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Overmedication

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Overmedication describes the excessive use of over-the-counter or precription medicines for a person. Overmedication can have harmful effects, such as non-adherence or interactions with multiple prescription drugs.

Over-the-counter medication overuse

Over-the-counter (OTC) medications are generally first-line therapies that people may choose to treat common acute illnesses, such as fevers, colds, allergies, headaches, or other pain. Many of these medications can be bought in retail pharmacies or grocery stores without a prescription. OTC medication overuse is most prevalent in adolescents and young adults.[1] This overuse is common due to the relatively low cost, widespread availability, low perceived dangers, and internet culture associated with OTC medications.[2] It is also important to note that many OTC medications come in combination formulations that contain multiple drugs. These combination formulations are often used with other substances, which complicates treatment for these types of overdoses. Furthermore, the easy access to information online can sometimes lead to self-diagnosis and self-medication, contributing to the potential for misuse and overuse.

Acetaminophen

Overuse of acetaminophen is the leading cause of liver failure in the Western world.[3] The maximum daily limit of acetaminophen is 4 grams per day for someone with a healthy liver. It is also highly recommended to go over the maximum daily limit. Exceeding the maximum daily limit could involve severe liver toxicity, liver failure, kidney failure, or even death.[4] People who have poor liver function or with chronic alcohol use disorder should either limit or not ingest acetaminophen to prevent morbidities.[5] Additionally, it is crucial to be aware that acetaminophen is an ingredient in many combination medications, increasing the risk of unintentional overdose. Patients should read labels carefully and consult healthcare providers to ensure they are not consuming excessive doses. In cases of suspected overdose, immediate medical attention is essential to mitigate potential life-threatening consequences.

Codeine

Main article: Opioid use disorder

Codeine is an opioid and shares similarities to other opioid overuse. Many OTC medications for cough have formulations that contain codeine, which people may seek to overuse. The common effects of codeine include miosis, respiratory depression, CNS depression, and decreased bowel motility. Opioid deaths are more related to super potent opioids such as fentanyl or for naive opioid users.[6] Despite the risk of death, dependence is another significant issue related to codeine overuse. Tolerance can build up, causing users to seek out more of the opioid, leading to dependence, especially with chronic daily use of codeine.[1] Additionally, the misuse of codeine-containing cough syrups has become a public health concern, as it can serve as a gateway to stronger opioids. It's important to monitor use and seek professional help if dependence is suspected. Moreover, education about the risks and signs of opioid addiction can play a crucial role in prevention and early intervention.

Dextromethorphan

Dextromethorphan, also shortened to DXM, affects the NMDA receptor and serotonin receptors which is believed to give its psychoactive effects at high doses. Similarly to codeine, DXM comes primarily in formulations that contain other OTC medications and is not common to find DXM on its own. Moreso, people who use DXM tend to use it concomitantly with other substances such as alcohol, hallucinogens, sedative drugs, and opioids.[1] DXM has dose dependent psychoactive effects with lower dose leading to more restlessness and euphoria and higher doses causing hallucinations, delusional beliefs, paranoia, perceptual distortions, ataxia, and out of body experiences.[1]

Diphenhydramine

Diphenhydramine is typically used for allergy relief, however, there are people who use it recreationally to help alleviate their sleeping problems, anxiety, and overall restlessness.[7] This is how overuse can occur. Acute effects are both psychiatric and physiological. For psychiatric effects a user may experience euphoria, hallucinations, or psychosis.[8] The physiological effects originate from the anticholinergic activity which may lead to tachycardia, dry mouth, blurred vision, mydriasis, CNS depression, and urinary retention.[8] While fatalities are not common it is primarily seen in individuals who have suicidal ideation who overuse the drug as a suicide attempt.[9]

Pseudoephedrine

Pseudoephedrine overuse is not common in the US due to the amount of the medication that can be purchased. The total amount of pseudoephedrine a customer can purchase in a day is 3.6 grams while a max of 9 grams of pseudoephedrine could be purchased in a 30 day cycle.[10] This is mainly due that ephedrine, pseudoephedrine, or phenylpropanolamine can all be used as precursor for methamphetamine production. Prior to the limiting supply of pseudoephedrine, it was used as a weight loss and athletic medication.[1] The habitual use of the medication has led to dependance for many user using for weight loss leading to symptoms of insomnia, diminished sense of fatigue, euphoria, and psychotic behavior. Withdrawal symptoms include restlessness, dysphoria, and distorted perceptions.

Special populations

Elderly

Seniors (65 years old and up) are commonly victims of overmedication/overprescribing. It may make sense that with older age comes more chronic conditions, however, taking that into account does not change the higher incidence of adverse drug events in people over 65 years of age.[11]

A report in 2018 by Human Rights Watch found that every week in American nursing homes around 180,000 residents are given antipsychotic drugs who do not have the diagnosis for which the drugs are approved. Most of these people have behavioral issues or some form of dementia. The drugs are often administered without informed consent. The reason these drugs are administered is for the sedative effect, which makes the people docile and easier to manage.[12]

Polypharmacy is defined as the use of multiple prescriptions medications, and most commonly seen in elderly people. [13] Elderly people have multiple medications to manage their chronic diseases placing them at higher risk for overmedication and adverse reactions.

Children

The overmedication of children has dramatically risen with those between the ages of 2 and 5 years old who are being prescribed atypical antipsychotics for bipolar disorders, developmental disabilities, ADHD, and behavior disorders.[14] Drug companies have benefited considerably with profits made in sales for drugs such as stimulants for hyperactive children, with half a million children in the United States receiving medication.[15][obsolete source] Children have become more involved with technology resulting in less play time outside and less time spent with parents. The long hours children spend with technology has impacted their attachment development, sensory and motor development, along with socialization skills, in return causing behavioral and psychological disorders and learning disabilities being diagnosed by psychotropic medication.[16]

If parents monitor their child's behavior and regulate their environment, it can help to prevent any future affective disorders. Medication is often prescribed to these children; however, it alone will not teach a child to create more valuable relationships at home or in the community. Other forms of intervention can be applied to supplement the effects of medication therapy and teach the child self-regulatory behaviors and healthy coping skills.[17] The increase of psychiatric medication of children may be a result of the declining support for caregiving, leading to psychopathology in which drugs are oftentimes the go to method of treatment.[14] Families do not always have knowledge regarding or the means to pursue other methods of intervention such as one-on-one therapy with the child, family therapy and parenting counseling that can teach effective parenting strategies to meet their child's specific needs. There is debate that healthcare professionals have been put under pressure to perform proficiently causing the influence of piecemeal polypharmacy.[18]

Overprescription

Overprescription can lead to medication misuse or abuse. Antibiotics[19] and Narcotic painkillers[20] are both common examples seen in both inpatient and outpatient settings.

Opioids

Opioids are used for pain management acutely or prescribed after a surgical procedure. A large issue with opioid prescription is the oversupply for pain management leading to opioid misuse. While opioids aid in short and long term pain management, overprescription or constant opioid-exposure allows people to be at risk for addiction or even sharing of medications for relief.[21] There is a rise within healthcare systems or departments to manage prescription day supply of opioids to avoid opioid misuse and abuse.

Antibiotics

See also: Antimicrobial resistance

One of the most commonly prescribed medications, antibiotics are a group of drugs that fight against or prevent bacterial infections.[22][23] The misuse and overuse of these medications over the years have led them to lose their affinity for fighting certain bacteria due to bacteria developing resistance.[22][23] Antibiotic over-prescription is one of the most significant contributing factors to the global antimicrobial resistance crisis.[24] Antibiotic overprescription is a problem in all areas of healthcare settings, whether in acute, primary hospitals, or dental offices.[24][25]

Half of all written antibiotic prescriptions are inappropriate, and as a result, antibiotic-resistant bacterial infections are increasing. In the recent years of the COVID-19 pandemic, inappropriate antibiotic prescriptions have increased. A systemic review of admitted COVID-19 patients who were prescribed antibiotics showed that 80% of the patients were given antibiotics upon admission without confirmed bacterial co-infections.

Another study showed that outpatient doctors are prescribing antibiotics for non-indicated diagnoses such as viral infections to gain patient satisfaction; the consequence of this is the occurrence of more antibiotic-resistant infections, greater adverse drug events, more drug-drug interactions, and 15,000 deaths a year in the US alone. Dentists also play a significant role in this issue; like medical doctors, they also fall under the pressure/expectations of patients and inappropriately prescribe antibiotics for non-indicated conditions that could otherwise be treated with other interventions against current guidelines.[25]

Undiagnosing to prevent overprescribing

Some diagnoses do not hold important clinical implications and do not require treatment. When they are treated, there is the potential for harm but little potential for benefit. The ERASE algorithm can help clinicians to Evaluate diagnoses through the consideration of Resolved conditions, Ageing normally and Selecting appropriate targets to Eliminate unnecessary diagnoses and associated medicines.[26] Undiagnosing relies on accurate and comprehensive medical records to inform a thorough review of diagnoses.[27]

Medication overuse headaches

Main article: Medication overuse headache

Medication overuse headaches, also known as rebound headaches, are caused by the overuse of pain-relieving drugs for headaches, such as migraine headaches.

References

  1. ^ a b c d e Schifano F, Chiappini S, Miuli A, Mosca A, Santovito MC, Corkery JM, et al. (2021-05-07). "Focus on Over-the-Counter Drugs' Misuse: A Systematic Review on Antihistamines, Cough Medicines, and Decongestants". Frontiers in Psychiatry. 12: 657397. doi:10.3389/fpsyt.2021.657397. PMC 8138162. PMID 34025478.
  2. ^ Chiappini S, Schifano F (2020-10-14). "What about "Pharming"? Issues Regarding the Misuse of Prescription and Over-the-Counter Drugs". Brain Sciences. 10 (10): 736. doi:10.3390/brainsci10100736. ISSN 2076-3425. PMC 7602178. PMID 33066476.
  3. ^ Bernal W, Hyyrylainen A, Gera A, Audimoolam VK, McPhail MJ, Auzinger G, et al. (July 2013). "Lessons from look-back in acute liver failure? A single centre experience of 3300 patients". Journal of Hepatology. 59 (1): 74–80. doi:10.1016/j.jhep.2013.02.010. PMID 23439263.
  4. ^ Chiew AL, Gluud C, Brok J, Buckley NA, et al. (Cochrane Hepato-Biliary Group) (February 2018). "Interventions for paracetamol (acetaminophen) overdose". The Cochrane Database of Systematic Reviews. 2 (2): CD003328. doi:10.1002/14651858.CD003328.pub3. PMC 6491303. PMID 29473717.
  5. ^ Buckley NA, Whyte IM, O'Connell DL, Dawson AH (January 1999). "Activated charcoal reduces the need for N-acetylcysteine treatment after acetaminophen (paracetamol) overdose". Journal of Toxicology. Clinical Toxicology. 37 (6): 753–757. doi:10.1081/clt-100102452. PMID 10584587.
  6. ^ Lavonas EJ, Dezfulian C (October 2020). "Impact of the Opioid Epidemic". Critical Care Clinics. 36 (4): 753–769. doi:10.1016/j.ccc.2020.07.006. PMID 32892827.
  7. ^ Smith SG (1984-08-24). "Nonmedical use of butorphanol and diphenhydramine". JAMA: The Journal of the American Medical Association. 252 (8): 1010c–1010. doi:10.1001/jama.252.8.1010c.
  8. ^ a b "Benadryl, Nytol (diphenhydramine) dosing, indications, interactions, adverse effects, and more". reference.medscape.com. Retrieved 2024-07-28.
  9. ^ Ramachandran K (Feb 2008). "Rare Complications of Diphenhydramine Toxicity". Connecticut Medicine. 72 (2): 79–82.
  10. ^ "Diversion Control Division | CMEA General Information". www.deadiversion.usdoj.gov. Retrieved 2024-07-28.
  11. ^ Safer D (September 2019). "Overprescribed Medications for US Adults: Four Major Examples". Journal of Clinical Medicine Research. doi:10.14740/jocmr3906. PMID 31523334.
  12. ^ Root B (2018-02-05). ""They Want Docile": How Nursing Homes in the United States Overmedicate People with Dementia". Human Rights Watch.
  13. ^ Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE (October 2017). "What is polypharmacy? A systematic review of definitions". BMC Geriatrics. 17 (1): 230. doi:10.1186/s12877-017-0621-2. PMC 5635569. PMID 29017448.
  14. ^ a b "The overmedication of our youth: An interview with Brent Dean Robbins, PhD". Society for Humanistic Psychology Newsletter. April 2012.
  15. ^ Gittelman M (1979). "Introduction: Refining Diagnosis and Behavioral Intervention: Key to Preventing Overmedication". International Journal of Mental Health. 8 (1): 3–9. doi:10.1080/00207411.1979.11448816. JSTOR 41350662.
  16. ^ Rowan C (2010). "Unplug—Don't Drug: A Critical Look at the Influence of Technology on Child Behavior with an Alternative Way of Responding Other Than Evaluation and Drugging". Ethical Human Psychology and Psychiatry. 12: 61. doi:10.1891/1559-4343.12.1.60. S2CID 58689722.
  17. ^ Luvmour J (2011). "Nurturing Children's Well-Being: A Developmental Response to Trends of Overdiagnosis and Overmedication". Journal of Humanistic Psychology. 51 (3): 350–368. doi:10.1177/0022167810386958. S2CID 146359625.
  18. ^ Zakriski AL, Wheeler E, Burda J, Shields A (February 2005). "Justifiable Psychopharmacology or Overzealous Prescription? Examining Parental Reports of Lifetime Prescription Histories of Psychiatrically Hospitalised Children". Child and Adolescent Mental Health. 10 (1): 16–22. doi:10.1111/j.1475-3588.2005.00111.x. PMID 32806815.
  19. ^ Thompson D (5 December 2016). "U.S. Doctors Still Over-Prescribing Drugs: Survey". WebMD.
  20. ^ Mozes A (25 March 2016). "Nearly All U.S. Doctors 'Overprescribe' Addictive Narcotic Painkillers: Survey". WebMD.
  21. ^ Stoicea N, Costa A, Periel L, Uribe A, Weaver T, Bergese SD (May 2019). "Current perspectives on the opioid crisis in the US healthcare system: A comprehensive literature review". Medicine. 98 (20): e15425. doi:10.1097/MD.0000000000015425. PMC 6531094. PMID 31096439.
  22. ^ a b Holmes AH, Moore LS, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, et al. (2016-01-09). "Understanding the mechanisms and drivers of antimicrobial resistance". The Lancet. 387 (10014): 176–187. doi:10.1016/S0140-6736(15)00473-0. ISSN 0140-6736.
  23. ^ a b Bassetti S (May 2022). "Optimizing antibiotic therapies to reduce the risk of bacterial resistance". European Journal of Internal Medicine. 99: 9–12. PMID 35074246.
  24. ^ a b Rowe TA, Linder JA (2019-07-03). "Novel approaches to decrease inappropriate ambulatory antibiotic use". Expert Review of Anti-infective Therapy. 17 (7): 511–521. doi:10.1080/14787210.2019.1635455. ISSN 1478-7210.
  25. ^ a b Dana R, Azarpazhooh A, Laghapour N, Suda KJ, Okunseri C (2018-04-01). "Role of Dentists in Prescribing Opioid Analgesics and Antibiotics: An Overview". Dental Clinics of North America. Dental Public Health. 62 (2): 279–294. doi:10.1016/j.cden.2017.11.007. ISSN 0011-8532.
  26. ^ Page A, Etherton-Beer C (May 2019). "Undiagnosing to prevent overprescribing". Maturitas. 123: 67–72. doi:10.1016/j.maturitas.2019.02.010. PMID 31027680.
  27. ^ Hosking SM, Etherton-Beer C, Page AT (July 2019). "Undiagnosing: Correcting the medical record to prevent over-intervention". Case Reports in Women's Health. 23: e00133. doi:10.1016/j.crwh.2019.e00133. PMC 6664263. PMID 31384565.
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