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Vol 1 | Issue 3 | Oct – Dec 2022                                                                                      Indian J Pharm Drug Studies | 92  

 Review Article 

Over-the-counter medicine abuse – A pharmacist’s emerging responsibility  

Martin Baby John, Alasandra Rose MS, Janice Jacson Mandumpala  

From, Pharm D intern, Department of Pharmacy Practice, Nirmala College of Pharmacy, Muvattupuzha, Kerala, India. 

Correspondence to: Janice Jacson Mandumpala, Pharm D intern, Department of Pharmacy Practice, Nirmala College of Pharmacy, 

Muvattupuzha, Kerala, India, Pin – 686661 Email: janice.jacson@gmail.com  

ABSTRACT 

Self-medication is an essential component of the healthcare system. Over-thecounter medications (OTC) are components of self-

medication. The administration of OTC medications in patients increases the risk of abuse of these drugs. With pharmacists being as 

accessible as they are, pharmacists are the first line of contact in purchasing OTC medications and have an upper hand in ensuring 

safety, and efficacy and preventing abuse in patients. This review aims to give brief information on OTC medications along with their 

abuse. The importance of patient and pharmacist interaction has been discussed. In addition, the potential for a behind-the-counter drug 

category and its prospective role in improving pharmacistpatient relations have been elaborated. This review gives knowledge on the 

barriers faced by pharmacists in OTC medication abuse and how it can be controlled and managed effectively. The current health system 

should work more effectively to provide a striking balance between the purchase of OTC medications and their abuse. 

Key words: Over-the-counter, abuse, misuse, pharmacists 

edications provided by pharmacists without the 

prescription of a doctor are known as over-

thecounter (OTC) medications. It is defined as 

‘medications that can be purchased without a prescription and 

are safe and effective when used according to the directions on 

the label, and as directed by a health care professional.’ In recent 

years there is an expanding trend of self-medication with OTC 

medicines and is becoming an increasingly popular practice 

around the world. As per recent estimates, the global prevalence 

of self-medication ranges from 11.2% to 93.7% [1].  

OTC medications are employed for common ailments and 

provide a cure for a wide range of conditions but not limited to 

headache, fever, muscular pain, heart-burn, common cold, and 

allergies [2]. OTC drugs have an advantage for the healthcare 

system as it boosts pharmacists’ skills along with the reduction 

of prescribed drug costs for the public. Pharmacists are the first 

point of care while dispensing OTC medications. However, the 

increasing availability of OTC medicines increases the patient’s 

risk of subjecting to interactions and adverse effects of drugs. 

Patients are encouraged to self-treatment which may lead to 

potential misuse of the medications [3]. The risk of OTC 

medicines may include self-diagnosis, incorrect treatment, 

addiction in the long run, drug interactions, and poly-pharmacy. 

This may be particularly more dangerous in vulnerable 

populations such as the elderly [4].   

The majority of patients don’t discuss the consumption of 

OTC medicines with their treating physicians therefore they 

tend to be unaware of the potential risks of the medications. The 

increased administration of drugs by patients has increased 

drastically in the absence of professional help. OTC medicines 

are consumed by customers and are not even recorded in many 

pharmacies [5]. The abuse of OTC drugs is not often intentional 

and it can arise due to incorrect information about the drugs such 

as improper dosage form, lack of knowledge, drug-drug or drug-

food interactions, and improper duration of the dose. There is a 

constant rising concern about the harms that can be associated 

with the use of OTC medications.   

The objective of this review is to give a brief understanding 

of the potential abuse caused by OTC medications. This review 

elaborates on the role of Pharmacists in managing OTC 

medications along with future steps that need to be taken to 

restrain the issue of OTC medications worldwide. This review 

gives a perspective to the pharmacists to reduce OTC 

medication abuse and strategies to implement betterment in the 

future.  

Abuse of OTC medications: The abuse of OTC medications is 

a cause of a significant rate of morbidity and mortality [6]. Most 

commonly abused OTC medications include caffeine, 

antihistamine, antitussives, expectorants, ephedrine, 

pseudoephedrine, steroids, etc.  Tinsley JA et al reported a case 

study of a thirty-three-year-old woman who was admitted for 

inpatient treatment of ephedrine abuse [7]. It was reported that 

the patient took 25 mg of a capsule every day for appetite 

suppression. This OTC ephedrine medication was lifted by the 

patient from the place where she worked which also led to her 

termination. The patient consumed the drug for 18 months. 

M 



Baby et al                                                                                                                         Over-the-counter medicine abuse 

Vol 1 | Issue 3 | Oct – Dec 2022                                                                                      Indian J Pharm Drug Studies | 93  

Even after the patient’s numerous attempts to discontinue the 

drug she failed due to constant rebound. This addiction also 

interfered with her daily chores and children’s duties. The 

findings on the patients’ data were unremarkable. This 

implicates the need to address the lingering threat of OTC abuse 

within the public domain.   

From the worldwide abuse of OTC medications cold or 

cough products consisting of dextromethorphan, analgesics, 

antihistamines, and hypnotics are widely highlighted for their 

potential abuse [8]. A rising number of cases have been reported 

with the abuse and misuse of propylhexedrine (Benzedrex), and 

OTC nasal decongestants. Misuse of propylhexedrine is 

associated with cardiac and psychiatric adverse effects [9]. 

Cough and antihistamines are the most highly abused OTC 

medication and sometimes the patients aren’t even aware of the 

abuse until they find the uncontrollable urge to consume 

medications. Similarly, dimenhydrinate is an anti-histamine 

OTC indicated for nausea and vomiting. It is more often 

misused for its psychotropic effects, including hallucinations 

and euphoria. In addition to frank abuse, there is also a potential 

for drug dependence upon long-term misuse [10]. Although, 

there is a general trend in OTC abuse of drugs from many 

different therapeutic classes and numerous dosage forms and 

drug delivery systems are implicated in OTC drug abuse.  

One of the main notable reasons for OTC medication abuse 

is an increase in access to medications [11,12]. Medications are 

made accessible by converting from prescription to OTC 

medications. These switches are done when a firm’s patent 

expires. However, in the case of prescription antihistamines like 

Claritin, Zyrtec, and Allegra, Blue Cross was petitioned to be 

switched to OTC by the parent companies [13]. Patient 

autonomy is increased by switching medications which 

eventually increases the decisions of healthcare. A record of 

total of 12.9 billion dollars in profit was generated for the switch 

of cold, allergy, analgesics, and dermal products. The exact 

reason for this switch to OTC medications has led to the abuse 

of medications.  

Table 1- List of most commonly abused OTC medications  

Class of drugs  Examples  References  

Antihistamines  Diphenhydramine 

and Coricidin  

[14] 

Cough medicines  Cough medicines 

containing  

dextromethorphan  

[15] 

Codeinecontaining 

products  

Compound 

analgesics  

(codeine with 

ibuprofen or  

paracetamol) and 

cough medicines  

[15] 

Analgesics  Aspirin and 

acetaminophen  

[16] 

Hypnotics  Sominex and nytol  [14] 

Laxatives (oral and 

rectal)  

Sodium phosphate 

laxatives and  

laxatives containing 

bisacodyl  

[17] 

Decongestants  Pseudoephedrine  [18] 

The role of a pharmacist in OTC medications: A patient has 

easier access to the pharmacist when compared to a general 

physician. Numerous issues that are faced by the patients can be 

easily resolved such as indecision in the brand name of OTC 

medication, proper medication use, and the exact duration of 

consumption of medications. There are many marketing 

strategies for different products which tend to confuse patients. 

One of the common marketing strategies is line extension [19]. 

A huge amount of capital is invested in OTC medication 

advertisements and in-line extensions. Once a manufacturer 

claims a brand name, other products under the manufacturer are 

sold under the same brand name which is called a line extension. 

For example, the brand name Tylenol has many extensions 

under the same brand name as Tylenol PM, Tylenol cold, and 

Tylenol cough. Line extensions of the same brand can 

sometimes be confusing for patients due to multiple ingredients 

in the formulations.   

Interaction of the patient with a pharmacist before buying 

any OTC medications or even prescription medications can help 

in better decision-making for the administration of the drug. 

Advertisements of OTC medication can usually be misleading 

as the advertisement focuses more on the advantages of the drug 

with minimal information on drug interactions and safety 

concerns [20]. This advertisement may also be a cause of poly-

pharmacy in patients. A pharmacist can give a better insight into 

the drug along with information on the side effects and safety 

concerns. In the recent years, there have been an evolving trend 

in the role of clinical pharmacists as a patient safety agent. As 

the pharmacists have a significant impact on public health and 

on improving patient's quality of life, there is need to 

incorporate minute details such as OTC medications, 

medication adherence and many others to ensure positive patient 

outcomes [21].  

The role of a Pharmacist in OTC medication abuse: Since 

ancient times pharmacists have always focussed on the drug 

distribution system. Over the past few years, there is an 

increasing number of incidences of chronic illness which has led 

to the prevention of the complex utilization of drugs and this has 

increased responsibility on the shoulders of pharmacists in 

providing broader services [22]. Pharmacists have demonstrated 

a productive impact on hospitals by obtaining medical history 

and medical reconciliation of patients [23]. There is an 

increasing demand for healthcare to increase a pharmacist’s 

role. Pharmacists are the initial point of contact while 

purchasing OTC medications. Pharmacists require regular 

monitoring of OTC medication in a specific population [8]. For 



Baby et al                                                                                                                         Over-the-counter medicine abuse 

Vol 1 | Issue 3 | Oct – Dec 2022                                                                                      Indian J Pharm Drug Studies | 94  

example, for elderly patients pharmacists should be on a better 

lookout and also for patients who ask for frequent refills [24].   

Pharmacists can manage the abuse of OTC medications by 

proactively improving their clinical skills and by giving oral and 

written information about the OTC medications to the patients. 

There are various programs for the management of prescription 

drugs along with refills of prescription drugs such programs 

should also be formulated for OTC medications. Various 

methods were used by pharmacists in the past to control OTC 

medication abuse, the most common three methods are keeping 

the compromised medications out of sight, questioning 

pharmacists upon refills of the medication, and refusing to sell 

any compromised products [4]. It was also proved that 62% of 

the pharmacists take measures to reduce OTC medication abuse 

by not displaying implicated medications and refusing the sale 

of such medications. In a study conducted by Frank et al to 

demonstrate the clinical management of dextromethorphan 

abuse [25]. 

It was found that dextromethorphan is an antitussive, 

inexpensive OTC medication and that the abuse of this drug was 

reported by dissociative effect. Huge amounts of ingestion of 

the drug can cause hypertension, tachycardia, and respiratory 

depression. Therefore, pharmacists should be well aware of the 

dissociative effects of the abuse of dextromethorphan. 

Pharmacists should also interview the patients before dispensing 

such medications with potential abuse. Other techniques used 

by pharmacists are reporting OTC medication abuse to a 

physician. Similarly, programs like prescription drug 

monitoring log information about a patient upon visiting the 

pharmacy for refills.   

Table 2- Common strategies by Pharmacists to control OTC 

medication abuse [8, 26]  

Specific 

locations  

Strategies initiated by pharmacists  

Pharmacy  1. Declining sales of implicated OTC 

medications  

 2. Immediately contact other 

pharmacies of the suspicious 

behaviour of the patient abusing OTC 

medication  

 3. Declaring products were out of 

stock  

 4. Prevent medication by hiding the 

supplies  

 5. Giving only a few amounts of 

medication   

Patient 

Participation  

1. Providing counselling to the 

patients on the potential abuse of the 

OTC medications   

 2. Raising awareness through the 

internet and support groups for 

advising patients  

 3. Giving out information leaflets  

Involvement of 

the doctor and 

other services  

1. Providing consultation  and  

2. Engagement by the doctor 

3. Giving referral to the physician 

Utilizing the services of private 

clinics  

 4. Using special services of drug and 

alcohol abuse  

Barriers to preventing OTC medication abuse: There are 

many challenges faced by pharmacists in monitoring OTC 

medication abuse. Pharmacists are never in the practice of 

keeping records of OTC medications and this creates a barrier 

to the necessary information for proper counselling decisions. 

In 2005 a survey was conducted by Adrea et al to evaluate drug-

related problems [25]. The survey was conducted on community 

pharmacists and the pharmacists were constructed to record 

basic statistics of the patients such as drug interactions, 

prescription, and non-prescription drugs along with patient data. 

The results of the pharmacists showed 10,427 drug-related 

problems. Most of the drugrelated problems were associated 

with drug-drug interactions. The conclusion of this study was 

that pharmacists are responsible for the proper use of 

prescription and OTC medications however the role of 

pharmacists in healthcare still needs to be recognized.   

Keeping in mind the potential abuse of OTC medications the 

US federal law government passed the Combat 

Methamphetamine Epidemic Act of 2005 (CMEA) [27]. This 

act was enacted to minter the amount the pseudoephedrine a 

person can purchase from a pharmacy. The main focus of this 

act was to decrease the illegal use of methamphetamine which 

can be produced from medications like ephedrine and 

pseudoephedrine which are commonly used cough and cold 

OTC medications. The CMEA has kept a limit on the purchase 

of nine grams of pseudoephedrine in a period of one month. The 

lack of pharmacists in monitoring the use of OTC medications 

has led to further open doors for abuse of OTC medications. 

Moreover, the legal laws of OTC medication distribution are not 

maintained and the laws are also not revised to keep up with 

pharmacists’ needs [25].  

For example, a study conducted by Tommy et al proved that 

in community pharmacies the pharmacists were overworked. 

The increased workload of pharmacists caused reduced 

attention for the patient’s OTC medication abuse. Pharmacists 

are present in limited numbers and pharmacy technicians play 

an important role in preventing OTC medication abuse as well, 

they give an extra layer to patient safety [28].  

Behind the counter [BTC] medications – A change maker: 

BTC medications are medications that are the third category of 

drugs that are available after consultation with the pharmacist. 

The pharmacist performs screening, necessary tests, and 

counselling before dispensing the BTC medication to the 



Baby et al                                                                                                                         Over-the-counter medicine abuse 

Vol 1 | Issue 3 | Oct – Dec 2022                                                                                      Indian J Pharm Drug Studies | 95  

patient. Patients consuming BTC medications could be 

suffering from increased blood pressure (BP), allergies, 

inflammation, and pain. OTC medication with the potential risk 

of high abuse can be included in the BTC medications list. If the 

pharmacists work in a collaborative manner with the patients 

they can lead to a safer use of medications. BTC medications 

serve as a bridge between OTC medications and prescription 

drugs.   

CONCLUSION  

This review concluded the essential role of pharmacists in OTC 

medication abuse. Pharmacists need to be well informed about 

the OTC medications along with their abuse. Pharmacist 

vigilance can help reduce OTC medication abuse. A better 

communication practice between pharmacists and patients can 

help in understanding the core of OTC medication abuse. Above 

all, the current health care system calls for more regulation on 

OTC medications, particularly the ones with identified potential 

abuse. There needs to be a striking balance between access to 

OTC medication and their risk of abuse.  

Table 3- Potential drugs that can be shifted from OTC 

medications to BTC medications.  

Medications  Example  Reference  

High cholesterol  Statins  [29]  

Hyperglycaemia  Insulin  [30]  

Cold remedies  Pseudoephedrine and 

ephedrine  

[7,27]  

Schedule V cough 

syrups  

Certain 

codeinecontaining 

products  

[30]  

Emergency 

contraceptives  

Plan B  [29,30]  

Painkillers  Painkillers with small 

amounts of codeine (up 

to 12.8 mg per tablet) 

and aspirin  

[23]  

Sleep aid/allergy  Diphenhydramine  [31,32]  

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Vol 1 | Issue 3 | Oct – Dec 2022                                                                                      Indian J Pharm Drug Studies | 96  

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How to cite this article: Martin Baby John, Alasandra Rose 

MS, Janice Jacson Mandumpala. Over-the-counter 

medicine abuse – A pharmacist’s emerging responsibility. 

Indian J Pharm Drug Studies. 2022: 1(3) 92-96. 

Funding: None                     Conflict of Interest: None Stated  

   

  


