“I Want A New Drug:” OTC Inhaler Abuse

As in the period of transition that followed the end of alcohol Prohibition, the medical community will need to adjust its approach to screening and evaluating patient cannabis use. The potential for use and abuse disorders are not the only risks of regular consumption; cannabinoids bind with cytochrome P450, for example–the same enzyme responsible for “Grapefruit Warnings” on many drugs that can affect bleeding risk and clotting disorders. 

Every substance we introduced into this delicate biochemical system changes our risk profile, and sometimes, not for the better. And sometimes we upset the delicate balance with new ways to misuse very old substances.

Such is the case of Propylhexedrine, sold under the brand names Benzedrex in the U.S. and Obesin in the U.K. Sharing a chemical structure extremely similar to methamphetamine–with all of the same appetite-suppressing, system-stimulating effects (and subsequent potential for abuse among determined users)–this easily obtained, inexpensive decongestant has seen rising abuse, especially in monitored situations.

The potential for and increasing incidence of propylhexedrine abuse was the subject of a presentation at the American Academy of Addiction Psychiatry (AAAP) 30th Annual Meeting.

Researchers undertook a review of the literature after two patients under court-ordered drug screening presented at the same medical center with propylhexedrine toxicity.

Propylhexedrine, sold under the brand names Benzedrex and Obesin (as well as others) is chemically extremely similar to methamphetamine–with all of the same appetite-suppressing, system-stimulating effects and subsequent potential for abuse.

Developed in the 1940s as an alternative to inhaled amphetamines (to stem a contemporary wave of amphetamine deaths and abuse in the post-war era), propylhexadrine has been used for more than 70 years. In that time the medical profession has paid little attention to the drug, which was regarded as a safe, non-addictive substance with little abuse potential.

Enter the era of the internet and those “scientists in their basement.” 

Today, a cursory Google search of the drug’s name is as likely to lead users to Reddit and YouTube as it is to Medscape or Drug.com. “How To” videos demonstrate methods of extraction, concentration, and administration. The horse is out of the proverbial barn–and that is why, at the end of the day, the physician-research team reviewing these inhalers recommend taking another look at whether the drug should be more tightly controlled than it currently is.

There is little hope of containing the outbreak of knowledge regarding how to abuse the substance. And while these products remain readily available, vigilance in health care settings is the next line of defense.

The Risks of Propylhexedrine Misuse

The research team presenting its findings on OTC inhaler abuse reviewed signs and symptoms culled from a review of English-language medical literature going back to 1970. The first reported published abuse case occurred that year. 

The first death associated with polyhexidrine abuse was reported in the literature in 1974, and in 2011, the first death reported in presence of polypharmacy (several other substances, including acetaminophen, morphine, promethazine, and kratom–an herbal preparation that, like cannabis, is legal in some states and municipalities and restricted in others).

Those who have injected, smoked, or insufflated the extracted substance may present with myriad symptoms:

  • Stimulant-induced psychosis:
    • Paranoia
    • Delusions
    • Agitation
  • Tachycardia
  • Hypertension
  • Cardiac arrhythmias

As patient advocates, health educators, and care providers, one of our most critical jobs is to ensure we always take a complete medication inventory–including information about OTC and supplements–always in a caring, compassionate, and nonjudgmental communication style. (Patients who do not trust providers to accept a full and accurate accounting of their current medications may not report the full array or extent of their use. This, in turn, can lead to complications and interactions with prescribed pharmaceuticals).

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