When most people imagine drugs of abuse, they think of legal substances, like alcohol and tobacco, prescription drugs, like opioid painkillers or benzodiazepines, or illegal drugs, like heroin, cocaine, meth, or marijuana. Although these are commonly abused substances, which can become addictive and produce dangerous consequences, they are not the only intoxicating substances available. Prescription drug abuse is on the rise in the United States, and as more regulators crack down on this problem, people who struggle with addiction or substance abuse are turning to over-the-counter (OTC) substances.

There are many substances that are available over the counter, which can, in large enough doses, cause intoxication, a euphoric high, or hallucinations. Many people may falsely believe that because these substances are legal and available at places like pharmacies and grocery stores that they are safer to abuse than illicit or controlled substances. Despite their widespread availability, it is very dangerous to abuse OTC substances.

Here are five of the most commonly abused over-the-counter drugs:

  1. Dextromethorphan (DXM)
    This substance is the main active cough-suppressing ingredient in over-the-counter medicines like Robitussin. The drug can either be found alone as the active ingredient or in combination with other active ingredients like acetaminophen (Tylenol), antihistamines, decongestants (pseudoephedrine), or expectorants (guaifenesin). A normal dose of DXM is about 15-30 mg, 3 or 4 times daily. The maximum recommended dose in a 24-hour period is 120 mg. Although some states are taking steps to regulate who can purchase over-the-counter medicines containing DXM and in what quantities, the drug is still legal for manufacture, sale, and ingestion in the US. However, the Drug Enforcement Administration (DEA) lists this as one of its “Drugs of Concern” due to its potential for addiction and abuse. When DXM is abused in large doses, the individual can experience euphoria and hallucinations, typically visual and auditory. Nonmedical doses of DXM range from 250 mg to 1,500 mg. Originally, DXM was found primarily in liquid cough syrups, but now it has been added in larger doses to gel capsules. Some people mix the liquid with soda; this practice is called “skittling” or “robo-tripping.” Symptoms of intoxication on DXM include lethargy, overexcitement, euphoria, disorientation, physical distortion, slurred speech, and hallucinations. Side effects and dangers of abusing DXM include, high blood pressure, sweating, nausea, vomiting, dehydration, loss of coordination, liver damage, seizures, extreme panic, aggression, and coma.
cough syrup
  1. Pseudoephedrine
    This drug is the active ingredient in many allergy, sinus, cold, and flu medicines, including Sudafed. It relieves the symptoms of sinus congestion, and in over-the-counter doses, it is typically safe to ingest. Some individuals abuse pseudoephedrine at higher doses because of the medication’s mild stimulant effects; however, this substance is primarily regulated due to its role in illicit domestic methamphetamine manufacturing. It used to be available over the counter, but now it is considered a “behind the counter” medication, in which a person must show their ID and sign for the medication at the pharmacy counter. The amount a person can purchase is limited as well. Still, some people abuse pseudoephedrine for its euphoric and stimulant properties. Abusing this medication can cause nausea, vomiting, weakness, restlessness, dizziness, stomach pain, breathing difficulties, irregular heartbeat, and sleep disturbances.
  1. Imodium
    Imodium is the brand name for the medication loperamide, and it has an active ingredient that helps to slow the movement of the bowel to reduce or prevent diarrhea. It is an OTC medication, and it should not be used to treat this problem on a long-term basis. Loperamide is a mild opioid, which is a small enough dose to bind to opioid receptors in the stomach and intestines, but it does not cross the blood-brain barrier in standard doses. However, high doses of Imodium can cause opioid-like effects, such as feelings of pleasure. It is also used by opioid-addicted individuals to ease their opioid withdrawal symptoms and cravings. Taking large amounts of loperamide can be very dangerous, as it can cause stomach pain, constipation, fainting, loss of consciousness, irregular heartbeat, kidney problems, and even overdose.

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  1. Dimenhydrinate
    Dimenhydrinate, which is marketed under the brand name Dramamine, is a medication taken to prevent motion sickness. It is an OTC antihistamine that some people abuse in order to get high. When people abuse dimenhydrinate in nonmedical doses, it induces intense euphoria and it can also cause hallucinations. Side effects of dimenhydrinate intoxication include flushed face and skin, large pupils, sleepiness or drowsiness, hyperactivity, hallucinations, confusion, seizures, coma, and difficulty speaking, swallowing, or standing.
  1. Diphenhydramine
    This is an antihistamine drug primarily found in medicines like Benadryl and it is used to treat allergies. Since it is not as regulated as other OTC drugs, such as pseudoephedrine, this substance can more easily be abused in large quantities, especially by teenagers or incarcerated individuals, to induce a euphoric high and potentially hallucinations. Diphenhydramine tends to be sought out for abuse in communities that do not have access to other intoxicating substances. Side effects of diphenhydramine abuse can include drowsiness, dizziness, nausea, vomiting, muscle weakness, nervousness, loss of appetite, vision problems, and painful urination. Benadryl overdose signs include low blood pressure, rapid heartbeat, seizures, confusion, delirium, hallucinations, tremors, and agitation.

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The nonmedical use of any medicine is dangerous. With over-the-counter medications, the amount of active ingredients is low, so it takes a large amount of any substance to induce any kind of intoxication. This can lead to organ damage, psychological problems, and overdose. Still, some substances available over the counter can be addictive or abused as part of a problem with polydrug abuse, or co-occurring mental health and substance use disorders.