Review Article

CME Article: Abuse of Medications That Theoretically Are Without Abuse Potential

Authors: Roy R. Reeves, DO, PhD, Mark E. Ladner, MD, Candace L. Perry, MD, Randy S. Burke, PhD, Janet T. Laizer, MD

Abstract

The potential for abuse of medications that are controlled substances is well known. Abuse of certain noncontrolled prescription drugs and over-the-counter medications also may occur. To some degree, any medication that exerts psychoactive effects may be abused if taken in high enough doses or by means that result in high serum or cerebrospinal fluid levels. Many clinicians may be unaware of the potential for abuse of these medications. This review examines evidence of the possibility of abuse of several common medications that theoretically do not have abuse potential, including cough and cold preparations, antihistamines, anticholinergics, antipsychotics, antidepressants, anticonvulsants, skeletal muscle relaxants, and antiemetics. Means by which such medications may be abused and biochemical and physiological mechanisms fostering their abuse also are discussed.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Cooper RJ. Over-the-counter medicine abuse--a review of the literature. J Substance Use 2013;18:82-107.
 
2. Shi CW, Bayard MA. Abuse of over-the-counter medications among teenagers and young adults. Am Fam Physician 2011;84:745-750.
 
3. Hughes GF, McElnay JC, Hughes CM, et al. Abuse/misuse of nonprescription drugs. Pharm World Sci 1999;21:251-255.
 
4. Reeves RR, Burke RS, Kose S. Carisoprodol: update on abuse potential and legal status. South Med J 2012;105:619-623.
 
5. Department of Health and Human Services. Emergency department trends from the Drug Abuse Warning Network, final estimates 1994-2001. www.oas.samhsa.gov/DAWN/final2k1EDtrends/text/EDtrend2001v6.pdf. Accessed January 13, 2014.
 
6. Reeves RR, Burke RS. Is it time for carisoprodol to become a controlled substance at the federal level? South Med J 2008;101:127-128.
 
7. Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. (SMA) 13Y4760, DAWN Series D-39 Rockville, MD, Substance Abuse and Mental Health Services Administration, 2013.
 
8. Del Paggio D. Psychotropic medication abuse in correctional facilities. Bay Area Psychopharmacol Newslett 2005;8:1-6.
 
9. Culberson JW, Ziska M. Prescription drug misuse/abuse in the elderly. Geriatrics 2008;63:22-31.
 
10. Compton WM, Volkow ND. Abuse of prescription drugs and risk of addiction. Drug Alcohol Depend 2006;83(Suppl 1):S4-S7.
 
11. Schwartz RH. Adolescent abuse of dextromethorphan. Clin Pediatr (Phila) 2005;44:565-568.
 
12. Drew CD, Knight GT, Hughes DT, et al. Comparison of the effects of D-(-)-ephedrine and L-(+)-pseudoephedrine on the cardiovascular and respiratory systems in man. Br J Clin Pharmacol 1978;6:221-225.
 
13. Sullivan G. Acute psychosis following intravenous abuse of pseudoephedrine: a case report. J Psychopharmacol 1996;10:324-325.
 
14. Hendrickson RG, Cloutier RL, Fu R. The association of controlling pseudoephedrine availability on methamphetamine-related emergency department visits. Acad Emerg Med 2010;17:1216-1222.
 
15. Tang AK, Tang WK, Liang HJ, et al. Clinical characteristics of cough mixture abusers referred to three substance abuse clinics in Hong Kong: a retrospective study. East Asian Arch Psychiatry 2012;22:154-159.
 
16. Romanelli F, Smith KM. Dextromethorphan abuse: clinical effects and management. J Am Pharm Assoc (2003) 2009;49:e20-e25.
 
17. Miller SC. Dextromethorphan psychosis, dependence, and physical withdrawal. Addict Biol 2005;10:325-327.
 
18. Schnoll SH, Chasnoff IJ, Glassroth J. Pentazocine and tripelennamine abuse: T’s and blues. Psychiatr Med 1985;3:219-231.
 
19. Cox D, Ahmed Z, McBride AJ. Diphenhydramine dependence. Addiction 2001;96:516-517.
 
20. Dinndorf PA, McCabe MA, Friedrich S. Risk of abuse of diphenhydramine in children and adolescents with chronic illnesses. J Pediatr 1998;133:293-295.
 
21. Baker SD, Borys DJ. A possible trend suggesting increased abuse from Coricidin exposures reported to the Texas Poison Network: comparing 1998 to 1999. Vet Hum Toxicol 2002;44:169-171.
 
22. Tanda G, Kopajtic TA, Katz JL. Cocaine-like neurochemical effects of antihistaminic medications. J Neurochem 2008;106:146-157.
 
23. Dilsaver SC. Antimuscarinic agents as substances of abuse: a review. J Clin Psychopharmacol 1988;8:14-22.
 
24. Land W, Pinsky D, Salzman C. Abuse and misuse of anticholinergic medications. Hosp Community Psychiatry 1991;42:580-581.
 
25. Buhrich N, Weller A, Kevans P. Misuse of anticholinergic drugs by people with serious mental illness. Psychiatric Serv 2000;51:928-929.
 
26. Reeves RR, Brister JC. Additional evidence of the abuse potential of quetiapine. South Med J 2007;100:834-836.
 
27. Murphy D, Bailey K, Stone M, et al. Addictive potential of quetiapine. Am J Psychiatry 2008;165:918.
 
28. Pierre JM, Shnayder I, Wirshing DA, et al. Intranasal quetiapine abuse. Am J Psychiatry 2004;161:1718.
 
29. Morin AK. Possible intranasal quetiapine misuse. Am J Health Syst Pharm 2007;64:723-725.
 
30. Hussain MZ, Waheed W, Hussain S. Intravenous quetiapine abuse. Am J Psychiatry 2005;162:1755-1756.
 
31. Yargic I, Caferov C. Quetiapine dependence and withdrawal: a case report. Subst Abus 2011;32:168-169.
 
32. Tamburello AC, Lieberman JA, Baum RM, et al. Successful removal of quetiapine from a prison formulary. J Am Acad Psychiatry Law 2012;40:502-508.
 
33. Reeves RR, Ladner ME. Potentiation of the effect of buprenorphine/naloxone with gabapentin or quetiapine. Am J Psychiatry 2014;171:691.
 
34. Lai CH. Olanzapine abuse was relieved after switching to aripiprazole in a patient with psychotic depression. Prog Neuropsychopharmacol Biol Psychiatry 2010;34:1363-1364.
 
35. Kumsar NA, Erol A. Olanzapine abuse. Subst Abus 2013;34:73-74.
 
36. Reeves RR. Abuse of olanzapine by substance abusers. J Psychoactive Drugs 2007;39:297-299.
 
37. Briggs NC, Jefferson JW, Koenecke FH. Tranylcypromine addiction: a case report and review. J Clin Psychiatry 1990;51:426-429.
 
38. Davids E, Roschke J, Klawe C, et al. Tranylcypromine abuse associated with delirium and thrombocytopenia. J Clin Psychopharmacol 2000;20:270-271.
 
39. Prahlow JA, Landrum JE. Amitriptyline abuse and misuse. Am J Forensic Med Pathol 2005;26:86-88.
 
40. Wohlreich MM, Welch W. Amitriptyline abuse presenting as acute toxicity. Psychosomatics 1993;34:191-193.
 
41. Delisle JD. A case of amitriptyline abuse. Am J Psychiatry 1990;147:1377-1378.
 
42. Dorman A, Talbot D, Byrne P, et al. Misuse of dothiepin. BMJ 1995;311:1502.
 
43. Cohen MJ, Hanbury R, Stimmel B. Abuse of amitriptyline. JAMA 1978;240:1372-1373.
 
44. Hepburn S, Harden J, Grieve JH, et al. Deliberate misuse of tricyclic antidepressants by intravenous drug users--case studies and report. Scott Med J 2005;50:131-133.
 
45. Khurshid KA, Decker DH. Bupropion insufflation in a teenager. J Child Adol Psychopharmacol 2004;14:157-158.
 
46. Langguth B, Hajak G, Landgrebe M, Unglaub W. Abuse potential of bupropion nasal insufflation: a case report. J Clin Psychopharmacol 2009;29:618-619.
 
47. Welsh CJ, Doyon S. Seizure induced by insufflation of bupropion. N Engl J Med 2002;347:951.
 
48. Kim D, Steinhart B. Seizures induced by recreational abuse of bupropion tablets via nasal insufflation. CJEM 2010;12:158-161.
 
49. Hill S, Sikand H, Lee J. A case report of seizure induced by bupropion nasal insufflation. Prim Care Companion J Clin Psychiatry 2007;9:67-69.
 
50. Reeves RR, Ladner ME. Additional evidence of the abuse potential of bupropion. J Clin Psychopharmacol 2013;33:584-585.
 
51. Yoon G, Westermeyer J. Intranasal bupropion abuse: case report. Am J Addict 2013;22:180.
 
52. Stahl SM, Pradko JF, Haight BR, et al. A review of neuropharmacology of bupropion, a dual norepinephrine and dopamine reuptake inhibitor. Prim Care Companion J Clin Psychiatry 2004;6:159-166.
 
53. Tinsley JA, Olsen MW, Laroche RR, et al. Fluoxetine abuse. Mayo Clin Proc 1994;69:166-168.
 
54. Menecier P, Menecier-Ossia L, Bern P. Fluoxetine dependence and tolerance. Apropos of a case (article in French). Encephale 1997;23:400-401.
 
55. Singh AN, Catalan J. Rave drug (ecstasy) and selective serotonin reuptake inhibitor anti-depressants. Indian J Psychiatry 2000;42:195-197.
 
56. Quaglio G, Schifano F, Lugoboni F. Venlafaxine dependence in a patient with a history of alcohol and amineptine misuse. Addiction 2008;103:1572-1574.
 
57. Gabapentin and pregabalin: abuse and addiction. Prescribe Int 2012;21:152-154.
 
58. Markowitz JS, Finkenbine R, Myrick H, et al. Gabapentin abuse in a cocaine user: implications for treatment? J Clin Psychopharmacol 1997;17:423-424.
 
59. Reccoppa L, Malcolm R, Ware M. Gabapentin abuse in inmates with prior history of cocaine dependence. Am J Addict 2004;13:321-323.
 
60. Norton JW. Gabapentin withdrawal syndrome. Clin Neuropharmacol 2001;24:245-246.
 
61. Drabkin R, Calhoun L. Anorgasmia and withdrawal syndrome in a woman taking gabapentin. Can J Psychiatry 2003;48:125-126.
 
62. Hellwig TR, Hammerquist R, Termaat J. Withdrawal symptoms after gabapentin discontinuation. Am J Health Syst Pharm 2010;67:910-912.
 
63. Tran KT, Hranicky D, Lark T, et al. Gabapentin withdrawal syndrome in the presence of a taper. Bipolar Disord 2005;7:302-304. .
 
64. Kruszewski SP, Paczynski RP, Kahn DA. Gabapentin-induced delirium and dependence. J Psychiatr Pract 2009;15:314-319.
 
65. Barrueto F Jr, Green J, Howland MA, et al. Gabapentin withdrawal presenting as status epilepticus. J Toxicol Clin Toxicol 2002;40:925-928.
 
66. Pittenger C, Desan PH. Gabapentin abuse, and delirium tremens upon gabapentin withdrawal. J Clin Psychiatry 2007;68:483-484.
 
67. Rosebush PI, MacQueen GM, Mazurek MF. Catatonia following gabapentin withdrawal. J Clin Psychopharmacol 1999;19:188-189.
 
68. Raby WN, Coomaraswamy S. Gabapentin reduces cocaine use among addicts from a community clinic sample. J Clin Psychiatry 2004;65:84-86.
 
69. Salehi M, Kheirabadi GR, Maracy MR, et al. Importance of gabapentin dose in treatment of opioid withdrawal. J Clin Psychopharmacol 2011;31:593-596.
 
70. Longo LP, Campbell T, Hubatch S. Divalproex sodium (Depakote) for alcohol withdrawal and relapse prevention. J Addict Dis 2002;21:55-64.
 
71. Elder NC. Abuse of skeletal muscle relaxants. Am Fam Physician 1991;44:1223-1226.
 
72. Schifano F, Marra R, Magni G. Orphenadrine abuse. South Med J 1988;81:546-547.
 
73. Khalil RB. Tizanidine for alcohol withdrawal. Med Hypothesis 2011;77:548-549.
 
74. Perry HE, Wright RO, Shannon MW, et al. Baclofen overdose: drug experimentation in a group of adolescents. Pediatrics 1998;101:1045-1048.
 
75. LeTourneau JL, Hagg DS, Smith SM. Baclofen and gammahydroxybutyrate withdrawal. Neurocrit Care 2008;8:430-433.
 
76. Rolland B, Bordet R, Deheul S, et al. Baclofen for alcohol-dependence: anticraving or partial substitution? J Clin Psychopharmacol 2013;33:280-281.
 
77. Nasti JJ, Brakoulias V. Chronic baclofen abuse and withdrawal delirium. Aust N Z J Psychiatry 2011;45:86-87.
 
78. Halpert AG, Olmstead MC, Beninger RJ. Mechanisms and abuse liability of the anti-histamine dimenhydrinate. Neurosci Biobehav Rev 2002;26:61-67.
 
79. Rowe C, Verjee Z, Koren G. Adolescent dimenhydrinate abuse: resurgence of an old problem. J Adolesc Health 1997;21:47-49.
 
80. Oliver M, Stenn PG. Is there a risk of dependence with therapeutic doses of dimenhydrinate? Psychosomatics 1993;34:459.
 
81. Ruben SM, McLean PC, Melville J. Cyclizine abuse among a group of opiate dependents receiving methadone. Br J Addict 1989;84:929-934.
 
82. Bassett KE, Schunk JE, Crouch BI. Cyclizine abuse by teenagers in Utah. Am J Emerg Med 1996;14:472-474.
 
83. Bailey F, Davies A. The misuse/abuse of antihistaminic antiemetic medication (cyclizine) by cancer patients. Palliat Med 2008;22:869-871.
 
84. Shapiro BJ, Lynch KL, Toochinda T, et al. Promethazine misuse among methadone maintenance patients and community-based injection drug users. J Addict Med 2013;7:96-101.
 
85. Peters R Jr, Yacoubian GS Jr, Rhodes W, et al. Beliefs and social norms about codeine and promethazine hydrochloride cough syrup (CPHCS) use and addiction among multi-ethnic college students. J Psychoactive Drugs 2007;39:277-282.
 
86. Dennison SJ. Clonidine abuse among opiate addicts. Psychiatr Q 2001;72:191-195.
 
87. Bueger M, Tommasello A, Schwarz R, et al. Clonidine use and abuse among methadone program applicants and patients. J Subst Abuse Treat 1998;15:589-593.
 
88. Schaut J, Schnoll SH. Four cases of clonidine abuse. Am J Psychiatry 1983;140:1625-1627.
 
89. Marin GA. Cimetidine: use, abuse, and overuse. J Med Soc N J 1981;78:595-597.
 
90. Daniulaityte R, Carlson R, Falck R, et al. “I just wanted to tell you that loperamide WILL WORK”: a web-based study of extra-medical use of loperamide. Drug Alcohol Depend 2013;130:241-244.
 
91. Simoni-Wastila L, Strickler G. Risk factors associated with problem use of prescription drugs. Am J Public Health 2004;94:266-268.
 
92. Reeves RR, Carter OS, Pinkofsky HB, et al. Carisoprodol (soma): abuse potential and physician unawareness. J Addict Dis 1999;18:51-56.