If you live in the United States today, you probably grew up with ads for popular over-the-counter cough and cold medicines such as Robitussin DM, NyQuil, DayQuil, Theraflu, and other syrups, lozenges, and capsules.

These over-the-counter medications contain the ingredient dextromethorphan (DXM), a medication that acts as a cough suppressant. When used as directed, DXM-containing medications can help people get through the day. Some medicines are combined with additional ingredients to assist with fever, pain, and other maladies.

How DXM Works In The Brain

Dextromethorphan is an N-methyl-D-aspartate (NMDA) antagonist. The chemical derives from methorphan, a d-isomer of codeine, so like the original opioid, dextromethorphan suppresses coughing. However, unlike codeine, DXM does not trigger the opioid receptors, so it is considered safer for consumption than even low doses of codeine, which can still cause relaxation and sedation by binding to opioid receptors and releasing serotonin and dopamine, leading to higher addiction risks.

The drug is quickly metabolized into an active molecule, dextrorphan. That molecule is then metabolized down further as it binds to brain receptors and moves through the digestive system.

At OTC doses, the drug is typically safe for short-term or as-needed use; however, there can be side effects.

  •  Drowsiness or sleepiness
  •  Dizziness
  •  Respiratory depression
  •  Nausea, vomiting, gastrointestinal discomfort, or constipation
  •  Tachycardia (irregular heartbeat)
  •  Feeling warm or feverish
  •  Trouble concentrating
  •  Dry mouth and throat

Rather than binding to opioid receptors, DXM binds to sigma ligands and the phencyclidine (PCP) channel. The active metabolite of DXM binds to high-affinity PCP sites, which may be part of the intoxication process at dangerously high doses.

When binding to brain receptors, especially at non-recommended doses, DXM releases serotonin. Even when taken at over-the-counter doses, DXM drugs are not recommended to be combined with prescription antidepressants, like monoamine oxidase inhibitors (MAOIs) and selective serotonin reuptake inhibitors (SSRIs).

This combination increases the risk of serotonin syndrome, a life-threatening condition in which too much serotonin is available in the brain. The individual can experience high fever and body temperature, fast heart rate, rapid breathing, hallucinations, and seizures.

In high doses, DXM is a dissociative anesthetic, much like ketamine. It can cause powerful psychedelic effects, which are typically dose-dependent. It is not possible to hallucinate or feel very high from a standard OTC dose, but people who abuse DXM often seek certain levels of dose-dependent effects.

There are four “plateaus” associated with specific doses of DXM, with a fifth that can quickly lead to toxicity or overdose.

  • Plateau 1: With 100 to 200 mg, you may experience mild stimulation, similar to drinking a lot of caffeine. This stimulation quickly goes away at higher doses, giving way to euphoria.
  • Plateau 2: With 200 to 400 mg of DXM, you may experience hallucinations, usually auditory, and euphoria or feeling high.
  • Plateau 3: With 300 to 600 mg of this drug, you may experience distorted visuals along with auditory hallucinations and a loss of motor control. You will have a hard time navigating reality and are in a high-risk state for falling or being in a vehicular accident.
  • Plateau 4: With 500 to 1,500 mg of dextromethorphan, you may experience dissociative sedation, much like mid-range doses of ketamine.
  • The “sigma” plateau: With 1,500 to 3,000 mg of DXM, you may experience similar effects to Plateau 4, but the experience will last much longer, and the risk of overdose is greater. Instead of dissociating from reality and feeling sedated for several hours, this feeling could last for days.

Abuse Of DXM

Not everyone uses DXM as directed. Recreational use of cough medicines containing DXM is popular.

A 2013 case study from the Clinical and Research Institute on Addictions at the University of Buffalo estimates that 1 out of 20 teenagers has experimented with DXM.

The National Institute on Drug Abuse (NIDA) says DXM is commonly abused by:

  •  Taking large doses of over-the-counter (OTC) medication that includes DXM as an ingredient
  •  Mixing DXM with alcohol
  •  Purchasing DXM powder to inject intravenously, snort, or mix with soda or alcohol

The case study also says that teens and young adults between the ages of 12 and 20 years old make up 51 percent of emergency room patients because of DXM intoxication.

In street slang, using cough medication recreationally is known as “robotripping.” Other nicknames for this practice are:

  •  Skittling
  •  Design

Nicknames for gel capsules and cough medicine that are used to get high are:

  •  Red hots
  •  Rojo
  •  Candy
  •  Skittles
  •  Red devils

Teenagers and people in other age groups may see the appeal in abusing DXM because it is legal and cheap. It may already be available in their homes and using it raises little suspicion.

Like any other substance, regular use of DXM could lead to misuse and even overdose.

How Dextromethorphan (DXM) Is Abused

The National Capital Poison Center (Poison Control) says the U.S. Food and Drug Administration approved dextromethorphan for use in over-the-counter medication in 1958. Manufacturers began including warnings on their product packaging to raise awareness about the dangers of DXM abuse.

Despite good intentions on the part of cough medicine makers, teenagers found that they could use medication with DXM to get high.

Red syrup in a small plastic cup

NIDA mentions that recreational use of DXM can cause effects such as:

  •  A spike in blood pressure
  •  Difficulty speaking
  •  Stomach pain
  •  Fatigue
  •  Loss of coordination
  •  Hyperactivity
  •  Increased sweating

Public health officials have also noticed that abuse of DXM also includes taking it with other substances.

What Happens If DXM Is Mixed With Other Things?

Various DXM-containing medications also have other ingredients. Multisymptom over-the-counter medication may contain decongestants, antihistamines, and acetaminophen. NIDA warns that taking products with acetaminophen could result in liver damage.

Even so, some people mix products that contain DXM along with other substances, including:

  • Alcohol. As described by NIDA, DXM is often combined with alcohol. Poison Control states that mixing alcohol with a product containing DXM and acetaminophen is dangerous. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) states that using alcohol with DXM-containing medicine, such as Delsym, could cause dizziness and even overdose.
  • Marijuana. The U.S. Centers for Disease Control and Prevention (CDC) warns that taking marijuana with prescription medications may change how those medications work. They do not mention DXM, but it is unwise to mix marijuana with DXM. Even on its own, a person may react differently depending on their health, genes, or the strength of the marijuana strain consumed. This implies that mixing marijuana and DXM could result in a negative experience.

NIAAA states that a person can also experience the harmful effects of alcohol and dextromethorphan even if they are taken at different times. Alcohol affects the following populations differently:

  • Women: Per NIAAA, women have less water in their bodies and may become intoxicated faster than men.
  • Senior adults: DXM abuse is rare among older people, but this group is more likely to require medications of various types. Taking alcohol along with any medication is more harmful to senior adults because age slows down a person’s metabolism. Alcohol remains in their body length, and this could make DXM use riskier for them, even when they do not intend to abuse it.

Short-Term And Long-Term Effects

Regular ingestion of DXM, or consistent misuse of products that contain DXM, leads to short-term and long-term effects.

Short-term effects of DXM include:

  • Vomiting. Cough syrups may sometimes include expectorants that cause vomiting, as mentioned by the Clinical and Research Institute on Addictions.
  • Impaired judgment. KidsHealth mentions that DXM may result in loss of motor control and even psychosis, which could result in reckless behavior.

Other short-term effects are:

  •  Redness
  •  Dizziness
  •  Itchy skin
  •  Paranoia
  •  Seizures

The long-term effects of DXM abuse still need to be studied, but DXM misuse can be fatal and result in brain damage. Overdosing on DXM is also possible.

Recognizing the signs of DXM misuse is key to finding help for a friend or loved one who may need it.

DXM Withdrawal

If dextromethorphan is consumed in doses larger than recommended over the counter, and larger doses are taken regularly to get high, your body may develop a dependence on DXM. Physical dependence means your brain requires the presence of a substance to reach chemical equilibrium feel normal.

When you do not have that chemical in your brain, you may experience withdrawal symptoms, which can be uncomfortable. Without medical intervention, withdrawal symptoms may lead to relapsing back into patterns of compulsive consumption.

Symptoms associated with dextromethorphan withdrawal reportedly include the following:

  •  Diarrhea
  •  Vomiting
  •  Stomach upset
  •  Cold shivers, or “rigors”

Anecdotal reports suggest that it takes about two days to overcome these common withdrawal symptoms without specific medical intervention. However, people who have abused large doses of DXM for a long time may suffer additional withdrawal symptoms such as:

  •  Intense cravings
  •  Flashbacks
  •  Hallucinations

These may begin three days after the last dose of dextromethorphan has been taken, so you may feel like you have stopped experiencing the more common withdrawal symptoms when the more intense ones begin. This can be very risky.

With many substances of abuse, withdrawal symptoms like cravings begin within one to three days after the last dose is consumed, but with DXM, individual reports suggest that cravings may take up to a week to begin.

Medical Supervision At A Detox Program

Drugs like opioids and alcohol have medications that can be used to ease the body off dependence on the substance while reducing the impact of withdrawal symptoms. These drugs are part of medication-assisted treatment (MAT), which allows safe tapering off certain intoxicating, addictive drugs while the individual undergoes therapy to reduce compulsive behaviors.

According to the National Institute on Drug Abuse (NIDA), there are currently no medications that can be used for MAT when it comes to dextromethorphan addiction.

This is true for the majority of over-the-counter medications, which means that the detox process may feel more intense and likely requires greater medical supervision to make it through safely.

The process of detox involves managing withdrawal symptoms, starting with a physical evaluation. A doctor, who may be your general practitioner but will more likely be an addiction specialist, will evaluate your experience of withdrawal symptoms from quitting DXM.

Mild symptoms mean you may be safe to attend an outpatient detox program and involve going in for checkups every few days or once a week while living at home. However, intense withdrawal symptoms—especially hallucinations and cardiovascular changes—may mean that you will be safer at an inpatient detox program where your vital signs can be monitored throughout the day.

The American Society of Addiction Medicine (ASAM) created a Continuum of Care to explain to clinicians and their patients how the different levels of treatment can be scaled. This scale mostly involves rehabilitation programs but can be applied to the detox process too.

  • Level 1 is outpatient services. The person will not need constant oversight and is safe to live at home.
  • Level 2 is more intensive services, involving more time spent in behavioral counseling and sometimes hospitalization for acute symptoms.
  • Level 3 is residential treatment, which focuses on behavioral therapy throughout the day while also keeping the individual away from intoxicating substances to reduce the risk of relapse.
  • Level 4 is medically managed intensive inpatient treatment, which is usually required for those who suffered from chronic diseases due to substance abuse. These individuals often need medication and care from a doctor along with behavioral therapy.

DXM Abuse: A Few Statistics

Dextromethorphan (DXM) abuse is not always taken seriously considering the necessity of cold and cough medicines. Monitoring possible signs of abuse of DXM is important.

  • Poison Control estimates about 6,000 emergency room visits are related to DXM per year. Most who visit the ER for DXM abuse are teens and young adults between the ages of 12 and 25.
  • About 33 to 50 percent of those who experiment with DXM misuse it regularly, per the Clinical and Research Institute on Addictions
  • NIDA cautions that it is possible to overdose on DXM intentionally and by accident.

On a positive note, a 2016 study published in Substance Abuse Treatment, Prevention, and Policy mentions that DXM abuse went down by 35 percent between 2010 and 2015.

Signs Of Abuse

Like any other substance, abuse of DXM is a concern, especially since teens are more likely to abuse the substance than other age groups.

As mentioned by NIDA, signs that a teen is misusing substances include:

  •  Changes in academic performance
  •  Differences in appetite
  •  Changes in sleeping patterns
  •  Hanging out with different peers
  •  Decreased interest in past hobbies
  •  Increased tension with family and friends

Similar signs in adults may be:

  •  Changes in appearance
  •  Decreased productivity at work

Exhibiting these signs might show that DXM abuse is part of a person’s life, and their misuse is serious. Thankfully, some treatments could help people who want to quit using DXM.

Treatment For Abuse

NIDA states that it is possible to treat people who misuse DXM, but currently there are no approved medications that can assist with this.

Some people may need to detox from DXM. When they attempt to stop using the drug, they may experience the following withdrawal symptoms:

  •  Problems sleeping
  •  Nausea and vomiting
  •  Cravings for DXM
  •  Goosebumps
  •  Cold flashes
  •  Bone and/or muscle pain
  •  Restless legs

NIDA mentions the following treatment approaches might be helpful for teens, but these principles can also assist adults:

Behavioral therapy

Working with a psychologist could help teenagers change their attitudes and learn the skills needed to make better choices. Therapy often teaches skills that assist in staying away from drugs and handling cravings without the use of drugs. This may include:

  • Individual therapy, such as cognitive-behavioral therapy
  • Group therapy, which may include participation in 12-step programs such as Narcotics Anonymous and attending peer counseling groups

Recovery therapy

This is often a way to continue applying skills learned in treatment for addictions. It may include:

  • Assertive Continuing Care (ACC), which involves attending group therapy
  • Recovery high schools are specially tailored for adolescents who need additional support in their recovery. They are usually separated from students at a regular high school or maybe a part of an alternative school.
  • Peer recovery support services, which involve participation in community centers for people in recovery (This allows clients to meet people who understand their path to sobriety, and it can even involve social activities that are free of drugs.)

Family-based therapies

These therapies involve the family in a teen’s recovery, including siblings and even close friends. It may involve a close look at:

  • Family communication styles that may have facilitated a teen’s previous drug use
  • The family’s overall mental health
  • Repairing relationships within the family

Treatment can also help a teenager who may be combining substances with DXM and can assist them in dealing with this as well.

Prevention

Individuals do not always intend to misuse drugs, even drugs as easy to find as medication with DXM. Parents can still take steps to prevent a teen’s use or misuse of DXM by:

  • Having honest conversations with their teens about the dangers of misusing drugs of any kind.
  • Keeping cough medicines out of the house or buying them only as needed (no stocking up).
  • Monitoring their teen’s internet use and making sure they are not looking through websites that sell DXM or provide pointers on how to misuse it.
  • Recognizing common signs of DXM use, side effects, or overdose.

Signs of a DXM Overdose

Not every DXM overdose results in a fatality, but Medline Plus reports that any of the symptoms below could mean that a person who took DXM requires medical assistance.

  •  Changes to blood pressure
  •  Twitching
  •  Palpitations (a pounding heartbeat)
  •  Sleepiness
  •  Constipation
  •  Nausea
  •  Vomiting
  •  Stomach and intestinal spasms
  •  Coma

Taking care of an overdose at home is not recommended. If someone is experiencing these signs of a possible overdose, it is imperative to get professional help right away.

Your local poison control center can answer any questions about an overdose and provide instructions.

Their services are confidential, and they can provide directions on what to do.

They can also assist even if the symptoms caused by DXM are not an emergency. In the event of an emergency, call 911.

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