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Drug Hazards Medica'ons (Over-‐the-‐Counter and Rx) and Illegal Drugs: Cau'ons and Guidelines for the Workplace
Megan E. Thompson, Pharm.D. Director of Experien<al Educa<on
Associate Professor of Pharmacy Prac<ce UNM College of Pharmacy
Outline
1. Common Medica<ons: Indica<ons, Cau<ons and Side Effects • Over-‐the-‐Counter (OTC) Medica<ons • Rx Medica<ons
2. Drug Test Implica<ons 3. “Designer Drugs” (Spice, Bath Salts, etc.)
• Use in the workplace • Drug Tes<ng
Over-‐the-‐Counter Medica<ons “OTC”
• Medica<on that does not need a prescrip<on
• Medica<ons in front of pharmacy counter • Includes medica<on for common illnesses like: – Allergies – Cough/cold – Pain – Stomach problems (gas, diarrhea, heartburn, etc.)
Commonly Used Over-‐the-‐Counter and Prescrip<on Medicines
Allergy Medica<ons (An<histamines)
Non-‐seda)ng • Clari<n® (loratadine) • Allegra®
(fexofendadine) • Zyrtec® (ce<rizine)
(all above products are available in “D” formula'on, i.e., Clari'n-‐D, Allegra-‐D, Zyrtec-‐D)
Seda)ng • Benadryl®
(diphenhydramine) • Chlor-‐Trimeton®
(chlorpheniramine) • Dimetapp®
(brompherniramine)
Benadryl®
• Used for allergies AND sleep • Allergy: Can be used topically for bug bites and skin
irrita<on from plant/animal exposures • Sleep:
– Not to be used greater than 2 weeks – Can build a tolerance to the seda<on
• Side Effects: Drowsiness, dry mouth, dizziness, nausea, cons<pa<on, dry eyes, headache, nervousness, toxicity = coma
Too much Benadryl®… • Can’t See • Can’t Pee • Can’t Spit • Can’t Sh…Defecate
Cough and Cold Products
• DayQuil®, NyQuil®, Tylenol® Cold and Sinus, Advil® Cold and Sinus, TheraFlu®
• Contain ingredients like: – Acetaminophen or Ibuprofen = pain/headache/body ache
– Pseudoephedrine = conges<on/stuffy head – Diphenhydramine = runny nose/watery eyes/sleep – Dextromethorphan = cough – Guaifenesin = chest conges<on – Alcohol = sleep
Cough and Cold Products *Cau<on*
• Read labels! • Most cough/cold products contain mul<ple ingredients
• Easy to overdose (especially on acetaminophen)
• Mul<ple ingredients = drug interac<ons with prescrip<on medica<ons
Cough and Cold Products *Side Effects*
• Drowsiness • “Hangover Effect” in the morning • Nausea • Liver toxicity • If you need it longer than 2 days you may have infec<on and need a prescrip<on (an<bio<c)
Dextromethorphan (DXM) • Cough suppressant • Common in cough and cold prepara<ons, ocen as a
combina<on product. • High doses can affect brain – Commonly abused – “Robo-‐tripping”
• Decreases responsiveness (don’t drive/use machinery) • Can last for varying amounts of <me (Delsym vs. NyQuil) • Only use measuring cup included in packaging
Energy Drinks • Caffeine Content – Coffee (8oz) 108mg – Espresso (2oz) 100mg – Brewed tea (8oz) 40mg – Mountain Dew (12oz) 54mg – Coca-‐Cola (12oz) 34.5mg
– Monster Drink 80mg** – Red Bull 80mg**
**Per serving. Also includes taurine, panax, and guarana
?!
Energy Drinks and Benadryl® • Using Energy Drinks to combat effects of Benadryl
• Energy Drinks • High doses of caffeine -‐ ~4x amount • Can be hidden as Guarana or yerba mate (Herbal caffeine)
• High amounts of sugars – converted to short term energy.
Sleep Aids • Diphenhydramine (Tylenol PM®) • *Zolpidem (Ambien®)
– Should not be used for >30days – SE: Dizziness, HA, N/V, rebound insomnia, hallucina<ons
• *Eszopiclone (Lunesta®) – Can be used for > 6 months – SE: Altered taste, headache, dry mouth
• *Benzodiazepines: Alprazolam, Clonazepam, Diazepam, Lorazepam – Can be used for about 4-‐6 weeks, used as needed – SE: high withdrawal (life threatening)
* = prescrip<on only
Commonly Used Prescrip<on Medica<ons
Prescrip<on Medica<ons
• Medica<on that must have a legal prescrip<on • Medica<ons kept behind pharmacy counter • Includes medica<ons for common illnesses like: – Pain – High blood pressure – High cholesterol – Diabetes – Cancer
Blood Pressure Medica<ons
• General Tips: You will feel worse before you get bener • First <me users will experience dizziness • Need to s<ck with it, let body readjust
• “Water pills”: HCTZ, furosemide • Corrects Blood pressure by removing water • Good idea to take in morning • Furosemide: potassium intake
• ACEi or ARBs: lisinopril, enalapril, valsartan, losartan • Internal Blood Pressure regula<on • Cough from ACEi in some people
Diabetes Medica<ons
• Insulin, Meqormin®, Glucophage®, Glyburide® • Can cause severe upset stomach, diarrhea • If not taken appropriately, can cause drama<c drop in blood sugar
• ↓ blood sugar = drowsiness, difficulty in concentra<ng, fain<ng, coma
• Uncontrolled diabetes is extremely dangerous
Common Pain Relievers
• NSAIDs = Motrin (ibuprofen), Advil (ibuprofen), Aleve (naproxen)
• Tylenol (acetaminophen) • Bayer, Excedrin, St. Joseph’s (aspirin) • *Ultram (tramadol) • *Percocet (oxycodone/acetaminophen) • *Lortab, Vicodin (hydrocodone/acetaminophen) • *MS Con<n (morphine) • *Oxycon<n (oxycodone)
* = prescrip<on only, narco<c
NSAIDs, APAP, ASA • NSAIDs – Non Steroidal An<-‐inflammatory Drugs – Pain reliever for inflamed areas
• Ideal for injury pain – Max Doses
• Ibuprofen: 3200mg each day • Naproxen: 1500mg each day
– Side effects: Stomach issues (biggest), Anxiety, headache
Acetaminophen (Tylenol®)
• Is in many OTC products • Used for pain relief, but not effec<ve for injuries with swelling/inflamma<on
• Also used for: – Headaches – Pa<ents who are unable to take NSAIDS – Fever reducer – all ages
• Max Dosage • 3000mg each day, total from all products • Liver damage
Aspirin (Bayer®, Excedrin®, St. Joseph’s®)
v Used for minor pain – Body aches
– prevent blood clot forma<on • Baby aspirin (81 mg) vs. regular aspirin (325 mg); benefit vs. risk
– Max dose • Variable
– SE: Major stomach irrita<on, bruising
Aspirin (Bayer®, Excedrin®, St. Joseph’s®)
• Used for minor pain, body aches • Preven<on of blood clots • Baby aspirin vs. regular aspirin for heart problems
• Side Effects: Major stomach irrita<on, bruising, NOT TO BE USED IN CHILDREN (any dose)
Alterna<ve Pain Reliever • Glucosamine & Chondroi<n – Considered a natural alterna<ve – Can be ideal if you can’t take NSAIDs – Glucosamine may be beneficial for moderate to severe pain but is not available by itself
– Mad Cow Disease? – Data is conflic<ng – Side effects: Nausea, stomach upset, cons<pa<on, diarrhea
Opioids/Opiates
• Opium derived from poppy plant • All are controlled substances • Require prescrip<ons • Highly regulated (Schedule II drugs) • Appropriate for severe or chronic pain sufferers • High abuse poten)al – Psychologically – Physiologically
Opioids/Opiates
• Medica<ons in the opiate family include: – Morphine (MS Con<n®) – *Oxycodone (Oxycon<n®)* – Oxycodone w/Acetaminophen (Percocet®) – Hydrocodone (usually combined with acetaminophen; Lortab®, Vicodin®)
– Hydromorphone – Codeine * = chemical structure
almost iden<cal to heroin
Other Prescrip<on Pain Killers • Tramadol (Ultram®) – Now a schedule IV narco<c – Used frequently in animals
• Fentanyl® – Patch – Injectable
• Demerol® – Usually used for pa<ents who can’t take opioids
• Flexeril® (cyclobenzaprine) – Muscle relaxant – Non-‐narco<c
Opioids/Opiates
• Appropriate for: – Chronic pain sufferers – Cancer pain – Trauma<c injury (limb amputa<ons, surgery, major bone fractures, severe burn)
– Pain scale 7-‐10
Prescrip<on Pain Killers *Cau<on*
• All will show up on a drug test • ALL pose a risk for misuse and abuse • Highly addic<ve • If misused/abused, body depends on them to func<on normally
Prescrip<on Pain Killers *Side Effects*
• Pain does not disappear – you just don’t care about it
• When used for the first <me: – “High” feeling, foggy, “out of body”, not in control – drunk-‐like effects (slurred speech, droopy eyelids, pin-‐point pupils)
– Drowsiness – Cons<pa<on (can use stool soceners) – Nausea/vomi<ng
Prescrip<on Pain Killers *Side Effects*
• Chronic users – Cons<pa<on – Erec<le dysfunc<on – “high” feeling goes away – Body depends on drug to func<on normally – Addic<on
An<-‐Anxiety Medica<ons (Benzodiazepines)
• Xanax®, Valium®, A<van®, lorazepam, alprazolam
• Referred to as “Benzos” • Narco<cs (Schedule III-‐IV) • Require a prescrip<on • Have some abuse poten<al
Benzodiazepines
• Highly effec<ve for: – Panic anacks – Mild-‐severe anxiety – Sleep – Nerve pain? – Common fears (public speaking, flying, heights, etc.)
Benzodiazepines *Cau<ons/Side Effects*
• Will show up on a drug test • Causes relaxa<on • Delays responsiveness (i.e., slow to react) • Drowsiness • Cons<pa<on
Medica<ons and Alcohol • Alcohol and Acetaminophen-‐both can harm liver • Alcohol and aspirin or NSAIDs-‐increased risk of ulcer or bleed • Alcohol and Benadryl-‐increased likelihood of blackout and
slowed breathing • Alcohol and DXM-‐increased risk of slowed breathing and
impaired movement • Remember: just because you don’t feel the medica<on
anymore doesn’t mean its not in your system. These effects can s<ll occur.
Drug Tests: What do they test?
5-‐ Panel (can be any 5 of the following)
• Cocaine • Amphetamines* • Methamphetamines • THC • Methadone* • Opioids* • PCP
10-‐Panel (can be any 10 of the following)
• Cocaine • Amphetamines* • Methamphetamines • THC • Methadone* • Opiates* • PCP • Barbiturates* • Benzodiazepines* • Tricyclic An<depressants* • Propoxyphene** *Prescrip'on Medica'ons
**Removed from market in 2010 (Darvon, Darvocet-‐N) due to fatal heart rhythm abnormali'es
Drug or Drug Class Examples of substances associated with False-‐Posi)ves (urine drug test; immunoassay)
Amphetamines Amantadine, buproprion, chlorpromazine, desipramine, doxepin, labetalol, methylphenidate, phenylephrine, promethazine, pseudoephedrine, rani)dine, trazodone, Vicks inhaler
Barbiturates Ibuprofen, naproxen (0.4% false posi<ve rate)
Marijuana* NSAIDs (ibuprofen, naproxen, ketoprofen), PPIs (Prilosec, Nexium, Protonix, Prevacid, Aciphex)
Opiates Dextromethorphan, diphenhydramine (methadone), doxylamine, quinolones, quinine, rifampin, verapamil (methadone)
Phenylcyclidine (PCP) Dextromethorphan, diphenhydramine, ibuprofen, imipramine, ketamine
*neither passive marijuana inhala<on nor inges<ng hemp-‐containing foods likely cause posi<ve result on Federal workplace drug tes<ng
Source: “Urine Screening for Drugs of Abuse”, The Pharmacist’s LeVer/Prescriber’s LeVer, PL Detail Document #280219, February 2012
Beyond Marijuana: “Designer Drugs”
History of “Spice” • Synthe<c cannabinoid • Designed as a research tool to study cannabinoid systems
• Found in herbal incense products • Sold on internet, gas sta<ons, convenience stores, tobacco shops and head shops
• Smoked for psychoac<ve effects • No legi<mate use for these substances • Plant material is purposely spiked with these substances (“Spike 99”)
How it’s used • Can be smoked, ingested as an infusion or inhaled
• Generally used by teenagers and young people interested in using psychotropic drugs
• Some<mes smoked together with cannabis • Difficult to separate the desired proper)es from unwanted psychoac)ve effects
• Content of ac<ve ingredient varies from 5 mg – 2000mg
Effects reported from users • “pressure behind the eyes and front brain” • “<red, stoned, fuzzy” • “…different feeling in the brain” • “euphoria” • “waves of unusual body energy” • Severe anxiety, paranoia • Sudden depression has been reported during withdrawal
from chronic use • Paranoia and hallucina<ons acer 1 use • Psychosis
Legal Implica<ons
• Federal: DEA made “Spice” illegal in all 50 states (2010)
• State: New Mexico: illegal to sell “Spice” or “Spice” containing products even if it’s labeled as incense
• Some smoke shops in NM s<ll selling it claiming it’s “…made with new ingredients that …are not included in the law banning the substance”
Legal Implica<ons
• Misdemeanor or Felony depending on quan<ty (treated in the same manner as marijuana) – Possession = misdemeanor (if > 8 oz = felony) – Distribu<on = felony – Cul<va<on = felony – Paraphernalia = misdemeanor (distribu<on of paraphernalia to a minor = felony)
• First <me offense = $50-‐100 fine and/or 15 days of imprisonment
“Bath Salts”/”Plant Food” • Sold legally in most areas in US; head shops, adult stores, gas sta<ons, skateboard shops, internet
• Ingested, inhaled, injected, smoked, snorted • Synthe<c cathinones – Central nervous system s<mulants – Effect similar to amphetamine – Found in Epsom Salt
• Undetectable in rou<ne urine drug screens, field tes<ng kits, drug-‐detec<ng canines
National Drug Intelligence Center
Prescrip<on Cathinone medica<ons • Buproprion – Zyban® – Wellbutrin® – Indicated for depression, tobacco cessa<on
• Diethypropion (IV) – Tenuate® – Indicated for weight loss, decreases appe<te
• Pyrovalerone (V) – Centroton® – Psychoac<ve drug with s<mulant effects – Indicated for depression, chronic fa<gue, lethargy, appe<te suppressant
“Smiles”, “Izzy”, “Isabel”
• Synthe<c phenethylamine chemical (serotonin receptor agonist)
• From the maker of Ectasy (Alexander Shulgin) • Untraceable in standard drug tests • Seizures, kidney failure, fatally high blood pressure
• “Uncoupling” – muscles cannot uncontract – Users can ‘t stop smiling
hVp://shine.yahoo.com/healthy-‐living/2c-‐smiles-‐killer-‐drug-‐every-‐parent-‐know-‐234200299.html
Ques<ons?
Thank you for your anen<on!
