Vol. 14 •Issue 3 • Page 50
Asthma Inhaler Abuse: A Disturbing New Trend?
Patients Who Take Extra Puffs May Be at Risk for Other Problem Behaviors
Drink a cup of coffee. Then another. Then another. And keep going.
Guzzle down about 10 cups and see how you feel.
Not that great, right?
Well, that's comparable to taking 20 puffs of a prescription asthma inhaler - a dangerous way that teens are trying to get high.
"Your heart would be racing. Your hands would be trembling. Your blood pressure would rise," said Joseph Rosman, MD, chief of pulmonary and critical care at Mount Sinai Hospital, Chicago. "I can't fathom why people would want to feel that way."
He's not alone. Little research exists on the youth abuse of asthma inhalers and how big of a problem it really is.
"What's so interesting is this isn't on anybody's radar screen," said Carol J. Boyd, MSN, PhD, RN, director of the Substance Abuse Research Center, University of Michigan, Ann Arbor. Dr. Boyd recently completed a pilot study that she hopes will begin to expose the issue.
The research, published last year in the Journal of Adolescent Health, found that 15 percent of eighth- and ninth-graders from a Detroit-area public school district used a nonprescribed asthma inhaler.1 Plus, these students were significantly more likely to smoke cigarettes and marijuana, binge drink, and use ecstasy and cocaine, compared to other high school students.
"We didn't think we would find this," Dr. Boyd said. "This was just kind of serendipitous. Initially, when we looked at it, we thought this is a little weird that kids are acknowledging that they're abusing asthma inhalers. Then, we saw that it was correlated with other problem behaviors related to substance abuse. That's when that little red flag came up, and we thought we should publish this."
The researchers, though, acknowledge some limitations.1 For starters, they had a relatively small sample size (496 eighth- and ninth-graders), and they didn't differentiate between beta-agonists and corticosteroid inhalers, which have different pharmacological mechanisms. However, the students most likely used short-acting medication because it's more common.
Also, the investigators didn't define the abuse, explained study co-author Christian J. Teter, PharmD, BCPP, assistant professor of pharmacy practice, Northeastern University School of Pharmacy, Boston.
"We don't know if every once in a while they're playing around and want to be all jazzed up. We don't know if they're using inhalers therapeutically, but just off-label use - like, 'You have an inhaler. I don't have mine. Let me use yours,'" he said. "This is still inappropriate because there are different types of inhalers with different therapeutic effects, which could be dangerous if a student uses the wrong inhaler in an emergency situation."
Other researchers share their concerns. Matthew Howard, PhD, professor of social work and psychiatry at the University of Michigan, surveyed 193 incarcerated youth in Missouri diagnosed with asthma.2 Of the 90 percent prescribed an inhaler, 26 percent had abused it (defined here as excessive use).
The abuse took several forms: Sixty percent did it to treat their own symptoms, 60 percent wanted to see what it would feel like, and 57 percent wanted to get high. (Subjects could answer more than once.)
"I was really shocked," Dr. Howard said. "It's a virtually unknown form of substance abuse."
He interviewed young asthmatics who took extra puffs on hundreds of occasions. "Some used them to the point of passing out."
Nausea, headache, vomiting and fatigue made the list of the short-term effects the abusers frequently experienced.
"Subjectively," Dr. Howard said, "they didn't seem too terribly concerned."
Based on pharmacology, it makes sense these teens experience trembling, anxiety and rapid heart rate from extreme use of asthma medications, Dr. Teter said. Beta-agonists aren't 100-percent selective, and you're going to see some stimulant-like effects. As for harms down the road, that's a bit trickier to determine.
"Until you know why they're using it or how they're using it, you can't say a whole lot about chronic long-term effects," he said. "If you really wanted to stretch it, if you have students who were using for sensation seeking-like purposes - people who were using exceedingly high doses - and they did have an underlying cardiac abnormality, there could be trouble. That would be the extreme case, but it's certainly possible."
That begs the question: Why do teens abuse asthma inhalers?
"Are they addicted to albuterol?" Dr. Boyd said. "No, I don't think so."
It seems asthma inhaler abuse is linked with other types of drug abuse, according to her research. But more studies must be conducted to make any clear conclusions.
"Are these kids that are abusing inhalers abusing Oxycontin and Vicodin eight years down the line?" she said. "We don't know that."
Young adults classified as intense sensation seekers will try anything available to change their consciousness, Dr. Howard said. And oftentimes, because of the nation's current asthma epidemic, asthma inhalers can be found easily.
More than 10 percent of the asthmatics Dr. Howard interviewed in his study said they felt more powerful and confident after they used the inhaler, "which suggests in a tentative way that there might be some psychological benefit that they perceive."
SPREADING THE WORD
While many of these teens may know the dangers of other common forms of inhalant abuse such as huffing paint or gasoline, they haven't been warned about the harms of excessive asthma inhaler use, Dr. Howard said.
Also, parents don't have a high index of suspicion that inhalers can be abused, he added, and people - particular young children - think of prescribed agents as inherently more safe and, perhaps, acceptable to share.
Realizing the potential dangers to her students, Christine Amstutz, RN, MN, decided to take action. The supervisor of health services at the William S. Hart Union High School District, located in the northern part of Los Angeles County, wrote up an item in the school newsletter distributed to parents about asthma inhaler abuse and sharing medication. She also spoke to the school board about the issue.
"Because I knew of a few cases, there's a lot more I don't know about," she said about her inspiration to be proactive. "It's going on behind your back, just like any other drug."
In her school district, students may carry their inhaler, if both the physician and parent have provided a signed self-administration form. Students caught sharing inhalers would be suspended because of the district's zero-tolerance policy for drugs of any kind.
"All I can do is make parents and kids aware," Amstutz said. "Kids don't realize they're doing anything wrong. It's not malicious. They think they're helping. Some kids don't have a clue that they can harm another kid by letting them use an inhaler."
People are "walking a fine line" when it comes to the topic of sharing asthma medication, Dr. Boyd said.
"People can die from an asthma attack," she said. "None of us really thinks that the kid who gives his friend on the soccer field his asthma in-haler because the friend doesn't have his is really the problem. But this is where it can lead to a problem.
"Kids think it's OK to share medication. They're not educated to think twice about it. The kids are assuming all the inhalers are the same, and they're not."
This is why the asthma care community must play an active role with young patients and parents to educate them about medication safety.
"Talk about where to store it," Dr. Boyd said. "What are the problems with sharing an inhaler? Why is it that the kids are compelled to take more puffs than they need? Maybe they need something different. Much of the abuse is lack of knowledge."
Parents always should be part of the educational process, added Kathy Garrett-Szymanski, RRT, AE-C, asthma center administrator at Long Island College Hospital, New York City.
"They should learn how to use it right just to make sure their children are using it right," she said. "Beyond that, they should be aware of how much they're using or how much they should be using. Every inhaler lists the number of inhalations contained in the canister. They should know that and have a general idea of when it's going to run out."
If mom goes to the drug store on Monday and by Wednesday she needs to make another trip, something's wrong.
As for the research side of things, Dr. Howard is "absolutely astounded" that more investigators haven't followed his path and explored this topic.
"It's such a wide open area," he said. "This is going to be a major issue. It's ripe for investigation."
1. Boyd CJ, Teter CJ, McCabe SE. Pilot study of abuse of asthma inhalers by middle and high school students. J Adolesc Health. 2004;34(6):531-4.
2. Howard M. Unpublished findings.
Mike Bederka is associate editor of ADVANCE. He can be reached at firstname.lastname@example.org.
OVER-THE-COUNTER INHALERS CAN CAUSE SEVERE ADVERSE REACTIONS
Abuse of asthma inhalers and the subsequent dangers aren't limited to the prescription variety. Gross misuse of over-the-counter epinephrine asthma inhalers can cause severe adverse reactions such as cardiomyopathy and catecholamine-induced sialadenosis, according to a report from the American Medical Association published in Chest.1
A review of the spontaneous adverse reaction reports related to OTC asthma inhalers from 1975 to 1997 found 286 reactions and 13 deaths. Poison control data from 1994 to 1998 reported two deaths in association with OTC inhalers.
Limited survey data suggest that approximately 20 percent of individuals using OTC epinephrine inhalers have mild-to-moderate persistent asthma. This concerned the AMA panel because these people might avoid seeking medical care, which may ultimately lead to disease progression and increased morbidity.
However, the occasional use of these products appears to be safe and effective when used according to labeled instruction by individuals with mild, intermittent asthma, they concluded.
That doesn't mean, though, these types of inhalers have many fans in the health care community.
"It's adrenaline in aerosol form - it's crazy," said Christian J. Teter, PharmD, BCPP, assistant professor of pharmacy practice, Northeastern University School of Pharmacy, Boston, concerned by patients' easy access to them.
"People think because you get it from a pharmacy, it can't hurt you," added Kathy Garrett-Szymanski, RRT, AE-C, asthma center administrator at Long Island College Hospital, New York City. "Whether it is prescription or over-the-counter, that's not true. Every single drug has side effects."
1. Dickinson BD, Altman RD, Deitchman SD, Champion HC. Safety of over-the-counter inhalers for asthma: report of the Council on Scientific Affairs. Chest. 2000;118(2):522-6.