Is Cough Syrup Safer Than Alcohol? The True Dangers of Alcohol Alternatives

In a recent survey conducted by the National Institute on Drug Abuse, 4.6% of 8th graders, 3.3% of 10th graders, and 3.2% of 12th graders reported misusing alcohol alternatives in the previous year.1

When taken in doses higher than recommended, alcohol alternatives affect the brain in the same way as alcohol and some prescription drugs, causing psychoactive effects.2

What Are Alcohol Alternatives?

Alcohol alternatives are medicines you can purchase over the counter. When used according to recommendations these medications ease symptoms of colds, flu, allergies, digestive problems, sleep disturbances, and other minor health complaints.

Alcohol alternatives include over-the-counter antihistamines (allergy medication), decongestants, cough suppressants, and sleep aids. When purchasing alcohol alternatives, no purchase limit and no personal identification are required. The active ingredients in alcohol alternatives create the potential for misuse.2

Below are the most misused alcohol alternatives and their active ingredients:3

  • Cough syrup—Dextromethorphan (DXM)
  • Antihistamine—Chlorpheniramine, diphenhydramine, promethazine
  • Decongestant—Pseudoephedrine

Another widely misused substance is over-the-counter sleep aids for those who have sleep disturbances, especially in college students who also misuse other substances as a form of self-medication.4

A survey of pharmacists reveals the alcohol alternatives with the most potential for misuse also include laxatives and certain commonly prescribed medications like hypnotics and codeine-containing products such as prescription cough syrup.5

Who Uses Alcohol Alternatives?

Two demographics most widely misuse alcohol alternatives:3

  1. Persons with a medical condition treated by the substance. They may have been given a prescription version of the alcohol alternatives as part of a treatment plan by their doctor. They may have been using over-the-counter medicines—either after prescription treatment or in place of it—for a long time.
  2. Persons with no medical condition who use alcohol alternatives for recreational purposes. For example, to achieve dextromethorphan high from cough syrup.

Anyone can purchase over-the-counter medicine at big box stores, grocery stores, discount stores, and pharmacies. While some medications have an age restriction or a limit on how much you can purchase at one time, many alcohol alternatives are readily available. In one study, 69% of pharmacists claim that misuse of over-the-counter medicines by customers is happening in their store.6

Another survey of almost 40,000 students in America asked if they misuse alcohol alternatives. Out of the total, 4.7% reported misusing over-the-counter drugs to get high, with 2.1% reporting they did so in the month before the survey.7

Most reported groups misusing alcohol alternatives are young adults and adolescents, including both high school and college students. Reasons youth and young adults misuse alcohol alternatives include to:8

  • Relax or calm down
  • Get dextromethorphan high or another chemical high
  • Relieve tension associated with psychological distress
  • Relieve pain
  • Fall asleep
  • Manage withdrawal symptoms related to alcohol misuse or misuse of another substance

The same risk factors put an individual at higher risk of misusing alcohol alternatives as put them at risk of misusing alcohol. For some, alcohol alternatives may be used if alcohol is not readily available. Risk factors include a family history of addiction, a personal history of abuse or trauma, or a past history of any substance misuse. Medical and mental health conditions may also contribute.9

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One reason youth and young adults use alcohol alternatives while below the legal drinking age is that they assume over-the-counter medications are safe—or safer than other ways to get high—because they do not require a prescription and can be purchased in a store instead of on the street.

Even if taken at much higher doses than the package recommends, many people in these demographics report considering alcohol alternatives to be safe methods of getting high, managing mental health symptoms, or inducing sleep and other desired results.10 However, this alcohol alternatives are not safe for recreational use or when taken over the recommended dose.

What Are the Dangers of Alcohol Alternatives?

Legal over-the-counter drugs can cause serious health consequences just like illicit drugs. Doctors report that hospitalizations related to misuse of alcohol alternatives often happen when youth mix over-the-counter medicine with prescription medication, alcohol, or illicit substances. Some of the hospitalized patients meet the criteria for being addicted to one or more of the substances. 11

Alcohol alternative misuse can potentially result in severe symptoms such as tachycardia (abnormal heartrate), seizures, or psychosis (experiences of unreality). Drug poisoning or overdose is a dangerous and potentially life-threatening possibility with many alcohol alternatives. A 2018 report indicated that 69% of emergency room visits by adolescents relate to medication misuse, with 39% directly relating to over-the-counter medications. 10

Other risks associated with misusing alcohol alternatives include the following:12

  • Interaction between the alcohol alternative and other medications you are taking
  • Allergic reactions
  • Worsened conditions or illnesses that already exist
  • Accidental overdose

Short-Term Effects of Alcohol Alternatives

Antihistamines, decongestants, cough medicines, sleep aids, and other over-the-counter medicines produce intense acute side effects when misused such as:3Alcohol alternatives can have numerous side effects.

  • Sedation
  • Euphoria from dextromethorphan high or other active ingredients
  • Respiratory depression
  • Central nervous system depression
  • Paranoia
  • Delusional beliefs
  • Out-of-body experiences
  • Mania
  • Irritability
  • Insomnia
  • Vomiting
  • Loss of motor coordination
  • Hypertension, or high blood pressure
  • Blurred vision

Long-Term Effects of Alcohol Alternatives

Depending on which substance is misused, its active ingredients, how much is used, and for how long, alcohol alternative misuse can have serious mental or physical consequences. Potential long-term effects include:3

  • Substance-induced psychosis, or an episode of or continuous experience of unreality that may include either hallucinations (i.e., sights, smells, sounds, or feelings of touch that do not correlate with reality) and/or delusions (i.e., thoughts or beliefs that directly contradict given evidence)
  • Cognitive decline
  • Neuropathy, or nerve damage, especially in the hands and feet
  • Folate deficiency
  • Seizures
  • Delirium, or an acutely disturbed state of mind that causes confusion and reduces awareness of one’s surroundings

Can You Become Addicted to Alcohol Alternatives?

When a substance is used over a long period of time, your body can develop a tolerance to it, which means you need a higher dose to achieve the intended effect. This process happens when you use any substance chronically, including over-the-counter medication.

Chronic use can also lead to the development of physical or mental dependence on the substance. Dependence occurs when you need the substance to function normally, such as to concentrate, manage stress, or get enough sleep. Alcohol alternatives can lead to dependence comparable to dependence on alcohol, prescription drugs, and illicit drugs. The body adapts to having alcohol alternatives and now needs it to function.12

While tolerance and dependence are different from addiction, if you develop tolerance and dependence, you have a higher risk of developing a substance use disorder—the diagnosis mental health professionals use to describe the behaviors and symptoms of addiction.

When you have a dependence on a substance, you will experience withdrawal symptoms when you try to stop using the substance, do not have access to it, or reduce how much you use it. Withdrawal is one of the symptoms mental health professionals use to determine if someone is addicted to a substance.

Withdrawal symptoms depend on the alcohol alternatives and any other substances you use, but may include:13

  • Flu-like symptoms—Such as chills, fever, sneezing, and cough
  • Digestive problems—Such as nausea, vomiting, and diarrhea
  • Aches and pains—Such as muscle spasms and cramps
  • Desire to use the substance—Manifests as intense cravings or urges
  • Mental health symptoms—Including anxiety, depression, or paranoia

Withdrawal symptoms are uncomfortable and can be difficult to manage. In some cases, they can require medical attention.

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In some cases, individuals misuse a different substance to reduce their withdrawal symptoms. This can be how someone starts misusing alcohol alternatives. Or, some may misuse other depressants—such as prescription medications or illegal substances—in order to avoid withdrawal symptoms.13, 14

What Do Parents Need to Know About Alcohol Alternatives?

Since teens are the biggest group known to misuse alcohol alternatives, parents need to know how to prevent and recognize this misuse. Here are the top 10 must-know facts about teens and alcohol alternatives:15

  1. You can overdose on over-the-counter medicines. While overdoses can look slightly different depending on which substance your teen uses, if they become extremely confused, unresponsive, unconscious, or very cold or hot to the touch, consider these symptoms a medical emergency. Vomiting, convulsions, chest pain, and heart rate changes may also indicate drug poisoning.
  2. Over 120 over-the-counter cold medicines contain DXM. Dextromethorphan (DXM) is one of the most commonly misused alcohol alternatives. DXM can be found either alone or combined with other ingredients in several types of medications, including Mucinex DM, Pediacare, Theraflu, and Dayquil. These medicines can be used safely when taken according to dosing recommendations, but some can be purchased without identification and have no restrictions on how many bottles or packages can be purchased in one transaction.
  3. Alcohol alternatives come in liquid, capsules, tablets, and powder forms. In addition to cold and flu medications, other medications like Alka Seltzer Plus, can contain DXM.
  4. Alcohol alternatives can be obtained in several locations. While many alcohol alternatives are readily available in retail stores or pharmacies, they are also often found in medicine cabinet at home or at a friend’s house.
  5. Anyone can buy alcohol alternatives online. Retail stores have some restrictions on alcohol alternatives with certain active ingredients, but alcohol alternatives can be purchased online including on social media sites. Online, individuals may be able to purchase prescription alcohol alternatives like cough syrup with codeine in it that they could not get in a pharmacy without a prescription.
  6. Stocking up is a warning sign of alcohol alternative misuse. Empty bottles of over-the-counter medicines in the house or garbage may indicate misuse. Also, if someone in your home purchasing these medicines even when they are not sick, missing medication in your home, and internet history including sites about alcohol alternatives can indicate misuse.
  7. Physical activation is a symptom of alcohol alternative misuse. Unusual symptoms of alcohol alternative misuse include dextromethorphan high, spasmodic movement of the eyeballs, appearing overly excited, inappropriate laughter, hallucinations, lethargy, sweating, and confusion.
  8. Accidents and injuries may point to alcohol alternative or other substance misuse. Alcohol alternatives and other common substances of misuse impair the senses and motor coordination, which can lead to clumsiness, injuries in groups of friends, and vehicle accidents.
  9. Changes in social and school behaviors can happen due to substance misuse. Behaviors specific to teen substance misuse include missing classes, poor academic performance, complaints from teachers, lack of interest in extracurricular or school activities, isolation, and changes in friend groups. A sudden increase or decrease in social media use may accompany these changes.
  10. Treatment is available for anyone misusing substances. Addiction treatment programs for teens identify the substances of concern and the detox processes required—if any—during intake. There are many centers and program types designed for the specific needs of youth and young adults who have developed or who are at risk of developing addiction.

If you, or someone you know, is misusing alcohol alternatives, treatment is available.

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Resources:

  1. National Institute of Drug Abuse. (2017). Over-the-Counter Medicines DrugFacts.
  2. National Institute of Drug Abuse. (2020). Over-the-Counter Medicines: Trends and Statistics.
  3. Schifano, F., Chiappini, S., Miuli, A., Mosca, A., Santovito, M. C., Corkery, J. M., Guirguis, A., Pettorruso, M., Di Giannantonio, M., & Martinotti, G. (2021). Focus on Over-the-Counter Drugs’ Misuse: A Systematic Review on Antihistamines, Cough Medicines, and Decongestants. Frontiers in Psychiatry, 12, 657397.
  4. Goodhines, P. A., Gellis, L. A., Kim, J., Fucito, L.M., & Park, A. (2019). Self-Medication for Sleep in College Students: Concurrent and Prospective Associations With Sleep and Alcohol Behavior. Behavioral sleep medicine, 17(3), 327–341.
  5. Sansgiry, S. S., Bhansali, A. H., Bapat, S. S., & Xu, Q. (2016, December 19). Abuse of Over-the-Counter Medicines: A Pharmacist’s Perspective. Integrated Pharmacy Research & Practice, 6, 1-6.
  6. Cooper, R. J. (2013, October 03). Over-the-counter medicine abuse – a review of the literature. Journal of Substance Use, 18(2), 82–107.
  7. Steinman, K.J. High School Students’ Misuse of Over-the-Counter Drugs: A Population-Based Study in an Urban County. Journal of Adolescent Health, 38(4), 445-447.
  8. Chiappini, S., & Schifano, F. (2020, October 14). What about “Pharming”? Issues Regarding the Misuse of Prescription and Over-the-Counter Drugs. Brain Sciences, 10(10), 736.
  9. Whitesell, M., Bachand, A., Peel, J., Bachand, A., & Brown, M. (2013). Familial, Social, and Individual Factors Contributing to Risk for Adolescent Substance Use. Journal of Addiction, 2013, 579310.
  10. Abraham, O. & Chmielinski J. (2018, October 15) Adolescents’ Misuse of Over-The-Counter Medications: The Need for Pharmacist-led Intervention. Innovations in pharmacy, 9(3), 1-7.
  11. Benotsch, E.G., Koester, S., Martin, A.M., Cejka, A., Luckman, D. & Jeffers, A.J. (2014). Intentional Misuse of Over-the-Counter Medications, Mental Health, and Polysubstance Use in Young Adults. Journal of Community Health, 39(4), 688-695.
  12. S. National Library of Medicine. (2021). Over-the-Counter Medicines. Medline Plus.
  13. Gupta, M., Gokarakonda, S.B., & Attia, F.N. (2021, July 31). Withdrawal Syndromes. Treasure Island (FL): StatPearls Publishing.
  14. National Institute on Drug Abuse. (2021). The Science of Drug Use and Addiction: The Basics.
  15. S. Drug Enforcement Agency. (2018). Prescription for Disaster: How Teens Misuse Medicine.

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