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

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.

Also widely used are OTC diuretics, which promote urinary excretion by the kidneys, reducing water retention. They tend to be mild compared to prescription diuretics. The active ingredients in most OTC products are weak diuretics such as caffeine, pamabrom, and herbs such as buchu leaf and uva ursi. (8) When used according to instructions, they are generally safe and can be helpful for premenstrual symptoms such as bloating.

ED patients abuse OTC diuretics to reduce weight. They are not effective weight-loss agents because the weight lost by fluid excretion is transient. Side effects from over-ingestion are usually mild--nausea, vomiting, gastrointestinal upset. The greater management problem occurs when OTC diuretics are discontinued. ED patients are unhappy with the resulting reflex fluid retention, swelling, and weight gain. As such, in outpatient settings, ED patients often return to diuretic abuse. Stopping OTC diuretic use in inpatient/residential settings may prove more successful.

Finally, there is syrup of ipecac, an OTC medication that induces vomiting and is meant to be used in emergency cases of accidental poisoning. Ipecac is also abused by bulimic patients early in the illness to induce vomiting before they learn to do so without it. Ipecac is again abused later in bulimia after patients lose their gag reflex. Although ipecac abuse tends to be sporadic, long-term sporadic use is dangerous. Ipecac can build up in the body and act as a muscle toxin, resulting in prolonged weakness and damaged heart muscles. Therefore, ipecac abuse needs to be stopped immediately if healthcare professionals detect it.

Issues specific to men

One in ten ED patients is male. In men, EDs can manifest differently. Instead of weight preoccupations, men tend to focus on the purported health benefits of calorie restriction, and many wish to bulk up rather than lose weight.

Cafri and colleagues suggest that men nowadays are more focused on their appearance. (9) They indicate that a muscular, lean body ideal has developed, and express concern that some men are adopting risky behaviors to gain muscle and lose fat in pursuit of this. OTC agents such as 1-testosterone and 4-hydroxytestosterone act as steroid precursors; these substances are not covered by the federal steroid ban, according to a December 13, 2002 Join Together news summary. Among men who answered an anonymous questionnaire given to 511 American gymnasium clients, in the past three years 18% admitted to using androstenedione or other adrenal steroids, 25% used ephedrine, and 5% used anabolic steroids. (10) Abuse rates in women were much lower for these substances, at 3%, 13%, and 0%, respectively.

An April 2007 Slate article reported that a recent movement seen mainly in men looks much like anorexia, except that the dietary regimen (known as calorie restriction with optimal nutrition or CRON) is designed to promote longevity through semi-starvation. Adherents--known as CRONies--may excessively use diet supplements. They believe they will slow their metabolism and, in turn, the aging process. Even though CRONies downplay the importance of their change in appearance, many are pleased with their slim physique.

Treatment strategies

Treating OTC abuse can be challenging, especially in outpatient settings. If the abuse is deeply ingrained, inpatient/residential settings may be more appropriate. These settings provide the controlled environments necessary to limit access to OTC agents, and allow for these medications to be stopped immediately rather than tapered.

Most OTCs can be stopped fairly rapidly. Except for some transient lethargy, low mood, and weight gain, there is little consequence to stopping stimulant diet pills abruptly. This is generally true for diuretics and stimulant laxatives as well, but special considerations apply.

Mild OTC diuretics can be stopped at once. Some transient reflex fluid retention and weight gain may occur, but these can usually be managed well in inpatient/residential settings by educating and reassuring patients that fluid retention is temporary. Stimulant laxative abuse should also be stopped abruptly, but the consequences of long-term abuse are challenging. Inpatient/residential treatment might be necessary because many ED patients find the resultant constipation, weight gain, and fluid retention intolerable. This weight gain, or edema, will often trigger patients to use their drug of choice, laxative or diuretic. In addition, the weight gain/edema can trigger increased body image distortions, further intensifying the desire to "use." The medical approach includes high-fiber diets, encouraging moderate exercise appropriate to the ED, and supporting fluid intake to counter constipation. It may be necessary for a time to use bulk-forming laxatives. If constipation persists, lactulose and enemas may be used as last resorts. (3,7)

In the treatment of patients with concurrent eating disorders and chemical dependency, experience suggests that both problems should be addressed together, preferably in inpatient/residential settings. Given the intensive medical monitoring needed to address EDs, an ED facility could be more appropriate for treating dually diagnosed patients. Staff should regard OTC substance abuse much as they do any CD problem. Staff should thoroughly check patients and their belongings for drugs prior to entering the facility or after passes, conduct room searches if drug use is suspected, and honestly confront patients as necessary.

Some patients are not ready to give up ineffective behaviors. Prochaska and colleagues (11) discuss the Stages of Change model (i.e., pre-contemplation, contemplation, preparation, action, maintenance). Interventions need to be tailored to the patient's stage of change. Interventions that work in one stage may be ineffective in another.

Although 12-Step principles apply, traditional 12-Step meetings might not be appropriate for patients who have become dependent on substances such as laxatives. Instead, cognitive-behavioral therapy helps patients to understand the connection between their underlying need(s) and their behaviors.

As an example of one scenario, a normal-weight female patient has a need to feel loved by a man. She may believe, irrationally, that if she loses 20 pounds she will be more attractive to men. She discovers she can lose pounds by abusing laxatives. After a few months, she is frustrated that weight loss has ceased, so she stops the laxatives and experiences rebound edema and weight gain. In desperation, she returns to the laxatives and increases the amount taken. This becomes a vicious and potentially deadly cycle of abuse. CBT can help this woman to untangle the legitimate need for love from the irrational belief and connected ineffective behavior.

Conclusion

Many clinicians and patients do not consider OTC products to be real medicines and, therefore, do not address their use. As clinicians, we need to be aware of and ask our patients about OTC abuse. ED patients who abuse OTC substances are often ambivalent about giving up their addictions, because these addictions have become a way to organize their lives and deal with stress.

OTC abuse undermines treatment and should be addressed directly. Cognitive-behavioral therapy and Stages of Change approaches are very helpful therapeutic methods when working with these patients with co-occurring diagnoses.

Kevin R. Wandler, MD, has been Vice President of Medical Services and Medical Director at Remuda Programs for Eating Disorders for more than 12 years. He is board-certified in general psychiatry, with added qualification in addiction psychiatry, by the American Board of Psychiatry and Neurology. His e-mail address is [e-mail]. Yong B. Lee, MD, is a Staff Psychiatrist at Remuda Programs for Eating Disorders in Virginia. He is a board-certified psychiatrist specializing in psychopharmacology, mood and anxiety disorders, attention-deficit disorder, and eating disorders.

References

1. Blinder BJ, Blinder MC, Sanathara VA. Eating disorders and addiction. Psychiatric Times 1998;15:30-3.

2. Wall AD, Eberly MC, Wandler K. Substance Use and Eating Disorders. The Remuda Review: The Christian Journal of Eating Disorders 2007;6:2-9.

3. Mitchell JE, Specker S, Edmonson K. Management of substance abuse and dependence. In Garner D and Garfinkel PE (eds.). Handbook of Treatment for Eating Disorders. New York: The Guilford Press; 1997.

4. Mitchell JE, Hatsukami D, Eckert ED, et al. Characteristics of 275 patients with bulimia. Am J Psychiatry 1985;142:482-5.

5. Haller CA, Benowitz NL. Adverse cardiovascular and central nervous system events associated with dietary supplements containing ephedra alkaloids. N Engl J Med 2000;343:1833-8.

6. Tinsley JA, Watkins DD. Over-the-counter stimulants: abuse and addiction. Mayo Clin Proc 1998;73:977-82.

7. Gwirtsman HE. Laxative and emetic abuse in bulimia nervosa. In Yager J, Gwirtsman HE, Edelstein CK (eds.). Special Problems in Managing Eating Disorders. Washington, D.C.: American Psychiatric Press; 1991.

8. Roerig JL, Mitchell JE, de Zwaan M, et al. The eating disorders medicine cabinet revisited: a clinician's guide to appetite suppressants and diuretics. Int J Eat Disord 2003;33:443-57.

9. Cafri G, Thompson JK, Ricciardelli L, et al. Pursuit of the muscular ideal: physical and psychological consequences and putative risk factors. Clin Psychol Review 2005;25:215-39.

10. Kanayama G, Gruber AJ, Pope HG, et al. Over-the-counter drug use in gymnasiums: an underrecognized substance abuse problem? Psychother Psychosom 2001;70:137-40.

11. Prochaska JO, NorcrossJ, DiClemente C. Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward. New York: HarperCollins; 1995.

BY KEVIN R. WANDLER, MD, AND YONG B. LEE, MD