42 | Nursing2010 | May www.Nursing2010.com

ALCOHOL AND ILLICIT drugs aren’t the only drugs thatteens abuse—according to a recent survey, one in five teensabuses prescription medications. Over-the-counter (OTC)medication abuse is also high. Many teens think that thesemedications are “safe” because they’re readily found in thehome, legally available, and their parents are using them.1

Substance use by teens can impair brain maturity andinhibit learning, thinking, and judgment.2 Along with thepotential for addiction, teens don’t understand the short-and long-term consequences of indulging in these danger-ous substances. Besides addiction, abuse of prescriptionand OTC medications can lead to liver and kidney damage,seizures, withdrawal syndromes, respiratory depression,and death.

By Susan Simmons, PhD, RN, ARNP-BC

Teens and prescription

drugs<

>A potentially dangerous combination

www.Nursing2010.com May | Nursing2010 | 43

44 | Nursing2010 | May www.Nursing2010.com

Recognizing the signs and symp-toms of substance abuse in teensis vital in getting them the treat-ment they need. Teens often feelinvincible, and it’s up to the adultsaround them—parents and health-care providers—to help themunderstand the long-term ramifica-tions of substance abuse. Knowingwhich drugs are most often mis-used by teens is the first step inrecognizing abuse.

Commonly abused drugsPrescription medications com-monly abused by teens includeamphetamines, sedatives, barbi-turates, and opioids (seeDangerous medications).3 The lat-est data show that the use ofthese medications for nonmedicalreasons ranges from nearly 3% ineighth graders to about 15% inhigh school seniors.4

Pseudoephedrine and dextro -methorphan, drugs commonlyfound in OTC cold and coughmedications, top the list of substances abused by teens.4

Pseudoephedrine can be madeinto methamphetamine, and dex-tromethorphan has opioid-likeproperties in high doses. A 2006

survey showed that 4% of eighthgraders and 6% of high schoolseniors abuse OTC cold medicinesthat contain dextromethorphan.3

Even though these numbers seemsmall, dextromethorphan abusehas multiplied tenfold from 1999to 2004.4

Teens may take these readilyavailable medica-tions out of themedicine cabinetand share themwith friendsat “pharmingparties.” Theytrade prescrip-tion medicationsand ingest them,with or withoutalcohol, and incombinations oramounts thatcan be deadly.5

Amphetaminesincrease BP,heart rate, tem-perature, andrespiratory rate.Teens who useamphetaminesmay exhibit

bizarre behavior and even haveseizures.

Sedatives and barbiturates canlead to respiratory depression anddeath. Withdrawal from barbitu-rates may cause seizures.

Misuse of opioids can also leadto respiratory depression anddeath. Acetaminophen, a compo-nent of many combination opioidproducts, can cause potentiallyfatal liver damage in high doses.Nonsteroidal anti-inflammatorydrugs combined with opioids cancause gastrointestinal bleeding andrenal damage.

Dextromethorphan, a nonopi-oid antitussive that some teensabuse, induces euphoria and hal-lucinations similar to those seenwith phencyclidine and opioids.Dextromethorphan is the D-isomerof the opiate agonist levorphanol.Bromide toxicity can also occurwith dextromethorphan; signsand symptoms of bromide poison-ing include behavioral changes,irritability, headache, confusion,lethargy, slurred speech, andanorexia.6

Identifying abuseMany factors can influence ayoung person’s decision to usedrugs, including peer pressure,depression, a history of physicalor emotional abuse, and a historyof parental drug abuse.7 Screeningparents and teens for potentialsubstance abuse may help youidentify those at risk. Talk withparents about how they can iden-tify others with substance abuseproblems, which may help themward off substance abuse prob-lems in their children.8

The Rapid Assessment ofAdolescent Preventive Services is a screening tool for assessingteens at risk for substanceabuse.9 The CAGE question-naire, usually used for assessingalcohol abuse, can be modifiedto assess drug abuse (see Howto use the modified CAGE ques-tionnaire).10

Dangerous medications11,12

Prescription OTC

Opioids Decongestant• hydrocodone • pseudoephedrine• oxycodone• propoxyphene• hydromorphone

Sedatives Cough suppressant• diazepam • dextromethorphan• alprazolam• zolpidem

Barbiturates Antidiarrheal (opioid-based)• pentobarbital • diphenoxylate • phenobarbital

Amphetamines• methylphenidate• methamphetamine

For a complete list, including street names, go towww.drugabuse.gov/DrugPages/DrugsofAbuse.html andwww.drugabuse.gov/DrugPages/PrescripDrugsChart.html.

Teens may take readily available

medications out of themedicine cabinet and

share them with friends at “pharming parties.”

These tools can help you startthe conversation to identifypotential risky behaviors. Havethe teen complete the question-naire in the room without thepresence of the parents to beginthe confidentiality process.Explain to the parents that you’dlike to initially see the teen aloneto help the teen take responsibilityfor his or her healthcare; let theparents know you’ll invite theminto the room after the exam togo over what’s been discussed,what’s been found, and whatplan’s been devised.

When you’re alone with theteen, let the teen know that sexu-al health matters are confidentialand won’t be shared with par-ents, and while almost all thingsdiscussed won’t be discussedwith parents, life-threateningbehaviors may have to be.Encourage the teen to begin anopen discussion with parentsabout sex, drugs, depression, orother concerns.9,10

During a physical exam, severalsigns and symptoms may alertyou to the possibility of drugabuse. Sudden, unexplainedweight loss or weight gain andeye signs may provide clues. For

example, abuse of sedatives andhypnotics may cause nystagmus;opioid abuse causes miosis.Stimulants and opioid withdrawalcan lead to mydriasis.10 Seeingthe signs provides a more detailedlist.

Confirming suspicionsUrine drug screens may confirmsuspected drug abuse, but accu-rate results depend on when thedrug was taken and how fast it’smetabolized. The sample mayalso be contaminated, and otherfactors can result in incorrect testresults for urine drug screens,including the presence of deter-gents or sodium chloride, hema-turia, acidic or alkalotic urine,and urine with a low specificgravity. Although associatedwith both false-positive and false-negative results, hair analy-sis can reveal chronic use becausethe hair stores drug metaboliteslonger.10 Hair analysis is nonin -vasive and has a larger window ofdetection than a urine drugscreen.

Once you’ve identified a teenwho’s abusing drugs, counselingand detoxification are the firststeps toward treatment. Be famil-iar with agencies in your areathat specialize in teen drug abuseand detoxification.10 Because it

often can take months to yearsfor someone to accept a diagnosisof drug abuse and to accept assis-tance, don’t argue with patientsor try to force them to accept thatthey have a problem. Continue toeducate them about the negativesof drug use with each visit in anonthreatening manner, and discreetly offer information on getting help. Families may alsobe addictive or in denial, sorecruiting them for assistancemay be counterproductive. Lookat each case individually.

Prevention tipsInvolving children in antidrugabuse programs while they’re inelementary school may discour-age them from abusing drugs asthey get older. Specific programsinclude Students TaughtAwareness and Resistance andStrengthening Families.10 Haveinformation on abuse preventionavailable to share with your teenpatients, seize opportunities toeducate them about drug andalcohol abuse, and teach themtechniques to handle peer pres-sure. Also talk to your teenpatients about depression; earlyidentification may help detersubstance abuse. Encourage com-munication between parents andchildren.

Seeing the signs2,7,10

Behavior Family/social School/work Physical

• agitation• mood swings• depression• difficulty coping• anxiety• hostility• borrowing money• stealing• getting arrested• using room deodorizers • using mouth-wash, cologne, perfume

• divided family• abuse in family (physical, emo-tional, substance)• not participaingin family activities• family members’depression, anxi-ety, substanceabuse• change in friends• change in social activities

• grades dropping• being late for or skipping school• missing work• changing jobs• getting fired

• red eyes• rhinorrhea• unexplained weight changes,especially weightloss• excessive sleepiness or insomnia

www.Nursing2010.com May | Nursing2010 | 45

How to use the modified CAGE questionnnaire10

Any “yes” answer to the questionsbelow should be investigated.Answering “yes” to two or morequestions suggests the need foradditional assessment into potentialdrug and/or alcohol problems.C = have you ever thought you

should Cut down on your druguse?

A = have people Annoyed you bybeing critical about your druguse?

G = have you ever felt Guilty aboutyour drug use?

E = have you ever used drugs firstthing in the morning as an Eyeopener or to get the day started?

Educate parents about the properstorage and disposal of prescrip-tion medications and remindthem to keep drugs and alcoholout of reach of all children, regard-less of age. Prescription and OTCmedications shouldn’t be disposedinto water sources unless accom-panying literature specifically statesit’s safe to do so. Medications canbe harmful to the environment,humans, and wildlife when theyenter the water system via toiletsand water drains. Advise parentsto dispose of medications in thetrash by removing them from theiroriginal containers, crushingthem, and mixing them into dis-tasteful substances such as kittylitter, spoiled foods, or coffeegrounds.13 Many communitieshave drop-off centers wheremedications can be disposed ofproperly.

Keep an eye on teensExperimentation with drugsbegins at an earlier age than it dida decade ago because prescriptionand OTC medications are morewidely available. Lend guidance,counseling, and education to bothparents and teens to help themstay safe and healthy. ■

REFERENCES

1. The Partnership for a Drug-Free America.Prescription medicine abuse: a serious problem.http://www.drugfree.org/Portal/DrugIssue/Features/Prescription_Medicine_Misuse.

2. Johnson County, Kansas. Known Facts aboutTeenage Alcohol Use and Abuse. 2005.

3. National Institute on Drug Abuse. NIDA infofacts: high school and youth trends. http://www.drugabuse.gov/infofacts/HSYouthtrends.html.

4. Office of National Drug Control Policy.Keeping your teens drug-free: a family guide.http://www.theantidrug.com/pdfs/resources/general/General_Market_Parent_Guide.pdf.

5. Greater Dallas Council on Alcohol and DrugAbuse: Teen substance abuse. http://www.gdcada.org/statistics/teens.htm.

6. Dextromethorphan abuse. Pharmacist’s Letter/Prescriber’s Letter. 2007;23(2):230208.

7. Lo CC, Cheng TC. The impact of childhoodmaltreatment on young adults’ substance abuse.Am J Drug Alcohol Abuse. 2007;33:139-146.

8. Lane WG, Dubowitz H, Feigelman S, et al.Screening for parental substance abuse in pedi-atric primary care. Ambul Pediatr. 2007;7(6):458-462.

9. Salerno J. Reducing risk behaviors in adoles-cents. Adv Nurse Pract. 2008;16:59-60, 62, 64.

10. Trachtenberg AI, Fleming MF. Diagnosisand Treatment of Drug Abuse in Family Practice.Monograph for the National Institute on DrugAbuse; 2005. http://www.drugabuse.gov/Diagnosis-Treatment/diagnosis.html.

11. National Institute on Drug Abuse. Commonlyabused drugs. http://www.drugabuse.gov/DrugPages/DrugsofAbuse.html.

12. National Institute on Drug Abuse. Prescrip-tion drug abuse chart. http://www.drugabuse.gov/DrugPages/PrescripDrugsChart.html.

13. Office of National Drug Control Policy.Proper Disposal of Prescription Drugs. http://www.whitehousedrugpolicy.gov/publications/pdf/prescrip_disposal.pdf.

Susan Simmons is a nurse practitioner at OlatheMedical Services, Inc., in Olathe, Kan., and is amember of the Nursing2010 editorial board.

46 | Nursing2010 | May www.Nursing2010.com