Are Over-the-Counter Medications Safer Because You Don’t Need a Prescription?
What Are Over-the-Counter Drugs?
Over-the-counter (OTC) drugs are everywhere. You may frequently encounter some of these medicines on store shelves and home medicine cabinets. If you can walk into a grocery store, pharmacy, or gas station and buy a drug that promises to treat the symptoms of an illness or problem, it is likely an OTC medicine.1
Available OTC medications are too numerous to name individually. Many are designed to treat what ails you—easing the impact of a common health conditions by managing unwanted symptoms, such as:1
- Cough and colds.
Some OTC medications promise a way to improve certain traits or abilities as a way to achieve your personal goals. People seeking these benefits may take OTC drugs for the purpose of boosting concentration, accelerating weight loss, or increasing energy.
Recently, as some states have added restrictions for certain medications that were previously available over-the-counter, another group of medicines emerged that exists between prescription and over-the-counter drugs. Called “behind-the-counter,” these drugs may be found in a different location of the pharmacy and require identification in order to purchase limited amounts.1 Still, no prescription is needed.
Are They Safe?
In the U.S., the Food and Drug Administration (FDA) tests and reviews all drugs. Only the safest medicines are allowed to be designated as OTC.2
Generally, OTC medicines are safe and effective when used to treat the intended condition or set of symptoms. When taking a new OTC medicine, always read the label to understand what the medication is, what it does, and how to use it. Consult your doctor to identify any special risks or dangers you may encounter by using the medication or giving the drug to someone else, especially children.
Despite the overall safety of OTC medications, not all of them are safe in all situations.2 Some OTC drugs produce unpredictable side effects or allergic reactions resulting in trouble breathing. OTC drugs may be contraindicated for use in people with certain medical conditions and can also interact negatively with foods, drinks, supplements, and other medicines to produce a variety of dangerous effects.2
The associated risks from OTC medicines increase dramatically when a person misuses them. OTC drug abuse happens when someone:1
Takes the drug in ways other than directed on the package by:
- Using too much.
- Using too often.
- Using in a different method than directed, such as crushing and snorting or dissolving in water and injecting.
- Intentionally mixes the drug with other substances to amplify the effects.
- Takes the drug only to get high from it.
It may seem odd for a person to abuse a simple OTC medicine, but some drugs contain active ingredients that cause psychoactive effects and thus, have a serious potential for misuse.1
Some may mistakenly believe this practice is safer than using illicit or prescription drugs, but all substance abuse carries severe risks to your mental and physical health.1 You should only take medicines to treat your symptoms and only as directed by your doctor.
The challenge for parents or other loved ones of someone who could be abusing OTC drugs is understanding how misuse can be dangerous, knowing the warning signs of abuse, and helping the user get treatment. With this information, you can react in educated and purposeful ways to prevent and reduce harm.
Common OTC Medications of Abuse
Since OTC drug abuse is always changing and evolving, this list may vary in your particular community. Continue seeking local information about the drug trends and effects of the abused substances from trusted sources like physicians and drug abuse experts.
What Are the Effects of These Drugs?
Every drug of abuse is consumed with a specific goal or intention in mind. Whether the individual is seeking an opportunity to feel pleasure, the chance to perform at a higher level, or simply the thrill of experimentation, they believe the substance will help them achieve that goal.
In reality, despite the perceived safety of OTC drugs, putting too much of any drug into your body can be extremely detrimental. The often-misperceived benefits are easily outweighed by the risks of hazardous outcomes.
In the brain, DXM acts on the same receptor/neurotransmitter system as the dissociative drugs ketamine and PCP. With high doses, DXM triggers hallucinations in which the user will see, hear, or feel things that are not present.7 People under the influence of DXM may also feel removed from their body or separated from their surroundings. These experiences are often pleasant initially because the drug causes a rush of dopamine (a highly rewarding neurotransmitter) in the brain.7 .
DXM is highly abused among high school students with about 3.6% of 10th graders abusing DXM, and other cough medicines, in 2017.7 Some of these teens consume the substance in combination with alcohol or marijuana to enhance the effects—an ill-advised and potentially dangerous mix.1
With DXM, the short-term desirable results quickly give way to:1
- Panic and high anxiety.
- Loss of motor control.
- Vision problems.
- Slurred speech.
- High blood pressure.
- Low energy.
- Stomach pain.
Loperamide is an anti-diarrheal that targets opioid receptors in the gut but is designed not to enter the brain when taken at recommended doses. Abusers who use loperamide in high doses or combine it with other drugs may experience some opioid-like effects.1
Some will use loperamide as a way to treat withdrawal from other opioids while others want the euphoric high it produces.1 The OTC drug can also trigger a host of unwanted consequences like:1
- Stomach pain.
- Loss of consciousness.
- Erratic or rapid heart rate.
- Kidney issues.
- Overdose and death due to slowed breathing.
Ephedrine or ephedra are central nervous system (CNS) stimulants that cause the release of a neurotransmitter called norepinephrine into the system.3 When this occurs, the user might feel increased levels of attention, focus, and energy, as well as appetite suppression for those seeking weight loss.8
Though ephedrine is known to be effective for weight loss, the dangers outweigh the potential benefits. Someone using ephedrine alone or in combination with caffeine will increase their risks of:8
- Experiencing hallucinations, paranoia, or delusional thinking.
- Dry mouth.
- Problems urinating.
- Sleep problems.
- Exacerbation of heart and kidney disease.
- Increasing blood sugar levels.
Due to the dangers, the FDA banned supplements containing ephedrine alkaloids in 2004.8 That being said, people are still able to obtain it relatively easy, especially with the emergence of online black market websites.
Like ephedrine, caffeine is a CNS stimulant that people use to provide a boost of energy and wakefulness.6 Products containing caffeine make claims about increasing alertness or improving mental or physical abilities.
Most people can tolerate caffeine well and can safely consume up to 400 mg per day—about 4 regular coffees.6 People abusing the substance will turn to products with higher caffeine content, such as caffeine pills, to elicit more powerful results. People may also consume energy drinks, such as Red Bull or Monster, as an alternative to coffee. These drinks are often mixed with alcohol.
Caffeine pills are typically very concentrated, so it will be easy to quickly meet and exceed the daily recommended levels. Too much caffeine can cause:6
- Restlessness and shakiness.
- Trouble sleeping.
- Fast or irregular heart rhythm.
- Dehydration from more frequent urination.
Eating disorders are a group of mental health conditions involving food, eating, faulty body perceptions, and extreme measures to lose or maintain weight.9 People with certain eating disorders commonly abuse laxatives as a way to feel less full and quickly remove food from the system in an effort to control weight.
Laxative abuse occurs when people use laxatives too often or use laxatives that are too strong for their situation. Healthy people rarely need the simulant laxatives like Dulcolax or Senokot, but these are the ones most frequently abused.4
Once it begins, laxative abuse can be challenging to stop despite the negative effects, including:4
- The cycle of constipation, diarrhea, and gas.
- Electrolyte imbalance.
- Blood in the stool.
- Impaired functioning of the intestines.
- Rectal prolapse—when the rectal mucosal lining protrudes from the anus.
Pseudoephedrine does not have a strong abuse potential alone, meaning that people will not take high doses to feel euphoric or desirable effects. Instead, products containing the substance, like Sudafed, are purchased in bulk to obtain enough pseudoephedrine to manufacture a batch of methamphetamine.1
Methamphetamine is a very powerful and addictive CNS stimulant that is frequently produced in illegal labs across the country.10 People will abuse meth by smoking, inhaling, injecting, or swallowing the substance. As a stimulant, meth will produce high energy and euphoria, but it can also cause:10
- Neurotoxic brain changes.
Since 2006, products containing pseudoephedrine have been located “behind the counter” and sellers are required to:10
- Limit how much someone can buy in a month.
- View photo identification of anyone buying the product.
- Maintain a log of who buys the substance and how much they purchase.
Diphenhydramine and other antihistamines are appealing drugs of abuse because of their off-label effects like sleepiness, feelings of calm, decreased shakiness, and a mildly euphoric high.5 At very high doses—over 300 mg, in the case of diphenhydramine—antihistamines can produce hallucinogenic effects, with some people abusing over 1,000 mg daily for these results.5 Hallucinations in and of themselves aren’t fatal, but the disconnect from reality can be dangerous and may lead to accidents, unwanted injuries, violence, and even death.
Antihistamines seem to be used most commonly by two distinct groups:5
- Teenagers looking for a mild high, improved sleep, or decreased anxiety from the cheap and available drugs.
- Adult males with schizophrenia who are on antipsychotic medications.
The Danger of Mixing Drugs
By now, the dangers that will likely arise from you or your loved ones abusing OTC drugs are evident. The risks are compounded when people:
- Mix multiple OTC drugs.
- Mix OTC drugs with prescription medications.
- Mix OTC drugs with alcohol or illicit substances.
Some people will engage in this practice accidentally without realizing the risks of mixing substances. Others will intentionally combine these substances as a way to modify the effects or increase the high from either substance alone.
Combining drugs that work differently in the brain (mixing a stimulant with a depressant) can somewhat mask the effects of either drug. In the case of caffeine and alcohol abuse, using large amounts of caffeine serves to minimize some of the subjective intoxication from the alcohol, which interferes with the ability to accurately recognize how drunk you are.6 This combination may lead to overconsumption, bad decisions, and alcohol poisoning.
By mixing multiple stimulants or multiple depressants, the person will experience results that are amplified. Ephedrine and caffeine both cause increased heart rate and blood pressure, which can prove dangerous, especially in an individual with pre-existing cardiovascular issues.8 Similarly, using loperamide with alcohol can cause profound respiratory depression, which could result in overdose and death.1
Codeine cough syrups are frequently combined with alcohol or caffeinated drinks.7 Although these syrups are not available over-the-counter, these drinks remain popular, especially among teens and young adults. These drinks are known by many names including:7
- Purple drank.
Young adults also commonly combine DXM-containing cough syrups with alcohol. In relatively recent years, this may have become an increasingly common practice due to the difficulty of obtaining codeine-containing cough syrups since some products, such as Phenergan w/ codeine, have been discontinued. The act of mixing DXM with alcohol or soda is called robo-tripping or skittling.1
One of the most widely-used OTC substances, acetaminophen, has a perception of safety, but over-the-counter drug misuse and abuse can make this substance extremely dangerous. Found in Tylenol, prescription opioid drugs like Percocet, and various cold medicines, too much acetaminophen can lead to overdose, liver failure, and even death.11
Acetaminophen overdose is a very common reason for calls to poison control hotlines and visits to emergency rooms.11 Like other OTC drugs, mixing acetaminophen with alcohol and other drugs will increase the risks of unwanted outcomes, particularly liver damage.
Mixing OTC medicines with illicit substances, prescription drugs, alcohol, and other substances can lead to unpredictable and deadly outcomes. Even when not combined with other drugs or alcohol, the misuse of some substances can still lead to significant health issues, including the development of compulsive drug use behaviors.=
Chronic Abuse & Addiction
One of the most impactful results of chronic substance use is addiction. Addiction is a condition characterized by intense drug cravings and compulsive use regardless of negative consequences.12 Once someone develops a substance addiction, it can be extremely difficult for them to quit using on their own.
The American Psychiatric Association (APA) has outlined several criteria which are used to help make a diagnosis of a substance use disorder—or, what is more commonly referred to in lay circles as addiction.9 A substance use disorder (SUD) is a mental health diagnosis precipitated by some level of drug or alcohol use where the person will:9
- Use more of the drug than intended for periods longer than intended.
- Spend most of their time, effort, and resources getting, using, and recovering from their substance.
- Make frequent but unsuccessful attempts to stop, slow, or control their use.
- Experience strong cravings for the substance.
- Struggle to manage obligations at home, work, or school because of the focus on using.
- Create significant conflict with loved ones or push people from their life.
- Sacrifice their social, occupational, and recreational activities in favor of substance abuse.
- Keep using the substance despite the risk of physical or mental injuries.
- Need more of the substance over time to maintain the desired level of effects (tolerance).
- Experience unpleasant or distressing withdrawal symptoms when they suddenly stop or reduce use.
Even having a few of these symptoms could indicate that you or your loved one has a problem with OTC substance abuse. Other clues pointing to OTC drug addiction include:
- Making frequent trips to various pharmacies, grocery stores, and gas stations to obtain the drug.
- Hiding, concealing, or lying to others about use.
- Stealing drugs or asking others to buy them.
- Possessing various empty and used medicine boxes or bottles.
- Changing physical appearance with dramatic changes in weight or self-care.
- Searching the Internet for information on how to abuse OTC drugs.
You might think it is impossible to become addicted to something as safe as an OTC medicine, but this is a common misconception. People can and do develop addictions to OTC medicines. Not recognizing the risk puts you and your loved ones in greater danger.
Addiction is often associated with another problem caused by chronic drug abuse—physical dependence. With physical dependence, the brain and the body adapt to the presence of the drug in the system that the person feels well and functions normally only when using the drug.12
When someone develops a physiological dependence on a drug, withdrawal symptoms will typically emerge with the sudden discontinuation or reduction in use. These symptoms can be painful and rather distressing and could possibly lead to relapse in efforts to alleviate withdrawal.
Some OTC drugs like caffeine can trigger physical dependence and withdrawal symptoms, while others like DXM and loperamide have not been studied enough to fully understand the potential, although there have been case studies involving withdrawal symptoms from these OTC substances.1
OTC Withdrawal Symptoms & Dangers
Caffeine has a well-documented withdrawal syndrome. It can range from mild to clinically significant, causing major impairment and distress in a person’s life.13 Common caffeine withdrawal symptoms reported by patients include:13
- Reduced alertness.
- Decreased contentedness.
- Depressed mood.
- Impaired concentration.
Other signs of caffeine withdrawal include:13
- Reduced or increased blood pressure.
- Reduced motor activity.
- Impaired cognitive or behavioral performance.
- Hand tremors.
- Skin flushing.
- Flu-like symptoms.
- Nausea or vomiting.
- Joint pain.
- Stomach pain.
Gradual reduction of caffeine use can help to prevent these withdrawal symptoms, while OTC analgesics, such as Advil, can manage headaches, which tend to be the most commonly reported symptom.13
Unlike caffeine, many other over-the-counter medications do not have enough research to confirm a formal withdrawal syndrome, but there are individual reports of unpleasant withdrawal symptoms associated with suddenly quitting OTC drugs.
For instance, there was one case studying involving a man who took dextromethorphan regularly for 6 years. He reported that he’d experienced nausea, excessive sweating, and sleep disturbances when he attempted to reduce his daily dosage of DXM on his own. He was eventually admitted to an inpatient hospital, where he experienced rapid heart rate, increased blood pressure, nausea, drug cravings, and profound sweating.14 The client’s physical symptoms resolved within 2 days. More research is needed to determine a documented withdrawal syndrome.
Likewise, one case study involved a man who abused loperamide for about a year and a half, ultimately building to a dose of 400 2 mg capsules a day. He arrived at the emergency department requesting referral for loperamide detox. His self-reported withdrawal symptoms included:15
- Tearing eyes.
- Excessive yawning.
- Profound sweating.
The patient entered a detox program to manage these symptoms then left voluntarily the following day. Days later, he died from cardiac arrest due to loperamide overdose days later. Although loperamide withdrawal may not be life-threatening, there is evidence that it can be rather unpleasant, and loperamide abuse can lead to cardiac complications, as demonstrated.15 Again, more research is needed to confirm a loperamide withdrawal syndrome.
Another case study involving a man with mild depression revealed that using pseudoephedrine for 2 weeks improved his mood and symptoms, but sudden discontinuation led to severe depression, far worse than he’d experienced prior to pseudoephedrine use.16 The specific withdrawal symptoms he noted included:16
- Severe fatigue and increased need for sleep.
- Reduced concentration.
- Slowed movements and cognition.
- Increased appetite.
- Profound sadness.
- Poor self-image.
These symptoms persisted for at least 4 days following pseudoephedrine cessation, and then he reported a partial improvement in depressive symptoms.16 Severe depression can lead to suicidal ideation or attempts, so it’s important to seek professional help if you struggle with pseudoephedrine addiction and/or depression.
There is also evidence that when people try to quit using antihistamine drugs like Benadryl and Dramamine after a period of chronic misuse, they may experience withdrawal symptoms, such as:5
- Increased problems sleep.
- Nasal congestion.
- Abdominal cramps and diarrhea.
Painful and uncomfortable withdrawal symptoms can make it difficult for people to quit using OTC drugs on their own. They may return to drug use to relieve these unwanted symptoms, thus perpetuating a cycle of quitting and abuse that can be challenging to break.
People hoping to recover from addiction often begin with a period of professional detoxification to jumpstart their sobriety. Professional detoxification is a set of strategies and formal interventions used to manage withdrawal and ensure someone’s safety and comfort throughout the process.17 Once a person achieves a medically stable, drug-free state, they are ready to transition into formal substance abuse treatment, where they can address the underlying issues that led to drug abuse in the first place.
It’s never too late to make a positive change in your life. If you are struggling with an addiction to OTC drugs or any other substance, professional addiction treatment can help you get clean and sober.
- National Institute on Drug Abuse. (2017). DrugFacts: Over-the-Counter Medicines.
- S. National Library of Medicine: MedlinePlus. (2016). Over-the-Counter Medicines.
- National Institutes of Health. (2004). Ephedra and Ephedrine Alkaloids for Weight Loss and Athletic Performance.
- Cornell University. (2017). Laxative Use: What to Know.
- Gracious, B., Abe, N., & Sundberg, J. (2010). The Importance of Taking a History of Over-the-Counter Medication Use: A Brief Review and Case Illustration of “PRN” Antihistamine Dependence in a Hospitalized Adolescent.Journal of Child and Adolescent Psychopharmacology, 20(6), 521–524.
- S. National Library of Medicine: MedlinePlus. (2015). Caffeine.
- National Institute on Drug Abuse for Teens. (2017). Cough and Cold Medicine (DMX and Codeine Syrup).
- National Center for Complementary and Integrative Health. (2016). Ephedra.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
- S. Food and Drug Administration. (2017). Legal Requirements for the Sale and Purchase of Drug Products Containing Pseudoephedrine, Ephedrine, and Phenylpropanolamine.
- S. National Library of Medicine: MedlinePlus. (2017). Acetaminophen Overdose.
- National Institute on Drug Abuse. (2018). Principles of Drug Addiction Treatment: A Research-Based Guide.
- Sajadi-Ernazarova, K.R., & Hamilton, R.J. (2017). Caffeine, Withdrawal. Treasure Island, FL: StatPearls Publishing.
- Mutschler, J., Koopmann, A., Grosshans, M., Hermann, D., Mann, K., & Kiefer, F. (2010). Dextromethorphan Withdrawal and Dependence Syndrome. Deutsches Arzteblatt International, 107(30), 537-540.
- MacDonald, R., Heiner, J., Villarreal, J., & Stroke, J. (2015). Loperamide dependence and abuse. BMJ Case Reports.
- Webb, J. & Dubose, J. (2013). Symptoms of Major Depression After Pseudoephedrine Withdrawal: A Case Report. The Journal of Neuropsychiatry, 25(2), 54-55.
- Substance Abuse and Mental Health Services Administration. (2015). Detoxification and Substance Abuse Treatment.
- National Institute on Drug Abuse. (2014). Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide.
- Massachusetts Executive Office of Health and Human Services. (2016). Substance Abuse Services Descriptions.