Dextromethorphan (DXM) is a widely available cough suppressant medication that is a major ingredient in more than 100 cough and cold medications sold over-the-counter (OTC) without a prescription.
Recreational users take doses exceeding 10 times the normal in order to achieve a high similar to that of ketamine or PCP. As the drug is easily and legally obtained from grocery stores, pharmacies and Internet sources, typical users are teens.
At recommended doses, DXM is quite safe. However, because abusers far exceed therapeutic doses and often take it with other substances, DXM abuse can lead to serious unwanted effects, including death.
Fast facts on DXM
- In 1956, the FDA approved DXM for use as a cough suppressant
- DXM abuse was recognized as early as the 1960s when it was the sole active ingredient in Romilar, an OTC product that was voluntarily removed from the market because of abuse
- Teens who abuse cough medicine are not after the alcohol content but the DXM
- Adolescents have been abusing OTC DXM products since the late 1990s, mainly because of the drug’s accessibility and false perceptions of safety
- A main source of prescription and OTC drugs for teenagers is the family medicine cabinet
- Around 1 in 11 teens have admitted to getting high on cough medicine
- DXM abuse causes a pleasurable increase in the amount of dopamine in the brain’s reward pathway
- Illicit use of DXM is referred to on the street as “robo-tripping,” “skittling,” and “tussin toss”
- Abuse of DXM is fueled by extensive “how to” abuse information on various websites
- The recreational use potential of DXM has traditionally not been well understood by either drug users or physicians.
DXM is a dissociative (disconnected from reality) anesthetic, synthetically produced and chemically related to codeine.
DXM suppresses the cough reflex by a direct action on the cough center in the medulla of the brain. It is the most commonly used cough suppressant and is in more than 120 cough and cold products available over the counter.
The typical adult dose is 15 or 30 mg taken three to four times daily. An individual seeking DXM intoxication will take 250 to 1,500 mg in one dose, which in some cough preparations is one entire package.
At these high doses, DXM will cause a hallucinogenic, trance-like euphoria, similar to that of PCP or ketamine. Typically, the intoxication from the DXM resolves within 6-8 hours.
Most DXM abusers ingest the drug orally as a liquid syrup, capsule or pill. Other forms can be snorted and even injected. Pure DXM powder can be bought online and is often mixed with alcohol to mask its taste. DXM is often taken in combination with other drugs such as marijuana and ecstasy.
Alternative names for DXM
Street names for DXM include:
- Poor man’s PCP
- Red devils
- Triple C
- Vitamin D.
Slang terms for DXM intoxication include:
Commercial names for DXM include Robitussin and Delsym. Common combination products containing DXM include Coricidin HBP Cough & Cold Tablets, TheraFlu, Triaminic, Robitussin DM and NyQuil Nighttime Cold Medicine, as well as many other brand and generic names.
The extent of DXM abuse is difficult to determine. The primary abusers of the drug are likely adolescents, young adults and those with a pre-existing substance use disorder. According to the 2015 Monitoring the Future study, 4.6% of 12th graders reported recreational use of cough syrups in the past year.
The National Poison Data System quantified the incidence of dextromethorphan abuse in the United States as 15.7 cases per 1 million citizens.
When the recommended dose is exceeded, side effects of DXM may include:
- Nausea and vomiting
- Hot flash
- Fast heartbeat
- Stomach pain
- Altered mental status
- Delayed response times
- Slurred speech
- Vivid auditory and visual hallucinations.
Abusers describe the DXM experience as occurring on four different plateaus; it is necessary to ingest increasing amounts of DXM to reach the next plateau.
- First plateau: mild stimulation
- Second plateau: intoxication, slurred speech, mild hallucinations
- Third plateau: an altered state of consciousness with impaired vision and other senses
- Fourth plateau: euphoria, mind and body dissociation or an “out-of-body” experience with a disconnect from all senses.
Abuse of combination DXM products also results in health complications from the other active ingredients; these include increased blood pressure from pseudoephedrine, liver damage from acetaminophen toxicity and other cardiovascular effects from chlorpheniramine.
The use of high doses of DXM in combination with alcohol or other drugs is particularly dangerous and deaths have been reported. Chronic abuse of the drug has also been associated with psychosis.
Dependency and addiction
DXM can be habit-forming to chronic recreational users, with abuse potentially progressing to addiction. Consultation with an addiction treatment provider or facility is recommended for anyone abusing DXM.
Pharmacist advises consumers to learn about the active ingredients in cough and cold medications to ensure proper treatment of symptoms.
With tougher laws restricting access to alcohol, tobacco and illicit drugs, a rising trend among adolescents is to raid their parents’ medicine cabinet in an attempt to get high.
Dextromethorphan (DXM) is widely available to the general public as a common ingredient in over-the-counter cough and cold formulations.
When taken in recommended doses for the treatment of cough, DXM is safe with rare side effects. When abused through the ingestion of extremely high doses, DXM causes hallucinations and dissociative effects, and can even result in death from the depression of the central nervous system.
Additionally, subsequent overdose of other medications present in DXM cough and cold products can have its own serious harmful effects to the recreational user. Parents, teens, medical providers and the general public need to be aware of the danger associated with dextromethorphan (DXM) abuse.