What Are The Side Effects of Mixing DXM & Alcohol?

What is DXM?

DXM (dextromethorphan) is a common antitussive medication that is a component of many cough and cold medicines such as Vicks Formula 44, Nyquil, Robitussin, and over 100 other formulations.¹
DXM has been available since the 1950s, though it was once removed from the market due to its potential for abuse. The drug was brought back in less palatable forms because of its usefulness as a cough suppressant. Over time, the drug has found its way into many different types of over-the-counter medications.

DXM is a synthetic derivative of morphine that inhibits the release and action of the excitatory neurotransmitter N-methyl-D-aspartate (NMDA), an action that helps to suppress the cough reflex. The drug is not controlled substance; however, the United States Drug Enforcement Administration (DEA) does list it as a drug of concern.

According to the available data from the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute on Drug Abuse (NIDA), the abuse of DXM typically occurs in younger individuals.² Abuse may be more prevalent in young females under the age of 18 and in males between the ages of 18 and 26 years old.

Data collected by SAMHSA indicates that emergency room visits as a result of abusing medications that contain DXM rose between 2004 through 2011 but remained relatively minor in comparison to the abuse of other drugs. Younger individuals often believe that because a specific medication is available over the counter, it is safe to use in any amount or in any manner. Although DXM abuse is not as popular as abuse of other substances, it can potentially be avoided by educating young people regarding the risks involved.

Alcohol abuse is a major issue in the United States, according to NIDA and SAMHSA. Over two-thirds of all individuals in treatment for a substance use disorder either have an alcohol use disorder as their primary substance use disorder or abuse alcohol in conjunction with other substances. In addition, over-the-counter cough medicines typically contain some amount of alcohol. For instance, Vicks Formula 44 contains 10 percent alcohol (20 proof) and various forms of Robitussin are 3.5-20 percent alcohol. Nyquil contains 25 percent alcohol.

Based on data collected in the past, SAMHSA states that among individuals 12-25 years old who report abusing an over-the-counter cough or cold medicine, Nyquil is the most commonly abused.³ Data collected by SAMHSA regarding emergency room admissions as a result of use of over-the-counter cough medicines indicates that in approximately 41 percent of these cases, individuals also reported using alcohol in conjunction with the over-the-counter cough medicine. Since drinking alcohol with over-the-counter cough and cold medications involves combining similar substances, the overall amount of alcohol consumed is increased.

Mixing Alcohol and DXM

Both alcohol and DXM are central nervous system depressants, meaning they decrease the activity of the neurons of the brain and spinal cord. Taking two central nervous system depressants together enhances their actions, potential side effects, and potential dangers, often far more significantly than using either alone.

It is impossible to separate the “purely physical effects” from the “purely mental effects” associated with any medicine, drug, or other substance. The effects of any substance occur as a result of an interaction between the physiology that is associated with the drug’s breakdown and assimilation, and the cognitive and emotional effects that interact with the physical process of using the substance. When substances are combined, these interactions become even more complex. The notion that ingesting any substance can produce “purely physical effects” or “purely mental effects” is a misconception, as these categories do not exist in the real world. All behaviors, reactions, and so-called physical states represent a combination of physical processes and cognitive or emotional mechanisms even if individuals are not overtly aware of their cognitive or emotional ramifications.

The DEA reports that the effects of abusing DXM vary significantly by the amount of the drug taken.⁴ At the recommended dosages, which are typically 15-30 mg every four hours, there are few minor side effects and very few common detrimental effects except for rare allergic reactions. When individuals use DXM in excess of its prescribed dosages, numerous varied types of effects can occur, depending on the dosage.

• Taking 100-200 mg of DXM often results in the sensation of mild to moderate stimulation. Taking this level of the drug along with additional alcohol would result in the feelings of stimulation being canceled out or suppressed by the central nervous system depressant effects of alcohol. This would result in more significant feelings of sedation and lethargy.
• Taking between 200-400 mg of DXM results in individuals experiencing hallucinations, most often visual hallucinations. Using this amount of DXM with a significant amount of alcohol would most likely exacerbate the hallucinations and could result in extreme psychosis.
• Taking 300-600 mg of DXM results in lethargy, sedation, and significantly impaired motor coordination and response times. Using this amount of DXM with additional alcohol would result in more severe sedation, extreme difficulties with motor coordination, extremely slurred speech, a potential loss of reality, delusional behaviors, and potential unconsciousness.
• Using more than 600 mg of DXM typically results in extreme sedation and dissociative effects, such as feeling as if one is leaving one’s body or as if things are not real. Taking this amount of DXM with alcohol would most likely produce severe lethargy, disorientation, and potential unconsciousness or coma that could result in serious damage to the brain or even death as a result of respiratory suppression.

The potential interaction between DXM and alcohol, of course, depends on the amounts of the drugs taken. As one takes higher amounts of the DXM, even a very small amount of alcohol could provide a significant interaction. Combining DXM with alcohol can also result in a number of other potential effects that include:

• Extreme nausea and prolonged periods of vomiting even with low doses of DXM
• Hot flashes, hypertension, accelerated heart rate, dizziness, and agitation
• Increased body temperature and blood pressure
• Extreme issues with anxiety and even panic attacks, potentially related to the dissociation and impaired judgment that can occur from DXM use, such that an individual begins to feel as if things are not real, as if they are leaving their body, and does not have the rational capacity to either understand their situation or logically interpret what is happening to them
• Potentially fatal seizures

NIDA lists a number of potential long-term problems associated with chronic abuse of DXM. These potential problems will only be exacerbated if DXM is chronically abused with alcohol. These serious potential long-term effects include:

• Potential liver damage
• Potential neurological damage as a result of respiratory suppression and hypoxia (reduced oxygen to organs and tissues)
• The development of numerous potential respiratory problems associated with chronic respiratory suppression
• Excess amounts of acid in the body
• Tolerance to both DXM and alcohol
• Physical dependence on alcohol
• The development of a substance use disorder or polysubstance use disorder

None of the above effects are either “purely physical” or “purely mental.” For instance, liver damage will often result in cognitive issues, such as confusion, issues with memory, and even delirium due to metabolic issues. Neurological damage can result in issues with simple or complex movements that can lead to accidents and other potential injuries.

Most of the data supplied by the DEA, NIDA, and SAMHSA suggest that even though chronic use of DXM is associated with the development of tolerance to the drug, physical dependence on DXM most likely does not occur. Nonetheless, individuals who chronically misuse or abuse any drug may develop a number of emotional attachments to using the drug to help them cope with stress, and when they discontinue the drug, this may result in a number of psychological and/or emotional stressors. Thus, chronic use of these drugs in combination can potentially result in very complicated issues associated with the development of a polysubstance use disorder. Because even moderate use of alcohol for prolonged periods of time can result in a severe alcohol withdrawal syndrome that can be potentially fatal due to the development of seizures, anyone who has repeatedly used alcohol and DXM together should consult with a licensed medical professional before they discontinue use of these drugs.

Addiction Treatment

DXM is an over-the-counter cough suppressant found in over a hundred different medications. Its abuse primarily occurs in younger individuals. Alcohol is a primary drug of abuse over all ages, and its abuse is a significant problem in the United States.

Using DXM and alcohol in combination represents a dangerous and potentially fatal practice. Because both drugs are central nervous system depressants, using them in combination enhances both their effects and can lead to numerous potentially serious conditions. The potential dangers of using these drugs in combination are significantly exacerbated when one uses DXM or alcohol at higher doses. Individuals who regularly abuse these drugs should seek professional help.

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Sources

1. Griffith , H. W. (2017). Complete Guide to Prescription & Nonprescription Drugs 2016-2017. 
2. National Institute on Drug Abuse Abuse. (2017). Over-the-Counter Medicines DrugFacts.
3. Substance Abuse and Mental Health Services Administration. (2021). Alcohol, Tobacco, and Other Drugs.
4. Connecticut State. (2021). Department of Children and Families.