Dextromethorphan

INTRODUCTION

A recent study conducted by the University of Michigan's Institute for Social Research reported a significant drop in illegal drug abuse among high school seniors (United States Alcohol, Drug Abuse, and Mental Health Administration, 1991). Nevertheless, a recent national poll of U.S. citizens and parents reported ". . . drug use in general and teenagers' drug use in particular [as being] this nation's number one problem" (Eggert & Herting, 1991). The National Institute on Drug Abuse also has reported only a modest decline in drug use. However, ". . . health officials see a new and terrifying danger - teenagers who regularly abuse and combine many different drugs end up with shattered and impotent lives" (Downey, 1991).

A wide range of drugs are being used by the teenage population: 10-13% of students studied by Miller and Gold (1991) reported use of inhalants and, according to Eggert and Herting (1991), over 55% of high school students use illicit drugs. However, the most common drugs used are those easily obtained, typically from their own homes. They may include alcohol, codeine, marijuana, or inhalants such as paint or glue. "Hard" drugs, such as heroin, crack, and PCP were rarely used (Lewandowski & Westman, 1991).

Drugs are used (experimentally or habitually) for many reasons, the most common of which is to produce an immediate euphoric effect. Other common reasons reported by students include ". . . to make me more popular with my friends, so people would like me, because my parents used them, because someone else wanted me to, to make me feel more like an adult, because my friends use drugs, because it was a habit, and because I could make extra money selling them" (Novacek, Raskin, & Hogan, 1991). Novacek (1991) also discovered that ". . . the more reasons people have for using drugs and alcohol, the more frequently they use them".

An important consequence of teenage drug abuse is the increase in suicide rates: 28,100 suicides are reported per year among 15- to 24-year-olds (Downey, 1990-91). "All available evidence suggests substance abusers are at increased risk for suicide" (Downey, 1990-91). Drugs have been reported as the primary method used among adolescent suicide attempts. In addition, ". . . the suicide rate among alcoholics is an astonishing 58 times higher than that of the general population with approximately one out of every three suicides in the population alcohol-related" (Downey, 1990-91).

Studies also show abuse of licit drugs to be a precursor of illicit drug use. "History of solvent use may indicate individuals at high risk for intravenous drug abuse [IVDA] and youths who have used solvents should be considered at high risk for severe drug abuse, including IVDA" (Dinwiddie, 1991)

The improper use of drugs for nonmedical purposes not only is damaging to individual health, but is harmful to the society in many profound ways. The drugs in question may be classified in two broad categories: (1) licit psychoactive drugs such as caffeine, alcohol, and nicotine, as well as over-the-counter preparations, including pain killers and cold medications; and (2) illicit psychoactive drugs such as cocaine, heroin, and marijuana. The forms of abuse include experimental use (a short-term trial); social recreational use (occasional indulgence among friends to share an experience); circumstantial (situational use in specific stressful circumstances); intensified use (long-term, regular, and habitual use); and compulsive use (frequent use of the drug to the point where an individual becomes physiologically and/or psychologically dependent) (Jones, Gallaher, Bernard, & McFalls, 1988).

Drug abuse, both illicit and licit, is an ongoing serious national problem. To date, neither prevailing social policies, general law enforcement apparatus (at national and local levels), nor community efforts have been able to contain the problem. Like a multiheaded hydra, it regenerates itself in various new forms. The paper focuses on the community of Waynesboro and addresses the question of whether abuse of dextromethorphan-based cough syrup is sporadic and occurs in only isolated cases, or has become a new form of this national social problem.

Background

In August 1990, the Food and Drug Administration's Drug Advisory Committee held a hearing concerning the abuse of dextromethorphan (DM)-based cough syrup. The hearing was in response to the committee's inquiry into the alleged abuse of the drug, a similar hearing by the Pennsylvania Drug, Device, and Cosmetic Board earlier that year, and various press reports. Also, several states had reported abuses by teenagers of cough products containing dextromethorphan hybromide, including: Alabama, California, Colorado, Connecticut, Florida, Indiana, Maryland, Massachusetts, New Jersey, New York, Pennsylvania, Utah, Virginia, and Washington (Andel, Szucs, & Rosenburg, 1991; Krenzelok, 1990). Further, perhaps responding to the abuse potential of DM-based cough syrup, the South Central Pennsylvania Pharmacists Association petitioned the Pennsylvania Drug, Device, and Cosmetic Board to place the drugs in Schedule V, thereby limiting the products to pharmacy or physician dispensing and to patients over 18 years of age (Andel et al., 1991).

The FDA's Drug Abuse Advisory committee had two primary objectives: (1) to collect the data necessary to define the nature and extent of the problem; and (2) to propose solutions and advise on the merits of these solutions (Food and Drug Administration, 1990). However, "... at this time, the scope of the problem, the significance of the problem, and the pharmacology of dextromethorphan have not been adequately described to make a decision" (Food and Drug Administration, 1990). At the time of the hearing, except for a study conducted at the Poison Control Center at the University of Utah Medical Center (McElwee, 1990), no social scientific research had been done on dextromethorphan abuse in the United States. Even with the Utah study, because of both sampling and nonsampling problems, the validity and reliability of the conclusions are questionable (Gfroerer, Adams, & Moien, 1988).

Concern over the abuse potential of cough syrups dates back to the 1950s and 1960s. At that time, most of the antitussives contained codeine or codeine-like compounds that had direct morphine-like abuse potential (World Health Organization Technical Report #437 cited in Food and Drug Administration, 1990). Dextromethorphan (DM), the dextro isomer of the codeine analog of leborphanol, is a cough suppressant ingredient in more than 75 preparations sold over the counter (OTC) without prescription. The drug was first marketed as a prescription antitussive in the early 1950s and became OTC in 1956 (Fisher, 1991; Andel et al., 1991). Reports of abuse of cough syrups containing DM date to the early 1960s, but the evidence is primarily anecdotal (Andel et al., 1991).

Dextromethorphan is commercially available in cough syrup in concentrations of 5 to 15 mg/5 ml and in a variety of sizes. Recent medical literature suggests that use in large quantities may produce phencyclidine (PCP)-like effects from the metabolic conversion of Dextromethorphan (DM) to its immediate metabolite Dextrorthan (DO) (Fisher, 1991). In order to achieve the desired state of inebriation, the drug is ingested by consuming large quantities of cough syrup: 4 to 20 ounces daily. The PCP-like effects include bizarre and hyperactive behavior as well as hallucinations (Krenzelok, 1990).

The Need for Research

Unlike other licit drugs such as nicotine and alcohol, DM is available over the counter to all age groups. Also, it is not associated with any widely known effects such as nicotine is for lung cancer and alcohol for cirrhosis of the liver and auto and other accidents. Because it is relatively cheap, legal, easily available, and its physiopsychological effects are not fully established or known to the potential abuser population, the abuse of DM-based cough syrup as a potential social problem is great.

This paper discusses the results of a preliminary investigation to determine whether teenage misuse of the drug is a pervasive problem.

The study was carried out in Waynesboro, Pennsylvania, a community that has a primarily rural, blue collar, white population. These characteristics differ from those of poor, urban, nonwhite communities, which are often associated with the phenomenon of drug abuse, or those of middle- and upper-class suburban white communities. The abuse of the substance in question, cough syrup or more specifically Robitussin DM, is quite different from the traditionally abused substances, both licit and illicit.

Beginning in 1987, the residents of Waynesboro began to detect behavior among its youth that suggested the development of a new social problem. The medical community began to receive reports of the misuse and abuse of cough syrup available over the counter. These reports were from school and law enforcement personnel who encountered children discussing the use of Robitussin-DM or Robo to get high during drug abuse resistance education classes. Large quantities of empty cough syrup containers of a variety of brands were discovered repeatedly in areas where youths gathered. A medical practitioner encountered patients who admitted recreational use of these products. His subsequent literature search revealed little to guide a medical response to the patient.(1) At the same time, pharmacists, school personnel, and law enforcement officials were brought together to discuss a response to the perceived problem. Further study was requested, a request which was reinforced by the hearings before the Food and Drug Administration (FDA) and the Pennsylvania Drug, Device, and Cosmetic Board.

METHOD

The primary hypothesis of this paper centers on the community's perception of DM-based cough syrup as an existing or potential social problem in Waynesboro. This is consistent with the definition of a social problem in social science literature: "... as conditions originating in the structure of social institutions that have a negative effect on individual and group well being and that are identified through a process of group definition" (Scarpitti & Anderson, 1992).

The analysis is based on data from a survey of school personnel of the Waynesboro School District. These include principals and other administrators, teachers, teachers' aides, counselors, librarians, clerical staff, nurses, and custodians. The survey population included 154 individuals from five elementary schools, 55 from the middle school, 49 from the high school, and 23 from the Central School District Office - a total of 281 respondents, which represents 65% of the school personnel.

In addition to demographic characteristics of the respondents, the survey instrument contained 18 questions regarding over-the-counter drugs being abused and, in particular, DM-based cough syrup. The objective was to determine from the definitions and perceptions of the school personnel whether DM-based cough syrup was so extensively abused that it qualified as a social problem, or if the abuse was only a potential social problem.

OTC products are legal, relatively cheaper than controlled substances, and their adverse effects, as noted, are relatively unknown. These substances are accessible to teenagers who may be afraid to break the law or cannot afford the more expensive illegal drugs. Also, the medicinal function of these products may give a curious teenager a false sense of safety in terms of experimentation. It is therefore reasonable to assume that most abusers and/or potential abusers of OTC substances are of precollege school age. Thus, the perceptions of the personnel of the school system of the community might be a reliable and valid indicator of the existence of a social problem.

RESULTS

School personnel were asked whether they agreed or disagreed with a list of statements concerning OTC products, such as the adequacy of government regulations, and the demographic characteristics of potential abusers of these products. Table 1 shows the percentage who agreed, were uncertain, or disagreed with the statements about OTC products. Although the population was almost evenly divided among those who agreed (37%), were uncertain (34%), or disagreed (29%) about the adequacy of government regulation of OTC products, over 90% believed that OTC products have a potential for abuse and that the potential for abuse for some of these products is greater than for others. Almost 70% agreed that OTC product abuse is increasing, nearly the same percentage who indicated that abuse was already a social problem.

The assumption that teenagers are the primary abusers or potential abusers of dextromethorphan-based cough syrup was confirmed by the fact that one-forth of school personnel in Waynesboro agreed that OTC product abuse in general was mainly a problem among teenagers, compared to fewer than 5% who believed such abuse to be primarily a problem among males, senior citizens, or racial minorities.

As also shown in Table 1, nearly two thirds believed that OTC product abuse leads to the abuse of controlled substances, while only a slightly smaller percentage (55%) concur with the statement that OTC products are abused along with controlled substances. Although 40% expressed uncertainty, the same percentage disagreed with the statement that current research into the use of OTC products and their abuse is adequate to protect the consumer.

Overall, the data presented in Table 1 indicate that the abuse of OTC products of one kind or another is perceived by the school personnel in Waynesboro's school district to be a social problem. Of the total study population, 62% reportedly are currently aware of the abuse or misuse of OTC products. These respondents were asked to name and rank the three most abused or misused OTC substances, the time and source of their knowledge, and the number of abusers or misusers.

As shown in Table 2, nearly half reported Robitussin cough syrup to be the highest abused OTC product, and an additional 44% listed cough syrup (generically or by product name). Although only 2.4% of those who listed a second OTC product named Robitussin, nearly one fourth reported some other cough syrup (generically or by name). The number of respondents who listed three OTC products was small, and only 8% of that group reported that Robitussin or some other cough syrup was the third highest abused OTC product. The total number of all OTC products reported (first, second, or third most abused combined) is 286, of which 83 were Robitussin, 94 were cough syrup (generic or other brand), and 109 were some other type of OTC product. It is therefore clear that the OTC product of greatest concern, with respect to abuse, is cough syrup - Robitussin by name, or in general.

When the respondents were asked to indicate the number of persons they know who are abusing the OTC product they had reported as most abused, nearly half of those who cited Robitussin knew of 10 or more abusers, as shown in Table 3. An even greater percentage of those who indicated that cough syrup (generic or another brand) was the most abused, knew at least 10 abusers (6%)(2). These percentages are striking. It seems that the abuse or misuse of Robitussin or cough syrup in general in the Waynesboro community, by far the most abused OTC product in the area, is of recent onset and was ongoing at the time of the survey. As shown in Table 4, only 12% of those who cited cough syrup and fewer than 5% of those reporting Robitussin as the most abused, first learned about such abuse or misuse before 1988; the vast majority first heard of this abuse from 1988 through 1990. More than 90% of both groups reported that they had most recently heard about this abuse in 1990, the year of the survey. One might conclude that only a small proportion of the population was aware of or perceived cough syrup abuse to be a social problem prior to 1988. However, from 1988 through 1990, either as a consequence of professional or informal contact and/or media exposure, knowledge and perception of abuse of cough syrup as a social problem became considerably more widespread.

DISCUSSION AND CONCLUSIONS

Without doubt, the legal definition of a particular drug, its cost, and its availability determine the form and extent of abuse. Drug abuse is often defined as a social problem in terms of the compulsive use of illicit psychoactive drugs. However, such a definition can be expanded to include the abuse of licit drugs when the negative consequences are abundantly apparent and/or are scientifically demonstrated, for example, the abuse of alcohol. Thus, the establishment of any condition as a social problem depends largely on the perception and definition of the community in question and on the scientific verification of that perception.

Beyond community attitudes, perceptions, and scientific verification, the definition of a condition as a social problem is also often affected and reinforced by law and other government regulations - which are a consequence of public attitudes and perception. Further, community or public sentiments with regard to drug use or abuse are partially influenced by the type of people who use the drug. For example, in the past, drug abuse was a social problem generally believed to be confined to nonwhites, the urban poor, and groups outside the mainstream of society, such as criminals and prostitutes. It is therefore not surprising that the general attitude toward illegal drug use was that it undermined moral restraint and often led to crime and other forms of deviance. The laws at that time reflected such public attitudes. However, those attitudes softened, even to the point of questioning the labelling of drug use as deviant or criminal when illegal drug use spread to the middle and upper middle classes (Scarpitti & Anderson, 1992).

The creation of laws and regulations with regard to substance abuse or misuse is also greatly influenced by the drug in question and the special interest groups behind it. For example, the laws that regulate cigarette smoking and alcohol consumption are far less strict than those that deal with the regulation of cocaine or marijuana use. These differences are not due solely to the harmful nature of the substances, but to differences in the economic and political power of the groups behind them.

The sale of cough syrup is a multimillion dollar industry. If the drug DM were to be reregulated to a prescription drug, the economic impact would be substantial. Thus, like the abuse of cigarettes or alcohol, identification of cough syrup abuse as a social problem has profound economic and political implications. However, unlike those other substances, due to its medicinal function, the implications are far more complicated.

Although further research is needed to identify the abuse of cough syrup as a national social problem, in the case of the community of Waynesboro, one might conclude from the perceptions of the school district personnel that OTC product abuse is increasing and is already a social problem. Robitussin specifically and other forms of cough syrup are considered to be the highest abused OTC product. It is striking that the respondents in this study reported knowing 10 or more persons who abuse cough syrup. But even in this community, much confusion still surrounds the phenomenon, as demonstrated by the fact that 40% agreed and 40% disagreed with the statement that current research is adequate to protect the consumer (Table 1).

Further study is required to identify the extent of the abuse problem, the characteristics of the abuser population, and the nature and forms of abuse of the drug. Currently, data on the second phase of this research is being organized for analysis. This data may identify the demographic characteristics of abusers and/or potential abusers, patterns of abuse, grade level of first abuse, and whether abusers already engaged in addictive behaviors, such as drinking, smoking cigarettes, and/or use of other drugs.

1 Almost all reports of DM abuse are based on anecdotal evidence (Andel et al., 1991).

2 The number of respondents citing other products as most abused who also reported the number of persons they knew to be misusing the product were too small to provide meaningful information.

REFERENCES

Andel, M. M., Szucs, V. A., & Rosenburg, J. M. (1991). What is the abuse potential of dextromethorphan? Hospital Pharmacist Report, July, 18.

Dinwiddie, S. H. (1991). Recognizing inhalant abuse. Family Practice Recertification, 13, 30-47.

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Eggert, L. L., & Herting, J. R. (1991). Preventing teenage drug abuse: Exploratory effects of network social support. Youth and Society, 22, 482-524.

Fisher, J. D. (1991). Dextromethorphan. Clinical Toxicology Review, 13, 1-2.

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Gfroerer, J. C., Adams, E. H., & Moien, M. (1988). Drug abuse discharges from non-federal short-stay hospitals. American Journal of Public Health 78, 1559-1562.

Jones, B. J., Gallagher, B. J. III, & McFalls, J. A., Jr. (1988). Social problems: Issues, opinions, and solutions. New York: McGraw-Hill.

Krenzelok, E. P. (1990). Non-prescription cough medicine abuse. Clinical Toxicology Forum, 2, 5.

McElwee, N. E. (Abstract) (1990). Vet. Hum. Toxicology, 32, 355.

Miller, N. S., & Gold, M. S. (1991). Organic solvent and aerosol abuse. American Family Physician, 44, 183-189.

Novacek, J., Raskin, R., & Hogan, R. (1991). Why do adolescents use drugs? Age, sex, and user differences. Journal of Youth and Adolescence, 20, 475-492.

Scarpitti, F. R., & Andersen, M. L. (1992). Social problems (2nd ed.). New York: Harper Collins.

United States Alcohol, Drug Abuse, and Mental Health Administration. (1991). Drug use among American high school seniors, college students, and young adults, 1975-1990. (Report No. 91-1813). Rockville, MD: National Institute on Drug Abuse.

Gerald R. Keenan, Director of Physician Assistants, Lee Hospital, Johnstown, Pennsylvania.

Tamara K. Richards, UMBC Choice Middle Schools Program, Hagerstown, Maryland.

Reprint requests to Momodou N. Darboe, Ph.D., Associate Professor of Sociology, Shepherd College, Shepherdstown, West Virginia 25443.

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