside the medical environment.

Validation of the Opioid Overdose Risk Behavior Scale, version 2 (ORBS-2)

OBJECTIVE

To examine the factor structure of a revised and expanded opioid overdose risk behavior scale and assess its associations with known overdose indicators and other clinical constructs.

BACKGROUND

Opioid-related overdose remains high in the U.S. We lack strong instrumentation for assessing behavioral risk factors. We revised and expanded the opioid overdose risk behavior scale (ORBS-1) for use among a broader range of people who use opioids.

SETTING & SAMPLING FRAME

Using respondent-driven sampling we recruited adults (18+) reporting current unprescribed opioid use and New York City residence.

METHOD

Participants (N = 575) completed the ORBS-1, ORBS-2, and a variety of clinical measures and then completed the ORBS-2 and overdose risk outcomes across monthly follow-up assessments over a 13-month period.

RESULTS

Principal components analysis was used to identify six ORBS-2 subscales, Prescription Opioid Misuse, Risky Non-Injection Use, Injection Drug Use, Concurrent Opioid and Benzodiazepine Use, Concurrent Opioid and Alcohol Use, and Multiple-Drug Polysubstance Use. All subscales showed moderate non-parametric correlations with the ORBS-1 and with corresponding clinical constructs. Five of the subscales were significantly (p < .01) positively associated with self-reported non-fatal overdose. Of note, the Risky Non-Injection Use subscale was the most strongly associated with past-month overdose indicators.

CONCLUSIONS

Psychometrics for the opioid overdose risk behavior subscales identified suggest the ongoing utility of risk behavioral instrumentation for epidemiological research and clinical practice focused on risk communication and minimization. Use of the entire ORBS-2 measure can provide insight into the proximal/behavioral factors of greatest concern to reduce overdose mortality.

Hikikomori: psychopathology and differential diagnosis of a condition with epidemic diffusion

OBJECTIVE

Hikikomori, from the Japanese words 'hiku' (to pull) and 'komoru' (to withdraw), is a clinical condition in which a subject locks himself/herself into his/her own house for more than 6 months. This condition is becoming relevant in Japan and other Asian countries, with new cases emerging in Europe and a steep increase in its incidence.

METHODS

In this article, the various psychopathological and diagnostic hypothesis and the different criteria proposed by the various authors have been analysed and compared, paying attention also to the new studies conducted in Europe and to therapeutic perspectives that are opening up for its treatment.

RESULTS

Numerous hypothesis have been put forward for the genesis of hikikomori, in particular, the hypothesis of a behaviour seen as a dysfuncion of the family system or as a result of our current modern society. Furthermore, this behaviour has been compared to other conditions such as internet addiction and a specific form of depression called Modern Type Depression (MTD).

CONCLUSIONS

Hikikomori could represent the clinical answer to a social evolution, similarly to other phenomena such as binge behaviours and use of psychoactive substances. Further studies are needed to clarify diffusion, diagnosticassessment and differential diagnosis.Key pointsHikikomori is now considered a contemporary society-bound syndrome linked to modern society changes.Hikikomori might be a coping strategy to avoid relationships, social judgement and possible failures.Hikikomori might represent an extreme suffering that needs to be identified early: it is linked to severe form of modern type depression and it is a risk factor for suicidal behaviours.It is important to inform and sensitise communities about hikikomori to assure early interventions.More clinical studies are needed to define a unitary and specific model of hikikomori and to structure focussed interventions.

Antihistamine-related deaths in England: Are the high safety profiles of antihistamines leading to their unsafe use?

AIMS

Antihistamines are routinely taken to control allergic reactions or sedation to induce sleep. There are, however, growing concerns regarding sedating antihistamine misuse. This research aims to evaluate deaths related to antihistamines in England occurring during 2000-2019.

METHODS

Cases reported to the National Programme on Substance Abuse Deaths from England occurring in 2000-2019 with antihistamine detections at postmortem were extracted for analysis.

RESULTS

In total, 1666 antihistamine postmortem detections were identified from 1537 cases. Sedating antihistamines available for purchase under pharmacist supervision but without need for a prescription (pharmacy-only medications) were present in a significant majority of cases (85.2%, P < .01). Despite an increasing trend for antihistamine-related deaths over time, the proportion of deaths where an antihistamine was implicated declined over the same period. Specific concerns with regards to the misuse of these pharmacy-only sedating antihistamines are raised with regards to the significant proportion of cases that were concluded as suicide (20.9%, P < .01), and the high prevalence of their use in combination with other central nervous system depressants (94.8% of cases).

CONCLUSION

This is the first report in over 40 years regarding antihistamine-related mortality from England. The rising trend in sedating antihistamine-related deaths may be contributed to by their increasing availability and the perceived negligible dangers associated with antihistamines, both from the general public and learned professionals. Awareness of the dangerous sedative properties that some antihistamines possess is, however, heightened in individuals deliberately seeking these effects. Urgent review of sedating antihistamines currently assigned under the pharmacy-only classification is needed to achieve antihistamine harm reduction.

Factors associated with the use of the prescription monitoring program by prescribers and pharmacists in Texas

PURPOSE

To describe Texas Prescription Monitoring Program (PMP) use and identify predictors of PMP query for opioid and benzodiazepine prescriptions by prescribers and pharmacists.

METHODS

Dispensation and query records from the Texas PMP for opioid and benzodiazepine medications dispensed between October 1, 2016 and December 31, 2018 were linked using common patient identifiers. Autoregressive linear regression was used to assess trends in utilization. Hierarchical logistic models were specified to identify factors associated with provider and pharmacist query of opioid and benzodiazepine prescriptions.

RESULTS

Despite a significant increase in the total number of pharmacists (β = 169.85, p < 0.0001) and prescribers (β = 301.59, p < 0.0001) who used the PMP every month, the ratio of active to registered pharmacists (β = -0.0001, p = 0.75) and prescribers (β = -0.0015, p = 0.10) did not change. Pharmacists and prescribers were significantly more likely to query opioid and benzodiazepine prescriptions of 14 days or more, and those issued to patients new to their practice. Pharmacists were most likely to query opioid prescriptions for oxycodone (aOR = 4.51, 95%CI = 4.42-4.60) and prescribers were most likely to query prescriptions for buprenorphine (aOR = 2.24, 95%CI = 2.15-2.35) compared to codeine.

CONCLUSION

Changes in PMP utilization between October 2016 and December 2018 were driven by increasing registration, not increasing frequency of use among registered users. Use of the PMP is inconsistent and dependent upon patient characteristics thus limiting the utility of the PMP as a decision support tool. These results support the need for policy mandating PMP use in Texas and provide a useful baseline and framework to evaluate the effectiveness of mandate implementation.

Focus on Over-the-Counter Drugs' Misuse: A Systematic Review on Antihistamines, Cough Medicines, and Decongestants

Background: Over the past 20 years or so, the drug misuse scenario has seen the emergence of both prescription-only and over-the-counter (OTC) medications being reported as ingested for recreational purposes. OTC drugs such as antihistamines, cough/cold medications, and decongestants are reportedly the most popular in being diverted and misused. Objective: While the current related knowledge is limited, the aim here was to examine the published clinical data on OTC misuse, focusing on antihistamines (e.g., diphenhydramine, promethazine, chlorpheniramine, and dimenhydrinate), dextromethorphan (DXM)- and codeine-based cough medicines, and the nasal decongestant pseudoephedrine. Methods: A systematic literature review was carried out with the help of Scopus, Web of Science databases, and the related gray literature. For data gathering purposes, both the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and PROSPERO guidelines were followed (PROSPERO identification code CRD42020209261). Results: After completion of the selection, eligibility, and screening phases, some 92 articles were here taken into consideration; case reports, surveys, and retrospective case series analyses were included. Findings were organized according to the specific OTC recorded. Most articles focused here on DXM (n = 54) and diphenhydramine (n = 12). When specified, dosages, route(s) of administration, toxicity symptoms (including both physical and psychiatric ones), and outcomes were here reported. Conclusion: Results from the systematic review showed that the OTC misusing issues are both widespread worldwide and popular; vulnerable categories include adolescents and young adults, although real prevalence figures remain unknown, due to a lack of appropriate monitoring systems. Considering the potential, and at times serious, adverse effects associated with OTC misusing issues, healthcare professionals should be vigilant, and ad hoc preventative actions should be designed and implemented.