Over-the-Counter Drugs

What Kind of Drug Is It?

Over-the-counter (OTC) medicines are preparations that are sold to consumers without a doctor's prescription. The most common OTC medications are used to treat aches and pains, allergies, drowsiness, and cold and influenza (flu) symptoms. OTC drugs are also commonly used to remedy coughs and sore throats, constipation (the inability to have a bowel movement), and diarrhea (loose, watery, or frequent bowel movements).

Other ailments that are relieved by OTC drugs include insomnia (having difficulty falling asleep or being unable to fall asleep); motion sickness; nausea (an upset stomach, sometimes combined with vomiting); and obesity (being extremely overweight). Herbal dietary supplements and vitamins are also sold over the counter. Volumes could be written on the use and abuse of OTC medications. The following entry attempts to provide as much relevant information as possible for the scope and intended audience of this encyclopedia.

Overview

The Italian adventurer Casanova (1725–1798) is often quoted as saying: "In wise hands, poison is medicine. In foolish hands, medicine is a poison." Such is the case with over-the-counter (OTC) drugs—those medicines found on shelves in drugstores, convenience stores, and supermarkets. The sale of nonprescription drugs, vitamins, and herbal dietary supplements is a multi-billion dollar industry. Improper use of these medications, however, can be dangerous. Some individuals take OTC drugs not for medical reasons but for recreational use. In other words, they take the drugs to get high.

Official Drug Name:
Anti-allergy drugs/antihistamines/decongestants: brompheniramine maleate (BROME-fenn-IRR-uh-meen MAL-ee-ate; Dimetapp), chlorpheniramine maleate (KLOR-fenn-EAR-uh-meen MAL-ee-ate; Clor-Trimeton, Coricidin, and Sudafed), diphenhydramine hydrochloride (dye-fenn-HY-druh-meen high-droh-KLOR-ide; Benadryl), guaifenesin (gwy-FENN-ess-inn; Humibid, Organidin NR, and Robitussin), hydrocortisone (HIGH-droh-KORE-tihzone; Hydrocort and Westcort), loratadine (lor-AT-ih-deen; Claritin), and pseudoephedrine hydrochloride (SUE-doh-ih-FEH-drinn or sue-doh-EFF-ih-drinn high-droh-KLOR-ide; Sudafed; also some forms of Claritin);
antiemetics: dimenhydrinate (di-men-HI-dre-nat; Dramamine) and meclizine hydrochloride (me-KLI-zeen high-droh-KLOR-ide; Antivert and Dramamine II Less Drowsy);
antitussives: dextromethorphan hydrobromide (deks-troh-meth-ORR-fan high-droh-BROH-mide; Robitussin and Coricidin);
dietary supplements: herbs or other botanicals, minerals, and vitamins;
pain relievers: acetaminophen (uh-SEE-tuh-MINN-uh-fenn; Tylenol), aspirin, ibuprofen (EYE-byoo-pro-fenn; Advil and Motrin), dyclonine hydrochloride (DYE-kloe-neen high-droh-KLOR-ide; Sucrets), phenol (FEE-nole; with or without menthol; Cepacol, Cepastat, and Chloraseptic);
sleep aids: diphenhydramine hydrochloride (dye-fenn-HY-druh-meen high-droh-KLOR-ide; Nytol, Sominex, and Unisom SleepGels), doxylamine succinate (dok-SILL-uh-meen SEK-sehnate; Unisom SleepTabs);
stimulants: caffeine (Caffedrine, No-Doz, and Vivarin);
stomach/intestinal remedies: bisacodyl (biss-ah-COE-dill; Correctol and Dulcolax), bismuth subsalicylate (BIZ-muth sub-sah-LISS-uh-late; Kaopectate and Pepto-Bismol), calcium carbonate (Rolaids and Tums), docusate (DOE-coo-sate; Colace), kaolin and pectin (KAY-oh-lin and PEK-tin; Kapectolin and K-P), loperamide hydrochloride (loe-PER-a-mide high-droh-KLOR-ide; Imodium), magnesium hydroxide (Phillips' Milk of Magnesia), psyllium (SIH-lee-um; Fiberall and Metamucil), senna (Exlax and Senokot), simethicone (sy-METH-ih-cone; Gas-X and Mylanta)

Also Known As: Various; some examples include: downers (for diphenhydramine and doxylamine); red devils, skittles, triple-C (for dextromethorphan hydrobromide); and uppers (for caffeine)

Drug Classifications: Not scheduled or Schedule V; sold without a prescription

In From Chocolate to Morphine, Andrew Weil and Winifred Rosen noted, "Sometimes, people who are desperate for drugs … consume overdoses of these preparations in an effort to get high." Still others turn to OTC drugs in suicide attempts. Illicit drug makers often use the ingredients found in certain over-the-counter preparations to create designer drugs in homemade labs. Harmful and addictive, designer drugs are sold illegally on the streets by drug dealers looking to turn a sizable profit.

From ancient times to the twenty-first century, people have experimented with plants and even animals for use in medicines. Every human culture has used its regional plant life to cure ills—or at least to ease them. Home remedies were passed down from generation to generation, with parents teaching children what herb or plant to grow to cure various ailments. Plants with greater potency, or strength, especially those with hallucinogenic properties, generally became the tools of the trade for the shaman or medicine man of the indigenous, or native, peoples. (Hallucinogens are capable of producing visions or hallucinations, which alter the user's perception of reality.) Shamans, who closely guarded the secrets of their potions, were trained spiritual leaders who sought to cure the sick and uncover hidden truths. By the time of the great ancient civilizations of Egypt, Greece, Rome, and the Mayan empire, scholars were already writing texts on medicines and poisons. The medical profession had been established.

Patent Medicines Are Introduced

In the nineteenth century, few laws existed in the United States to regulate what ingredients went into medicines, or what sort of medicines could be sold. Traveling salespeople could peddle "patent medicines," which were over-the-counter drugs containing secret ingredients not listed on the label, and "tonics" and "elixirs" that promised they could cure just about anything. In those days, truth in advertising wasn't practiced by many who were looking to make a quick buck.

Larger companies manufactured bottled products, sold over the counter, with comforting names like "Mrs. Winslow's Soothing Syrup." No laws required that these products contained labels listing their ingredients. Plus, drug makers did not have to prove that their tonics actually worked or could achieve anything close to what advertisements claimed these medicines could do.

Patent medicines fell into two categories: 1) Those containing drugs such as alcohol, cocaine, heroin, marijuana, morphine, and opium; and 2) those containing little or no drug content at all. (Separate entries on alcohol, cocaine, heroin, marijuana, morphine, and opium are also available in this encyclopedia.) Many people used these medicines thinking they were effective and safe. Some even gave the products to their children and infants.

Addictions Run Rampant and the Government Steps In

As the twentieth century began, however, babies and children frequently faced addiction and death from so-called tonics containing narcotic drugs. Such drugs are painkillers that can easily become habit-forming. Grown men and women became dependent on their "medicines," thinking that they needed the tonics in order to function. They were unaware that they were consuming dangerous, addictive drugs.

This development, combined with fears about unsanitary conditions in meat-packing plants, led Congress to enact the Food and Drugs Act in 1906. With the passage of this act, the U.S. government took the first steps toward the regulation of patent medicines. The Food and Drugs Act did not ban any specific medicines, but it did require that companies list the medicine's ingredients on the label. Finally, Americans could look at a bottle of tonic and know exactly what it contained.

What's in a Name?

Patent medicine advertisements made all sorts of claims about what certain products could do for the consumer. Many promised they could "cure whatever ails you," while others just promised to treat specific ailments. In some cases, the medicines failed to produce any relief or led to addiction of various drugs, such as cocaine. Other home remedies did provide some relief.

Here's a look at some of the interesting names of patent medicines from that bygone era.

• Cocaine Tooth Drops
• Christie's Magnetic Fluid
• Dr. J. Hostetter's Stomach Bitters
• Dr. Morse's Indian Root Pills
• Dr. Pierce's Golden Medical Discovery
• Gooch's Mexican Syrup
• The Great Dr. Kilmer's Swamp-Root Kidney Liver & Bladder Cure Specific
• Lash's Kidney and Liver Bitters
• Lydia E. Pinkham's Vegetable Compound
• Mrs. Winslow's Soothing Syrup
• M&R Licorice Wafers (for throat irritation)
• Moxie Nerve Food
• Stanley's Snake Oil
• Stearns' Headache Cure
• Warner's Safe Kidney & Liver Cure

In 1914, the Harrison Narcotics Act sought to curb the use of habit-forming drugs such as opium and cocaine. This act required prescriptions for these and other addicting narcotics. In 1937, marijuana was taken off the medical market. The following year, the U.S. Food, Drug, and Cosmetic Act (FDC) required that all new drugs, both prescription and over-the-counter, be tested for safety in animal and human studies before being released to the public.

The Role of the FDA

All medicines sold in the United States fall under the regulation of the U.S. Food and Drug Administration (FDA). The agency began in 1862 as the Bureau of Chemistry. Its name was changed to the Food, Drug, and Insecticide Administration in 1927 and shortened to the Food and Drug Administration in 1930. This agency has many responsibilities that encompass safety testing, ingredient labeling, and the listing of nutritional guidelines on products that are ingested. It also regulates the ingredients in cosmetics and oversees the design of poison labels, tamper-resistant packaging, and child-proof caps on medicines and household cleaning products.

In addition, the FDA demands that drug companies label their medicines clearly, so that consumers can easily determine the proper usage and dosage information for every OTC medicine sold in the United States. The FDA must approve all medicines, both prescription and OTC, before the drugs are released for public use. Medicines that are shown to be dangerous can be recalled by the agency and removed from the market.

Every OTC medicine has undergone scientific tests, first on animals and then in controlled human studies. The FDA continues to monitor medicines after they have been approved due to concerns about long-term use of certain substances and their link to diseases such as cancer or to health risks such as liver damage. Often, medicines will first be approved for prescription use. Some eventually become OTC drugs once they prove safe.

For example, in the early 1980s, the popular pain reliever ibuprofen (Advil and Motrin) was available only by prescription. In the 1990s, the allergy drug Claritin required a prescription. In the early twenty-first century, guaifenesin (an ingredient in many OTC cough and cold products such as Robitussin) entered the OTC market after a period of prescription-only use. All of these drugs received OTC approval by the FDA only after their safety had been established.

Substances Not Under FDA Control

Some substances sold over the counter are not reviewed by the FDA. In 1976 the Proxmire Amendments stopped the FDA from limiting the potency, or strength, of vitamins and minerals contained in food supplements and from classifying high doses of vitamins as drugs. Less than twenty years later, the 1994 Dietary Supplement Health and Education Act (DSHEA) declared that herbal supplements such as St. John's wort (Hypericum perforatum) and ginseng (JINN-sing; Panax ginseng) were foods rather than drugs. As such, herbal and

dietary supplements are not typically regulated by the FDA unless a problem is reported.

"About 60 percent of U.S. consumers believe that dietary supplements must be approved by a government agency like the Food and Drug Administration before they can be sold to the public," according to the Harris Poll's Nancy Wong, as quoted in the Nutrition Action Healthletter. But that is no longer the case. The Healthletter continued: "Before DSHEA, if the FDA questioned a supplement's safety, the manufacturer had to prove that it was safe." Bruce Silverglade of the Center for Science in the Public Interest told the Healthletter, "DSHEA shifted the burden of proof." He added, "[T]hanks to DSHEA, the FDA has to prove that supplements are dangerous."

Although makers of herbal products cannot label them for medical use, the FDA cannot test them for safety until they are suspected to be unsafe for human use. In 2004 the FDA banned the sale of the herbal supplement ephedra (ih-FEH-druh; Ephedra sinica), but only after use of the substance had been tied to numerous deaths and health-related emergencies. (An entry on ephedra is available in this encyclopedia.)

Hundreds of OTC products line the shelves of drugstores and grocery store pharmacies. It is important to note that those marketed as medicines for specific problems are regulated by the FDA. Those marketed as vitamins or herbal dietary supplements have not received rigorous testing and review by the FDA.

What Is It Made Of?

In From Chocolate to Morphine, Weil and Rosen noted that cough syrups and cold remedies are "a mixed bag of different formulas and strengths." Many over-the-counter medicines are synthetic substances, meaning they are created in a lab from chemicals. Others, such as herbal supplements and caffeine, come from plants. (Separate entries on herbal drugs and caffeine are included in this encyclopedia.) Some OTC drugs contain depressants, while others contain stimulants.

Quite often, the ingredients in these preparations were included in prescription-only medications for several years before being released for sale over the counter. In some cases, OTC drugs contain smaller amounts of an active ingredient—the chemical or substance in a compound known or believed to have a therapeutic, or healing, effect—than the prescription drug of the same type. Ibuprofen is a good example of this. The drug can be purchased in the nonprescription strength of 200 milligrams per tablet or capsule at any drug or grocery store. However, a prescription is needed for the more potent 800-milligram pills.

How Is It Taken?

Over-the-counter medicines are usually taken by mouth. They are available in pills, capsules, chewable tablets, liquids, powders to be mixed with water or juice, and lozenges (such as cough drops). Other over-the-counter drugs include nasal sprays, throat sprays, and creams and lotions that can be applied directly to the skin.

Are There Any Medical Reasons for Taking This Substance?

Over-the-counter preparations are taken as dietary supplements or for temporary relief of a variety of symptoms. Medicines for allergies, pain relief, coughs, colds, flu symptoms, sore throats, digestive troubles, motion sickness, sleeping problems, and weight loss are all available over the counter.

Usage Trends

Typically, over-the-counter drug use is not tracked in surveys of illicit drug abuse because these medicines are not considered illegal. But the Partnership for a Drug-Free America (PDFA) began including questions on OTC drug abuse in its 2003-2004 survey. Results of the 2004 Partnership Attitude Tracking Study (PATS) were released on April 21, 2005. According to the study's authors, "an alarming number of teenagers are abusing a variety of … over-the-counter (OTC) medications to get high." Results indicate that about 9 percent of teens, or around 2.2 million young people, had experimented with cough syrup and other over-the-counter products purely for their intoxicating effects. PATS researchers see this as a sign that "OTC medicine abuse has penetrated teen culture."

The Growing Problem of Dextromethorphan Abuse

The trend in experimental OTC drug use is riskier than it may sound. A twenty-year-old Texas man was found guilty of "intoxication manslaughter" after deliberately misusing an OTC drug. (Man-slaughter refers to the unintentional killing of a human being.) The man testified in court that he had taken thirty Coricidin tablets in order to hallucinate. While driving under the influence of the Coricidin, he struck and killed another driver. Beth Wilson reported in the Amarillo Globe-News that the driver was sentenced to seven years in prison and received a $7, 000 fine.

Coricidin contains dextromethorphan, a common but potentially dangerous ingredient in multi-symptom cough, cold, and flu remedies. (An entry on dextromethorphan is included in this encyclopedia.) According to the 2004 "Pulse Check" report released by the Office of National Drug Control Policy (ONDCP), Coricidin HBP Cough & Cold is the "particular brand [that] contains the highest concentration of dextromethorphan, making it the most popular among users." Cough and cold tablets like Coricidin contain 30 milligrams of dextromethorphan hydrobromide and 4 milligrams of chlorpheniramine maleate.

Abuse of products containing these substances is especially high in the southern and western parts of the United States. "Pulse Check" researchers noted that "in Tampa/St. Petersburg, [Florida], incidents are reported of adolescents taking 20 to 43 tablets at a time, sometimes in combination with another over-the-counter medication, dimenhydrinate (Dramamine)." In addition, according to the

report, dextromethorphan-related "overdoses and thefts from groceries and pharmacies" were on the rise. By 2005, some pharmacies in Florida, Colorado, and Oregon had placed these products "behind the counter" and were limiting sales to one box per customer.

Dextromethorphan has generated considerable attention for its mind-altering effects. But the other active ingredient in Coricidin—chlorpheniramine maleate—has also been shown to impair judgment in users. The case of a mysterious plane crash in Florida in late 2003 was eventually linked to chlorpheniramine. After a lengthy investigation, it was determined that the engines and propellers of the twin Cessna 441 were in working order at the time of the crash. According to the National Transportation Safety Board (NTSB), the pilot had a high level of chlorpheniramine in his system at the time of the crash. According to the NTSB crash report: "Post accident toxicology testing of the pilot's blood revealed chlorpheniramine, an over-the-counter sedating antihistamine, at more than ten times higher than the level expected with a typical maximum over-the-counter dose."

The Pseudoephedrine/Methamphetamine Connection

Methamphetamine, one of the most dangerous illicit drugs of the early twenty-first century, is brewed from the active ingredient in some

OTC Abuse and the Elderly

OTC drug abuse is not just a teenage problem. It also affects adults, including the elderly. In general, many people overuse or misuse OTC drugs because they believe that they are safe to use. Some people think that OTC drugs are milder than prescription drugs, but fail to remember that some of those same OTC medications were once available by prescription only.

Drug abuse, or misuse, by the elderly occurs for a variety of reasons. As people age, they may require daily use of one or more prescription medications to treat a variety of ailments. According to Maura Conry in Geriatric Times in 2000, the elderly "use 30% of the prescriptions written and 40% of OTC drugs sold in the United States." Thus, seniors may be taking several prescriptions and OTC drugs that counteract with one another and not realize it.

"Since metabolism rates slow down considerably as we age, many prescription and OTC medications stay in the body longer and increase the likelihood of harmful drug interactions," note the authors of "Chemical Dependency and the Elderly." Such problems cause more than 100, 000 deaths each year. "Patients have arrived at emergency rooms and hospitals after taking 15 or more drugs and OTC remedies," noted Conry. Emergency staff are hard-pressed to determine the cause of the problem when so many drugs are involved.

Many seniors may not realize that combining certain medications causes serious side effects, and they may be accidentally combining drugs with the same active ingredient. Some seniors have multiple doctors, such as a primary care physician and a cardiologist. On occasion, patients forget to tell each doctor what prescriptions they are already taking or what OTC drugs they use. Plus, many get their drugs from multiple sources: samples from the doctor's office, OTC drugs from the grocery store, and prescriptions from the local drugstore or by mail order. In such cases, no one source is checking whether the amount and type of drugs being used on a daily basis are safe.

The article "Abuse and Misuse of Medications in the Elderly" and other medical sources point out various problems that seniors face when using drugs. These problems include: 1) being unable to read the label; 2) being unable to hear the doctor or pharmacist's instructions; 3) being unable to understand the warnings on the label and how they apply to him or her; 4) being forgetful and taking too many or not enough doses at prescribed times; 5) taking more drugs than prescribed when chronic pain or conditions don't respond to the usual dosage; and 6) becoming confused about when to take the medicine and how much to take.

over-the-counter cold products. (An entry on methamphetamine is available in this encyclopedia.) Amateur drug makers in home laboratories produce the drug by cooking ephedrine or pseudoephedrine and mixing it with other easy-to-obtain chemicals. The FDA banned ephedrine-containing pills and powders in 2004, but as of mid-2005, illicit supplies were still available through the Internet. Pseudoephedrine remains a key ingredient in legal OTC cold medicines.

In 2004 and 2005, lawmakers throughout the United States began efforts to restrict access to pseudoephedrine-containing OTC medicines. Several states, including Michigan, Oklahoma, and Oregon, passed laws that made it harder to purchase products like Sudafed (which contains pseudoephedrine hydrochloride). The restrictions include: 1) placing the product "behind the counter" in the pharmacy area of drugstores, where a careful count of the stock can be maintained; 2) requiring photo identification to prove the buyer is at least eighteen; 3) requiring buyers to sign a logbook at the time of purchase; and 4) limiting the number of pills that can be sold per transaction. In August of 2005, Oregon became the first state to pass legislation making pseudoephedrine a prescription-only drug. Oregon lawmakers hope that the new law, scheduled to take effect in mid-2006, will reduce the number of illegal meth labs operating in the state.

Effects on the Body

OTC drugs can affect the body in many ways, depending on the type of medicine being taken, the condition being treated, and the general health of the user.

Allergy Medicines

Allergic reactions stem from the body's reaction to irritants from the environment. Breathing pollen grains or pet dander causes stuffy nose and cough in people who are allergic to these substances. Touching poison ivy or being stung by a bee produces itching and swollen skin. Allergies can also cause watery eyes, sore throat, and digestive problems. People with severe allergies—to peanuts or shrimp, for instance—can have life-threatening reactions if they consume even a tiny amount of those foods.

Because allergies are chronic, or lasting conditions, a large number of medicines have been developed to treat them. Pharmacies stock skin rash ointments, nasal sprays, liquid medicines, and pills. Many of the liquid and pill preparations are multi-symptom formulas with more than one active ingredient.

The Role of Histamines

Allergy symptoms are caused by histamines, which are chemicals that are produced by the cells of the immune system. Histamines are like warning signals that alert an individual to the presence of an allergen—the pet dander, the pollen, or the substance that's causing the allergic reaction. The release of histamines produces uncomfortable symptoms that are hard to ignore—symptoms such as inflammation, sneezing, nasal congestion, and even dizziness or labored breathing.

Some allergy medicines contain antihistamines, chemicals that work to stop the body's production of histamines. The most common OTC antihistamines are diphenhydramine hydrochloride and brompheniramine maleate. Taken at regular doses, these drugs may cause mild drowsiness as they relieve allergy symptoms. At higher doses, they can bring on severe anxiety, which is the feeling of being extremely overwhelmed, restless, and worried; insomnia, or difficulty sleeping; muscle tremors; and even hallucinations, which are visions or other perceptions of things that are not really present.

Some people are so sensitive to diphenhydramine that the standard dose can make them feel nervous and uncomfortable. It is possible to overdose on diphenhydramine, and the consequences can be very serious. An overdose can lead to coma or death if emergency medical treatment is not obtained.

Relieving Stuffy Nose, Headache, and Itching

Other allergy medications function differently, targeting the symptoms of an allergic reaction rather than blocking the production of histamines. Medicines containing decongestants work by widening nasal passages and thinning mucus in order to relieve a stuffy nose and headache. Common decongestants include pseudoephedrine hydrochloride and chlorpheniramine maleate. These ingredients can cause intense anxiety, hallucinations, convulsions, vomiting, and irregular heartbeat if taken in higher doses than what is recommended. The decongestant guaifenesin is a mucus thinner that has fewer dangerous side effects, but it will cause nausea and vomiting if taken at overdose levels.

Nasal sprays are another popular form of treatment for allergy symptoms. These should be used with care, following the directions on the bottle. Overuse of nasal sprays can produce a rebound effect, which causes even more swelling in the nasal passages than the original allergen would have produced. Overdoses of certain nasal sprays can bring on symptoms such as an irregular heartbeat and high blood pressure.

Some poison ivy creams and lotions contain hydrocortisone. Hydrocortisone is a synthetic drug that counteracts the body's response to an allergen. It reduces itching and swelling, but overuse may lead to skin irritation. Hydrocortisone does not prevent the spread of poison ivy, so it is not recommended for use on unaffected skin.

Cough, Cold, and Flu Medicines

Irritating coughs have many sources. The most common reason for a cough is a post-nasal drip, or the draining of mucus from the nose down into the throat. The body reacts to this drip with a cough so that the mucus will not clog the trachea (TRAY-kee-uh) or move into the lungs. The trachea, commonly called the windpipe, is the tube in the throat that carries air to the lungs. Coughing also occurs when the body attempts to expel particles from the lungs or bronchial tubes. This kind of coughing is associated with several conditions: 1) bronchitis—an illness that affects the bronchial tubes in the lungs, leading to shortness of breath and coughing; and 2) pneumonia—a disease of the lung, usually brought on by infection, that causes inflammation of the lung tissue, fluid buildup inside the lungs, lowered oxygen levels in the blood, and difficulty breathing. Other coughs, known as "dry coughs," are simply a reaction to an irritation of the throat and can linger with no other symptoms present.

Persistent coughing—a cough that lasts for more than two weeks—may be a sign of a more serious problem, including pneumonia,tuberculosis, or even lung or throat cancer. Over-the-counter cough medicines are designed for brief use. If a cough does not respond to an OTC product within a week, a doctor should be consulted.

When It's Good to Cough

A cough that brings mucus from the throat to the mouth is called a "productive cough." Productive coughs—while annoying—prove that the body is working as it should to protect the lungs. Patients with productive coughs should not try to suppress them, except perhaps at night in order to get uninterrupted sleep. Taking cough suppressants during the day may actually prolong the time it takes to get rid of a productive cough.

Influenza Pandemic of 1918

Many people experience bouts of colds and flu throughout their lives and receive relief from OTC drugs. But back in 1918, an uncommon influenza spread quickly around the world that was so deadly, no drugs could stop it. It was called a "pandemic," because it was an epidemic that affected the entire world.

The influenza struck toward the end of World War I (1914–1918). Some reports of the flu surfaced in March of 1918 at a military base in Kansas, and then again at a base near Boston, Massachusetts, in August of that year. The virus quickly spread throughout the United States, and made its way overseas. Many people became infected by this unusually deadly flu. The virus killed its victims quickly, some dying within two days to a week of becoming infected.

When the war ended in November of 1918, people throughout the world celebrated the news. In San Francisco, California, many residents headed into the streets to celebrate, wearing masks made of gauze to keep them from breathing in germs. The flu eventually faded. But by the time the epidemic was over, more than 600, 000 Americans had died, with at least 25 million people perishing worldwide. The Centers for Disease Control and Prevention (CDC) notes that the final death toll may have actually reached 50 million people.

Since the majority of minor coughs stem from colds, allergies, or the flu, most multi-symptom products contain antitussives along with medicines to thin or eliminate mucus. The most popular antitussive in OTC cough syrups is dextromethorphan, which is usually combined with other active ingredients. Dextromethorphan taken at higher-than-recommended doses can produce an hallucinogenic experience. Its abuse as a recreational drug has led several pharmacy chains to place certain cough products behind the counter or demand proof that the buyer is over the age of eighteen. Recreational use of high doses of dextromethorphan can lead to physical and psychological addiction. Physical addiction occurs when the body

craves more of a drug; psychological addiction is the belief that a person needs to take a certain substance in order to function.

Flying Germs

Common colds are caused by viruses that pass easily from person to person through the air. The cold germ can also survive on surfaces such as doorknobs or light switches. So the virus can be passed if someone touches these germ-laden surfaces, then uses that finger or hand to touch one's eyes, nose, or mouth. When the virus invades the body, chemicals in the body's immune system attempt to fight off the infection. Symptoms such as stuffy nose, sneezing, sore throat, and cough are responses designed to keep the germs from reaching the bronchial tubes leading into the lungs. Cold symptoms that last for more than ten days, or that get worse rather than better over time, may indicate a more serious problem such as the development of bronchitis or pneumonia. A doctor should be consulted in such cases.

Influenza, or the flu, is also caused by a variety of viruses. The flu is highly contagious and usually occurs in winter, when people spend more time indoors. Its symptoms are often more severe than those associated with an ordinary cold. Patients develop fever, body aches, cough or sore throat, and sometimes nausea, vomiting, and diarrhea. All of these symptoms arise from the body's immune system response, so older people or those with immune deficiencies run the risk of developing complications, especially pneumonia. For this reason, older individuals and people with immune problems, such as cancer patients and people living with acquired immunodeficiency syndrome (AIDS), are encouraged to get annual flu shots.

The Multi-Symptom Trap

Colds and flu bring on a host of symptoms, so most OTC cold and flu medications contain several active ingredients. Each active ingredient targets a specific symptom. acetaminophen works on fever, body aches, and headaches. Dextromethorphan hydrobromide controls coughs. Pseudo-ephedrine hydrochloride and its related compounds are decongestants that open clogged nasal passages. Chlorpheniramine maleate is an antihistamine. Some "PM" or "overnight" remedies include alcohol. Some "stay alert" daytime remedies include caffeine. To complicate matters further, the liquid forms of these preparations contain sweeteners such as sucrose (SUE-krose; sugar) or the sugar substitutes saccharine (SAK-uh-rin) or aspartame (AH-spar-tame).

OTC cold and flu medicines are formulated to treat the symptoms of these illnesses once they occur. Such remedies are not effective in warding off colds or flu and should not be taken as preventative measures. For years the herbal dietary supplement echinacea (eck-inn-AY-shuh; Echinacea purpurea and Echinacea angustifolia), derived from the purple coneflower, was thought to have cold-prevention properties. However, scientific tests have shown that the herb does nothing to prevent colds from occurring and has no effect on cold symptoms that already exist. Results of a study led by Dr. Ronald B. Turner of the University of Virginia School of Medicine were published in the July 28, 2005 issue of the New England Journal of Medicine. Turner's study evaluated the effects of treatment with echinacea or a dummy pill on 399 patients who had been infected with a cold virus. The researchers saw no benefit in using echinacea to treat the colds.

OTC Pain Relievers: The Big Three

The three most common over-the-counter pain relievers are aspirin, acetaminophen (Tylenol), and ibuprofen (Advil and Motrin). All three products work well to control minor headaches, muscle aches, menstrual cramps, arthritis pain, and fever. Doctors even recommend small daily doses of aspirin for people with heart problems. Although these products are valuable painkillers when used correctly, they can produce dangerous side effects when overused.

Some Tips on Avoiding Colds and Flu

According to the Centers for Disease Control and Prevention (CDC), "The most important thing that you can do to keep from getting sick is to wash your hands." That doesn't mean just running your hands under water. Proper hand washing requires soap and scrubbing action to help remove the germs from the skin. The CDC recommends that people wash their hands before handling food or eating, after handling animals or their waste, and after using the restroom.

Anyone who catches a cold or the flu needs plenty of rest to enable the body to fight the infection. In From Chocolate to Morphine, authors Andrew Weil and Winifred Rosen noted that OTC cold remedies "may actually prolong colds by making people less aware of their illness and less likely to take good care of themselves." Taking a few days off from school or work to rest also helps protect others from catching those germs. Frequent hand washing will minimize the spread of the germs at home.

No medication will cure a cold or flu. However, old-fashioned remedies such as warm tea with honey and lemon or a hot bowl of chicken soup can provide some relief from nasal congestion and throat irritation. Even sucking on a lollipop or a hard candy can be soothing. Those seeking relief in an OTC product should follow the package directions carefully, especially with any formula containing dextromethorphan.

Aspirin and Acetaminophen Can Kill More Than Just Pain

According to Daniel Carr in a 2002 bulletin from the American Pain Society, about 22 percent of fatal poisonings in the United States each year involve an over-the-counter painkiller—especially aspirin and acetaminophen. Nearly nine out of ten of these deaths are suicides.

Acetaminophen overdose is one of the leading causes of calls to poison control hotlines every year. In a March 2004 article for the New York Times, William M. Lee noted that misuse of this drug leads to an estimated 56, 000 emergency room visits annually, with some 450 deaths—usually from liver failure. Symptoms of acetaminophen overdose establish themselves slowly, with little stomach upset. Sometimes, by the time the patient reports pain, the damage cannot be repaired. Multiple organ failure follows.

Aspirin overdose shows symptoms more quickly, but it can kill faster. It causes thinning of the blood, and at the same time it irritates the stomach lining. Internal bleeding begins, especially throughout the digestive system. toxic doses of aspirin work on the part of the brain that controls breathing. The rate of breathing can be slowed to dangerously low levels, resulting in death. Seizures, or sudden violent spasms or convulsions, may also occur.

As Pamela Grim noted in a 1998 Discover article, "This 'harmless' little pill can have deadly effects. … The kidneys, the liver, and the brain … can shut down forever, depending on the amount ingested. Patients can … crash and burn in the blink of an eye." If caught in time, aspirin overdose can be treated with activated charcoal to induce vomiting. Still, a patient will often face a long period of recovery from internal injuries.

Fatal overdoses of ibuprofen occur less frequently, but when they occur they are usually caused by kidney failure. Interestingly, one of the symptoms of ibuprofen overdose is headache and abdominal pain—exactly what the drug is designed to treat.

Sore Throat: Is It Strep?

Sore throats are common among children and adults. As with a cough, a sore throat can stem from post-nasal drip or from a minor infection. These kinds of sore throats usually subside after a few days, and the pain can often be relieved by gargling with a simple mixture of table salt, baking soda, and warm water.

The two main active ingredients in over-the-counter sore throat remedies are phenol (with or without menthol) and dyclonine hydrochloride. Sprays containing these substances act by temporarily blocking nerve irritation. Menthol-containing lozenges also act on nerve endings in the throat. Patients with diabetes or allergies to artificial sweeteners should check the inactive ingredients in any sore throat preparation. Some products include sugar or artificial sweeteners to enhance the taste.

A sore throat accompanied by fever or nausea may be a sign of bacterial infection, particularly streptococcus (strepp-toe-KOK-uss), better known as "strep throat." Left untreated, strep throat infections can lead to rheumatic fever (roo-MAT-ik FEE-ver), a severe infection that results in fever, a rash, pain and swelling in the joints, and sometimes permanent damage to the heart valves. Strep infections cannot be treated with OTC drugs, but they do respond to prescription antibiotics, which are medicines that kill bacteria in the body. Doctors can test for strep by swabbing the throat and examining the sample for the presence of streptococcal bacteria.

Digestive Remedies: Antacids, Anti-Diarrhea Medicines, and Laxatives

Digestive system problems range from nausea and heartburn (a burning sensation in the stomach and esophagus) to diarrhea and constipation. In healthy people, most of these problems clear up in a day or two. More serious stomach problems include: 1) ulcers—the breakdown of mucus membranes, usually in the stomach; 2) cancers of the stomach or colon; and 3) irritable bowel syndrome (IBS)—an incapacitating condition, usually brought on by periods of extreme emotional stress, that causes abdominal pain and severe diarrhea, alternating with periods of constipation. These disorders require prompt medical treatment.

Surprising Discovery about Ibuprofen

Dr. Jon Sudbo of the Norwegian Radium Hospital in Oslo, Norway, led a study on ibuprofen use among smokers. Originally, Sudbo focused his research on whether ibuprofen might decrease the risk of mouth cancer in people who smoked. However, his results, which were released in 2005, led to significant findings on a completely different topic. In an article titled "Over-the-Counter Painkillers May Pose Risk," MSNBC.com reported that the Norwegian smokers who took over-the-counter pain relievers such as Advil and Motrin "for at least six months had twice the risk of dying of a heart attack, stroke or other heart-related problem."

OTC Abuse and Eating Disorders

Another group of digestive ailments is connected with two psychological disorders: anorexia nervosa (an-nuh-REK-see-uh ner-VOH-sah) and bulimia nervosa (bull-EEM-eeh-yuh ner-VOH-sah). Men and women who suffer from these serious eating disorders have distorted views of their bodies. They see themselves as overweight no matter how thin they are. People with anorexia nervosa have an intense fear of gaining weight. As such, they deprive themselves of calories, either by eating too little or by abusing laxatives. The use of laxatives causes food to move through their systems before it can be digested fully. People with bulimia nervosa engage in long periods of bingeing on food, then force themselves to vomit before the food can nourish them. These patients may also abuse laxatives.

More about Laxatives: Rebound and Dependence

OTC laxatives are available as pills, liquids, or fibrous powders that are mixed with water or juice. Some of the active ingredients in laxatives include bisacodyl, docusate, magnesium hydroxide, psyllium, and senna, among others. Warning labels on these products caution users not to exceed the recommended dose and not to use the products for more than a week at a time, unless told to do so by a doctor.

Overdose or long-term use of laxatives can disrupt the body's chemistry and undermine the body's natural ability to eliminate waste. Laxatives are habit-forming if used daily and can be very dangerous in overdose. They can deplete the body's potassium supply, leading to an irregular heartbeat. At higher doses they frequently cause diarrhea, severe cramps, and dehydration. People using laxatives for occasional constipation are advised to drink plenty of water along with the medication.

Be a Careful Consumer

In August of 2005, the U.S. Food and Drug Administration updated its "Consumer Education: Over-the-Counter Medicine" Web page. Through posters, pamphlets, and public service announcements, "Consumer Education" encourages people to read the labels on every over-the-counter drug they take. The site also offers safety tips on medicating sick children, driving while taking OTC medicines, avoiding dangerous drug interactions, and preventing overdoses.

One poster featured on the Web page shows two bottles of medicine side by side with the caption: "Don't take me with him." The warning goes on to explain that "different over-the-counter or prescription medicines [may] contain the same active ingredient. So when you take more than one medicine at the same time, it's possible to take too much of the same active ingredient."

The FDA wants consumers to "take the time to be safe." The Web site reminds buyers that OTC medications should be used only as directed, and usually only for a few days. In addition, patients should choose medicines specific to their symptoms. For instance, some allergy medicines contain antitussives, or cough suppressants. Patients who have stuffy noses but who are not coughing do not need the antitussive ingredient. When in doubt about which medicine to use, the FDA advises consumers to ask their doctor or pharmacist for advice.

Overuse of laxatives causes a rebound effect in the user. People who suffer from rebounding notice a worsening of the very symptoms that they sought to relieve with the use of a medicine. When laxatives are taken for too long a period of time or in larger-than-recommended doses, severe constipation may result after the medicine is stopped.

Anti-Diarrhea Meds

Anti-diarrhea medicines are often overused, but not for purposes of weight loss. Some people take them much longer than recommended as they try to end their diarrhea problems themselves, when they really should go to their doctor to find out what's causing the trouble. The active ingredient in the most often used OTC diarrhea remedies is loperamide hydrochloride. These medications should not be used for more than two days. If diarrhea persists beyond that period, or if a fever or blood in the stool develops, a doctor should be consulted. Loperamide should not be used in cases of suspected food poisoning from bacteria such as salmonella, e-coli, or shigella.

Taken as directed for a few days to treat mild diarrhea, most OTC diarrhea medicines are very safe. However, in cases of overdose, preparations containing loperamide hydrochloride, bismuth subsalicylate, or kaolin and pectin do present dangerous symptoms, including nervousness, drowsiness, and dizziness.

Antacids: They Aren't Candy

The most popular forms of antacid on the OTC market are chewable pills or tablets containing compounds of magnesium or calcium. Doctors may even recommend calcium-containing antacids for daily use in women who do not consume enough natural calcium in their diets. Taken in small, recommended doses, antacids are safe.

At overdose levels, though, they can cause both immediate and long-lasting problems. Antacids containing the ingredient simethicone can produce nausea, abdominal cramps, muscle aches, dehydration, and irregular heartbeat. Calcium-based antacids produce similar symptoms at overdose. These medicines carry another risk as well. Taken at high doses over a prolonged period of time, they can cause a buildup of calcium in the body that leads to painful calcium deposits in the kidneys known as kidney stones.

Because chewable antacids often look and taste like candy, children may want to eat them. Such medications should be kept in child-proof containers out of their reach. In case of an overdose, a doctor or poison control center should be contacted immediately.

Dietary Supplements: Vitamins, Minerals, and Herbal Drugs

"Dietary Supplements" is the catch-all term used to describe vitamins, minerals, and herbal drugs.

Vitamins and Minerals

Vitamins are compounds that are necessary for proper nutrition but, in most cases, cannot be produced by the body. The usual means of obtaining vitamins is from eating healthy foods. When people do not eat well, for whatever reason, they may need to supplement their vitamin intake. Marion Webb reported in the April 12, 2004 edition of the San Diego Business Journal that 40 percent of Americans consume at least one vitamin pill a week. As with other OTC drugs, it is wise to consult a doctor before beginning vitamin use.

The major vitamins include A, C, D, E, K, B-12, and seven B-complex vitamins. The body only requires small amounts of these nutrients to function properly. Fat-soluble vitamins such as A, D, E, and K are stored in fatty tissues. It is very difficult to deplete these stores of vitamins and very easy to suffer an overdose from their pill forms. Vitamins C, B-12, and the B-complex vitamins are water soluble. They exit the body quickly by way of the urine and must be replaced more often. This can be done by eating fresh fruits and vegetables, whole grains, beans, nuts, vitamin-fortified breakfast cereals, and meat.

Minerals, too, are substances derived from the diet that aid the body in its functions. Important minerals include calcium for bone strength, iron for maintaining red blood cell levels, and magnesium, which is essential for nerve and muscle action, bone formation, and enzyme activity. Experts say that the best way to receive sufficient amounts of these nutrients is to eat foods containing them—dairy products and cheese for calcium, meats for iron, and green, leafy vegetables, nuts, and whole grains for magnesium.

More Is Not Better

It is possible to overdose on vitamins and minerals. Some specific symptoms are listed below.

• Too much vitamin A can cause headache, fatigue, nausea, diarrhea, dry skin, hair loss, bone pain, and enlargement of the liver and spleen. Extremely high overdoses cause swelling in the brain.
• Too much niacin (a B-complex vitamin) may result in liver damage.
• Too much vitamin D can bring on muscle weakness, excessive thirst and urination, digestive disturbances, bone pain, and high blood pressure.
• Too much vitamin E can cause abdominal cramps, nausea and vomiting, diarrhea, and reduced absorption of other vitamins.
• Too much calcium can lead to diarrhea and the production of kidney stones.
• Too much iron can cause nausea, abdominal cramps, constipation, diarrhea, and liver damage.
• Too much magnesium can result in nausea, vomiting, diarrhea, dizziness, muscle weakness, and heart damage.
• Too much zinc leads to problems absorbing other vitamins.

The Herbal Craze

In the 1970s, many Americans became interested in alternative medicine, including the medical use of herbs. (An entry on herbal drugs is available in this encyclopedia.) Herbal preparations have been used by cultures worldwide for thousands of years to treat conditions ranging from arthritis pain and menstrual cramps to depression, memory loss, and anxiety. Most herbal dietary supplements are bottled the same way as OTC medicines and vitamins, with the active ingredients highly concentrated into pills. This, however, is not the way native cultures consume herbs. The doses in OTC herbals are much higher than those found in the leaves and teas consumed by those who first discovered the benefits of these products.

The San Diego Business Journal estimated that in 2004, herbal dietary supplements were a $4 billion-a-year market in the United States. Anyone of any age can purchase them. However, some of the products warn that they should not be used by children under the age of twelve.

"Tastes Like Candy" But It's Not

Manufacturers of children's multivitamins strive to make their products taste like candy so that kids will take them willingly. Many children's chewable vitamins look and taste like gummies or sweet and sour candies. One company, Vitaball, even sells a vitamin-packed chewing gum ball.

Like many OTC medications, however, vitamin and mineral supplements can be life-threatening at overdose levels. Small children are especially at risk because of their low body weight. In fact, a common cause of emergency room visits for children is vitamin overdose.

A multiple-vitamin overdose is very serious and requires immediate attention. Parents, babysitters, or other caregivers who suspect an overdose in a child should seek emergency medical care. In order to treat the overdose properly, doctors will need to know the patient's age, weight, the type and number of multivitamins taken, and any other health problems the child may have. Caregivers should not attempt to induce vomiting at home.

Herbals: Safety Issues

Many people who use herbal supplements are not aware that these products do not meet the same FDA requirements as medicines. Technically, herbal supplements are considered foods. Their labels are carefully worded so they don't imply that they will relieve any specific symptoms. Highlighting the many unknowns connected with herbal drug use, California congressman Henry Waxman noted in Nutrition Action Healthletter in 2003: "The dietary supplement market is the Wild West. … There are no requirements that a company prove anything about either the safety or the effectiveness of its products before they go to market."

After nearly thirty years of unregulated human use of herbal supplements, drug researchers began to pinpoint the dangers of specific substances. In 2004, for instance, the FDA banned the use of the natural supplement ephedra, also called ma huang (ma-HWANG), in any product sold in the United States. Ephedra has been used in China for thousands of years as a treatment for asthma (AZ-muh), a lung disorder that interferes with normal breathing. It contains substances very similar to amphetamines that can have a powerful stimulating effect on the heart. (A separate entry on amphetamines is available in this encyclopedia.) The FDA's ban came after research revealed that numerous deaths and injuries were linked to the use and abuse of the herbal supplement.

According to the Nutrition Action Healthletter, other herbal dietary supplements have been shown to produce serious side effects as well. For example, echinacea can cause stomach cramps, skin irritations, and other allergic reactions. Guarana (gwah-rah-NAH; Paullinia cupana), a plant that contains natural caffeine, causes the same symptoms as caffeine in use and overdose. Caffeine affects the brain, digestive system, heart and breathing rates, kidneys, body temperature, and other body functions.

St. John's wort may cause upset stomach, rash, fatigue, or restlessness. It should not be used in combination with any other psychoactive substances, including antidepressants, caffeine, anti-anxiety medicines, or drugs for attention-deficit/hyperactivity disorder (adhd) or schizophrenia. St. John's wort also reacts badly with certain prescription heart pills, drugs for high cholesterol (kuh-LESS-tuh-rol), oral contraceptives (birth control pills), blood thinners, and antacids.

Weight Loss Preparations

Obesity and its related health problems were major concerns for doctors and patients in the early twenty-first century. Obese individuals weigh at least 20 percent more than their ideal body weight. The CDC's Division of Nutrition and Physical Activity (DNPA) noted that in 2005, more than 60 million Americans were obese. And since the 1980s, obesity has become more and more of a problem for children in the United States. According to the DNPA's "Overweight and Obesity" home page, "the percentage of young people who are overweight has more than tripled since 1980. Among children and teens aged 6-19 years, 16 percent (over 9 million young people) are considered overweight."

Weight gain usually occurs when people eat too much and/or exercise too little. In some cases, however, obesity is linked to serious health problems. The condition can be hereditary, which means it is passed on genetically from parent to child. It can also be a result of hormone imbalances. Whatever the cause, overweight or obese individuals face higher risks of heart trouble, high blood pressure, and diabetes than people who maintain an ideal weight.

Over-the-counter fad diet products rarely, if ever, fulfill their promises. Still, the diet pill industry reaps huge profits. In 2004, Forbes magazine estimated that Americans spend about $27 billion each year on "miracle" diet pills, powders, and other products. But weight loss is one health problem for which no quick fix exists. Through its food pyramid and other programs, the U.S. Department of Agriculture urges Americans to seek realistic weight loss solutions. The food pyramid shows the types of foods one should include in his or her daily diet, including dairy, grains, fruits, vegetables, meats, and beans. In 2005, the famous food pyramid was revised to include a little stick figure running up a flight of steps. This is a reminder that a balanced diet and daily exercise are the most effective ways to achieve a healthy personal weight.

OTC Pills and Herbals for Weight Control

Weight loss pills and herbal supplements both work by speeding up the body's metabolism. Diet pills generally contain some kind of amphetamine, and herbal supplements rely on plants that either contain caffeine or mimic caffeine's behavior in the body. Individuals who take diet pills may notice a "speedy" or "peppy" feeling, even at normal doses. In overdose, FDA-approved diet pills can cause agitation, anxiety, insomnia, hallucinations, heart palpitations, and high blood pressure. In 2004 the FDA banned the sale of the herbal weight loss supplement ephedra. Producers of herbal supplements have responded by creating a vast array of ephedra-free items for sale over-the-counter.

The manufacturer's label on most diet pills recommends using the products only for a few months. Some people ignore this important warning and continue taking the pills. Diet pills can be habit-forming and may produce withdrawal symptoms when discontinued. The most frequent withdrawal symptom is rapid weight gain. People who begin a program of OTC diet pills may find themselves hooked on the pills both physically and psychologically as they convince themselves that they will become obese again if they quit.

Motion Sickness Pills

Motion sickness, sometimes known as vertigo, does not affect everyone. For those who suffer from it, however, a car ride or an airplane flight can trigger a variety of uncomfortable symptoms, including sweating, dizziness, an increased heart rate, nausea, vomiting, and trembling. The disorder seems to be hereditary, passed down from parent to child. It stems from the way unpredictable movement affects an organ in the inner ear that controls balance. Anxiety about the symptoms can make the condition worse.

People who suffer mild cases of motion sickness can usually control the symptoms by breathing fresh air and by concentrating on a fixed point on the horizon. The symptoms end quickly when the car, boat, or plane trip ends.

OTC Herbal Weight Loss Aids

Herbal supplements do not undergo the same kind of safety testing required for over-the-counter and prescription medications. Not much is known about the various herbs used for weight loss. What is known, say researchers, is that some of them may be dangerous. Popular herbal weight-loss preparations may include the following ingredients:

• Bitter orange (Citrus aurantium) contains a stimulant called synephrine (sinn-EFF-rinn) that mimics the behavior of adrenaline (uh-DREN-uh-linn) in the body. Synephrine is similar to ephedrine and pseudoephedrine in its chemical structure. The herb can, in some instances, boost heart rate and blood pressure, especially when taken in high doses.
• Chitosan is made of the fiber from the shells of lobsters and shrimp. It can cause death in individuals with seafood allergies and has not been proven to promote weight loss.
• Chromium is poisonous at high doses.
• Garcinia cambogia has not been proven effective in reducing weight, but it has been linked to breathing and digestive problems.
• Usnic acid can cause liver damage with prolonged use.

OTC motion sickness pills contain antiemetics (an-tee-ih-MEH-tiks), compounds with the same active ingredients as antihistamines. Antiemetics are drugs that reduce nausea and vomiting. The FDA has approved two antiemetics for use in motion sickness medicines: dimenhydrinate (Dramamine) and meclizine hydrochloride (Antivert). It is important to note that the FDA has not approved the use of meclizine hydrochloride in children under twelve years of age.

Bad Trips

From time to time, abusers of motion sickness medicine appear in clusters in various parts of the United States. At high doses, dimenhydrinate can cause intense and long-lasting hallucinations. It also affects the memory center in the brain, so sometimes the abuser cannot recall what has happened during the experience. Dimenhydrinate hallucinations are often frighteningly real to the user. The hallucinations may be visual, making everything seem liquid or producing visions of monsters, insects, or snakes. They may also manifest themselves as distorted sounds. Some users have even reported hearing voices. At very high doses, dimenhydrinate causes paranoia, difficulty breathing, convulsions, and coma.

Once the symptoms of a dimenhydrinate trip begin, it can take up to twelve hours for them to subside. The other motion sickness medicine available over the counter is a nondrowsy formula called meclizine hydrochloride. Like dimenhydrinate, overdoses of meclizine can cause hallucinations, muscle tremors, blurred vision, difficulty breathing, and in worse cases, convulsions and coma.

Nonprescription Drugs Have More Side Effects Than You Might Think

Just because OTC drugs are available without a prescription doesn't make them safe for everyone. Dosage instructions must be followed exactly to avoid possible overdose, allergic reactions, and dangerous drug interactions. Consider these facts:

• Acetaminophen can damage the liver.
• Caffeine can cause increased heart rate, nervousness, and high blood pressure.
• Chlorpheniramine maleate, an antihistamine, can cause drowsiness, dizziness, nervousness, nausea, and irregular heartbeat.
• Dextromethorphan hydrobromide and related compounds can cause hallucinations, psychotic behavior (behavior associated with a dangerous loss of contact with reality, sometimes leading to violence against oneself or others), and an inability to move.
• Diphenhydramine hydrochloride can cause nervousness, anxiety, hallucinations, muscle tremors, and irregular heartbeat.
• Pseudoephedrine hydrochloride and related decongestants can cause nervousness, sleeplessness, dizziness, and anxiety.
• Sucrose can bring on a coma in people suffering from diabetes.

Users of motion sickness preparations need to take certain precautions. The drugs do not work after motion sickness symptoms start, so it is necessary to take the medication at least fifteen to thirty minutes before the bothersome motion begins. The pills usually work for eight to ten hours. Pregnant women and nursing mothers should consult a doctor before taking these drugs.

Sleep Aids

Over-the-counter sleeping pills are intended for use by people who usually fall asleep easily. Every box of OTC sleep aids bears the warning: "For occasional use only." Individuals who suffer from a recurring inability to fall asleep—or stay asleep—should consult a doctor. Since one of the main causes of insomnia, or the inability to sleep, is pain, some OTC sleep aids contain analgesics as well as active sleep-inducing compounds. Other products are formulated to bring on sleep during colds and flu.

The most common OTC sleep aids are antihistamines, including diphenhydramine hydrochloride and doxylamine succinate. These are the same ingredients in cold and allergy formulas that cause mild drowsiness. In long-term use or abuse as sleep aids, both compounds can actually make insomnia worse. In addition, they can increase agitation and nervousness in the user. As with other OTC drugs, it is important to treat only the symptoms of insomnia, and not medicate for cold, flu, or pain if those problems are not present.

Stimulants

Just as people sometimes have trouble falling asleep, others sometimes have trouble staying awake. OTC stimulants usually contain caffeine and are designed for occasional use only. Even at recommended doses, OTC stimulant products can cause nervousness and irritability. With regular use, OTC stimulants become habit-forming. Users quickly develop a tolerance to these drugs. Extreme drowsiness and lack of energy may occur when OTC stimulants are discontinued.

Overdose symptoms of OTC stimulants include nervousness, insomnia, irregular or rapid heartbeat, convulsions, and coma. Stimulants that come in time-release preparations should never be crushed and consumed as powder. This increases the possibility of overdose and possibly fatal poisoning.

Reactions with Other Drugs or Substances

Mixing OTC and prescription drugs can have many adverse reactions, or negative side effects, depending on the medications being combined, the condition being treated, and the person taking the drugs. Certain combinations can affect blood pressure and breathing, alter one's heartbeat or heart rate, cause drowsiness or dizziness, and lead to nausea, diarrhea, and various other complications. In cases of pregnancy, many OTC and prescription drugs not only work on the mother, but can affect the baby as well.

As such, people should always check with their doctor or pharmacist before starting any new medications and/or combining drugs. In addition, drug manufacturers include various warnings about drug interactions. The warnings are listed on the drug's box, bottle, or on paper instructions inside the package. Also, many pharmacies provide information for customers noting possible drug interactions. Before taking any drug, it's important to read all the warnings. People should also be aware of any effects associated with combining OTC drugs with alcohol, caffeinated beverages, herbal and dietary supplements, and various illegal drugs.

Anxiety, Allergy, and Cold/Flu Remedies

Anyone taking a prescription medication, particularly one for anxiety or depression, should ask a doctor before taking any OTC allergy preparation. Pregnant women and nursing mothers should avoid OTC allergy medicines altogether.

Manufacturers' labels on multi-symptom cold and flu medicines warn users not to drink alcohol—and sometimes even beverages containing caffeine—while taking these medicines. Alcohol can cause dizziness and disorientation, and it also dehydrates the body, possibly causing cold symptoms to last longer. In addition, patients taking prescription medicines should consult a doctor before adding cold and flu remedies to their mix of drugs. Substances such as diphenhydramine, dextromethorphan, and caffeine can react badly with prescription medicines for depression, anxiety, and liver problems.

Dextromethorphan may increase the effects of other drugs that cause drowsiness, including antidepressants, alcohol, antihistamines, sedatives, pain relievers, anxiety medicines, seizure medicines, and muscle relaxants. Likewise, chlorpheniramine maleate and pseudo-ephedrine hydrochloride should not be mixed with other medications for colds or allergies, or with any type of tranquilizer, sedative, or sleeping pill.

People with diabetes or allergies to artificial sweeteners should check the ingredients listed on any sore throat medication, cough syrup, or cough drop, since many of these substances contain some form of sugar or sweetener. Some cough syrups also contain alcohol.

Motion Sickness, Diet Pills, and Sleep Aids

Mixing motion sickness medicines with alcohol, sedatives, tranquilizers, or other antihistamines can cause extreme drowsiness.

Diet pills should not be combined with antihistamines, certain prescription antidepressants, coffee or caffeinated soft drinks, or heart medications. Mixing diet pills with other drugs and substances can lead to high blood pressure and an irregular or rapid heartbeat.

Sleep aids should not be combined with alcohol, caffeine, or prescription medications for anxiety or depression. For OTC sleeping pills that contain the active ingredient diphenhydramine, use of Benadryl or any other diphenhydramine-containing medication should be stopped—even if it is only applied to the skin.

Stimulants and Laxatives

OTC stimulants should not be taken with coffee, tea, or other beverages containing caffeine because caffeine is a stimulant too.

Some laxatives can interfere with the absorption of other medicines. Anyone taking a prescription medication, or even an OTC preparation, should check with a doctor before using a laxative.

Treatment for Habitual Users

Although over-the-counter medications are legal, users can still become addicted to them, both psychologically and physically. In cases of overdose, a doctor or poison control center should be contacted immediately. Counseling with a licensed therapist or psychiatrist can help recovering abusers identify the underlying reasons for their attraction to the drugs.

Consequences

Over-the-counter drugs are capable of altering a user's judgment. Driving skills may become impaired, thus increasing the chance of a crash. Mixing alcohol with OTC medications typically intensifies the effects of a product's active ingredients, stripping users of their ability to reason and make levelheaded decisions. Abuse of nonprescription drugs also puts the user's general health at risk. Breathing difficulties, organ failure, and even death may result in cases of overdose.

The Law

OTC drugs are often the subject of research studies and make news headlines when people experience problems when taking certain drugs. Here's a look at some past and recent issues involving OTC drugs and the law.

Product Tampering

It is against the law to tamper with the packaging of any OTC medicine in order to change its ingredients or misrepresent its contents. Anyone who purchases an OTC preparation and finds the box open or the safety seals removed should return the medicine to the place of purchase immediately and report the discovery to both the store and the police.

Product tampering became a major issue in the early 1980s when someone poisoned several bottles of Tylenol capsules with cyanide. Several people in the Chicago, Illinois, area purchased the capsules and later died after taking the tainted pills. It was believed that someone had tampered with the bottles on the store's shelves. This tragedy led the makers of Tylenol and other products to create new safety seals—special wrappings placed securely over bottle tops, boxes, and other packaging that will clearly show any evidence of tampering. If the safety seal is broken, customers are advised to return the product to the store.

Intoxication

The word intoxication is most often used when describing someone who is drunk. When intoxicated, people lose physical and mental control. For example, their speech becomes slurred, they can't operate their cars safely, and they don't think clearly. Drugs, both legal and illegal, can cause intoxication, too. Individuals who abuse OTC drugs and cause crashes or injuries while under the influence of such drugs face charges similar to those imposed for driving drunk.

Over the Counter or Behind It?

As of 2005, some "over-the-counter" medications were being reclassified as "behind-the-counter" medications because of growing patterns of their misuse. The U.S. government had not yet passed any laws against possession of dextromethorphan by the summer of 2005, even though the OTC ingredient has been linked to recreational substance abuse. Some large chain pharmacies have placed cold, cough, and allergy medicines containing dextromethorphan behind the counter. Other stores require proof of age before the product can be purchased. If recreational abuse of dextromethorphan continues or becomes more widespread, the FDA may decide to reclassify it as a prescription-only medicine.

Pseudoephedrine, the active ingredient in over-the-counter cold medicines such as Sudafed, caused a considerable legal stir in 2005. More and more states sought to limit sales of pseudoephedrine because it is used in the manufacture of the highly addictive drug methamphetamine. Pseudoephedrine became a "behind-the-counter drug" in more than a dozen U.S. states.

However, in August of 2005, Oregon became the first state to take it one step further. Oregon lawmakers introduced and passed a bill that would make cold and allergy medications containing pseudoephedrine available by prescription only. This action came after Oregon representatives put the "behind-the-counter" system to the test. According to Charles E. Beggs in an article on KGW.com, Northwest NewsChannel 8, Democratic representative Greg MacPherson and three of his colleagues "shopped for cold medicines … and easily bought enough in an hour to make several weeks' supply of meth for four users." Oregon's groundbreaking bill is scheduled to go into effect in mid-2006.

For More Information

Books

Adderly, Brenda D. The Doctors' Guide to Over-the-Counter Drugs. New York: Warner Books, 1998.

Austin, Steve. The A-Z Guide to Drug-Herb and Vitamin Interactions. Three Rivers, MI: Three Rivers Press, 1999.

Bird, Stephen. Pain Relievers, Diet Pills, and Other Over-the-Counter Drugs. Broomall, PA: Chelsea House Publishers, 2000.

Brodin, Michael B. The Over-the-Counter Drug Book. New York: Pocket Books, 1998.

Clayman, Charles B., ed. The American Medical Association Encyclopedia of Medicine. New York: Random House, 1988.

Physicians' Desk Reference for Nonprescription Drugs and Dietary Supplements, 25th ed. Montvale, NJ: Thomson Healthcare, 2004.

Schull, Patricia Dwyer. Nursing Spectrum Drug Handbook. King of Prussia, PA: Nursing Spectrum, 2005.

Silverman, Harold M. The Pill Book, 11th ed. New York: Bantam, 2004.

Weil, Andrew, and Winifred Rosen. From Chocolate to Morphine. New York: Houghton Mifflin, 1993, rev. 2004.

Wolfe, Sid M. Worst Pills, Best Pills: A Consumer's Guide to Avoiding Drug-Induced Death or Illness. New York: Pocket Books, 2005.

Periodicals

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See also: Alcohol; Amphetamines; Caffeine; Designer Drugs; Dextromethorphan; Diet Pills; Ephedra; Herbal Drugs; Methamphetamine