What are eating disorder patients taking? Clinicians need to recognize over-the-counter drug use in clients with eating disorders

Addiction Professional, Sept-Oct, 2007 by Kevin R. Wandler, Yong B. Lee

Americans purchase over-the-counter medications to treat an amazing array of problems: colds, diarrhea, headaches, even baldness. Americans also purchase a range of herbal preparations that purportedly slow aging, increase attention, improve sexual potency, and offer emotional balance. Many eating disorder patients abuse these OTC substances, sometimes with life-threatening consequences.

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For millions of Americans, an ED has become a way of life, a way to organize their existence. Chemical dependency also can become an all-encompassing, maladaptive way of life. Eating disorders and chemical dependency often co-occur. Blinder and colleagues in a 1998 study reported a 26% co-occurrence. (1) At our program, Remuda Programs for Eating Disorders, where patients have high acuity levels, the rate of co-occurrence is 40%. (2)

ED patients abuse the usual suspects: nicotine, alcohol, marijuana, cocaine, and amphetamines. We also see some abuse of opiates, hallucinogens, solvents, and so-called designer drugs such as Ecstasy. But we also encounter a third group of abused substances--OTC medications. Healthcare providers often overlook OTC substances. As such, their use and misuse can continue for a prolonged time, occasionally with disastrous health consequences. If the clinician does not ask, the patient often does not tell.

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In ED patients, OTC use is widespread. Mitchell and colleagues in a 1997 study indicate that the most commonly abused substances in ED patients are OTC laxatives; they cite prevalence data ranging from 18% to 75%. (3) In research on 275 bulimic outpatients, 20% reported daily laxative use to control weight and 61% had used laxatives at some point during their illness. (4) At Remuda, more than half the patients reported using one or more OTC products to control weight. Specifically, 43% of adults and 25% of adolescents reported using laxatives; 28% of adults and 16% of adolescents used appetite suppressants.

It is important to note that some ED patients also abuse prescription medications, including prescription diet pills, diuretics, and laxatives. Anabolic steroids, banned in the United States, are smuggled into the country for illegal use. Even prescribed veterinary drugs have been diverted for abuse. Although banned by the World Anti-Doping Code for athletes both in and out of competition, the animal stimulant clenbuterol is abused as a diet drug by ED patients.

Commonly used medications

Most OTC diet pills contain the stimulants ephedrine, pseudoephedrine, and phenylpropolamine. Because phenylpropolamine has been linked to increased stroke risk, the Food and Drug Administration in 2000 issued a health advisory warning regarding phenylpropolamine and removed it from all OTC products. Ephedrine and pseudoephedrine remain readily available in OTC diet pills, decongestants, and energy boosters, despite growing evidence linking these products to death, heart attacks, stroke, seizures, and psychiatric emergencies including psychosis and mania.' (5)

Ephedrine enhances the release of norepinephrine from neurons in the sympathetic nervous system. By doing so, it can raise blood pressure, speed up metabolism, suppress hunger, and elevate mood. Ephedrine is thus abused as both a diet pill and a stimulant.

Tinsley and Watkins cite a growing body of literature attesting to the abuse and dependence potential of ephedrine products. (6) Although ephedrine's usual recommended maximum dose is 120mg, the mean daily dose among five of the patients they studied was 1,450mg. Two of these patients had EDs. One suffered a submyocardial infarction resulting from ephedrine abuse.

Other widely used OTC agents include laxatives, which promote bowel movement through the large intestine. ED patients tend to use stimulant-type laxatives, which trigger copious, watery diarrhea. This results in subjective feelings of weight loss, helping ED patients regain a sense of control, especially following binge episodes. (3,7) Commonly used stimulating laxatives contain the active ingredient phenolphthalein. ED patients use these laxatives excessively. At Remuda we have seen patients who have been taking more than 100 of these laxatives a day.

Although these laxatives are used by ED patients for weight loss, they are ineffective for this purpose. By the time food reaches the large intestine, most calories have been absorbed. Transient weight loss is primarily from fluid lost in diarrhea.

The copious, watery diarrhea resulting from laxative abuse can have serious medical consequences. Patients can become severely dehydrated and lose electrolytes, such as potassium. The brain then triggers secondary hyperaldosteronism (increased secretion of aldosterone by the adrenal gland) to compensate; once the laxatives are stopped, this in turn can lead to reflex fluid retention with peripheral edema, a sense of feeling bloated, and weight gain. Chronic abuse of stimulant-type laxatives can result in permanent damage to the large intestine, leading to extreme constipation, fatty stools, malabsorption problems, lethargic colon, and even death.