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Dextromethorphan (DXM) Abuse and Addiction: Treatment, Symptoms, and Signs

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Editorial Staff
Editorial Staff
The editorial staff of American Addiction Centers is made up of credentialed clinical reviewers with hands-on experience in or expert knowledge of addiction treatment.

A bottle of cold medicine poured into a spoon

Dextromethorphan (DXM) is an antitussive, or cough-suppressing, medication that is available in over 100 different over-the-counter products. Its intended use is to control coughing associated with allergies or illnesses, such as the flu, the common cold, bronchitis, and other lung disorders. It comes in a number of different forms, including chewable tablets, lozenges, syrups, capsules, and even dissolvable strips to be placed under the tongue.

Medications that contain DXM include a number of familiar medications, such as Robitussin, NyQuil, Vicks Formula 44, etc. Street names for the drug include DXM, skittles, red devil, Robo, cousin, triple C, and a number of others. Some users commonly refer to abuse of this drug as Robo- tripping in reference to its being consumed in cough syrups (the term Robo being taken from the cough medicine Robitussin).

The drug has an interesting history, as it was released in the 1950s and became a significant drug of abuse that was eventually removed from the market. Later, manufacturers began to redistribute the drug in a formulation that had a significant unpleasant taste in an effort to curb abuse of the drug; however, sales were poor, and manufacturers began making it taste better. This opened the door for the drug to become a significant drug of abuse again, mostly with younger people. Because dextromethorphan is not a controlled substance and can be purchased in a number of over-the-counter products, its potential abuse is even more problematic.

The Mechanism of Action of DXM

DXM is actually produced from a derivative of morphine, but it is not an opiate and has a different mechanism of action from opiate drugs like Vicodin, OxyContin, heroin, morphine, etc. DXM has an affinity for receptors in the brain that are specialized for the excitatory neurotransmitter NDMA (N-methyl-D-aspartate). It is an antagonist for NDMA, meaning it inhibits the actions and release of NDMA, and this action accounts for its efficacy in suppressing the coughing reflex.

When taken as directed, the drug actually has very few side effects that include some potential for nausea, stomach cramps, constipation, mild dizziness or drowsiness, and mild headache. When taken in amounts far beyond its recommended dosages or at frequent intervals at significantly less than four hours apart, the drug has a number of different effects, depending on the dosage.

The Effects of DXM

The effects associated with taking any drug or medication will vary by the dosage or amount takes, and DXM is no exception this case. The recommended safe dosages for the use of DXM vary between 15 mg and 30 mg taken within a four-hour period. Taking the medication in this dosage and at these recommended time periods will not result in any significant effects, and the antitussive effects will typically last throughout the timespan associated with this recommended use. Of course, individuals who abuse the drug will not adhere to this recommended schedule.

The Drug Enforcement Administration (DEA) reports that there are four levels or plateaus of abuse that occur with DXM. In its most recent release of its analysis of the effects of DXM abuse, the DEA listed DXM as a “drug of concern.” The four plateaus of abuse listed by the DEA include:

  • The first plateau: The most basic level of abuse occurs when individuals take between 100 mg and 200 mg. The DEA reports that dosages at this level result in feelings of stimulation.
  • The second plateau: The next plateau occurs when individuals take dosages between 200 mg and 400 mg. The most common effects of using the drug in this dosage range are visual hallucinations and euphoria.
  • The third plateau: The third plateau occurs at dosage levels between 300 mg and 600 mg. Individuals taking DXM at this level will experience hallucinations, euphoria, significant perceptual distortions of objects in the visual field, and significantly impaired motor functioning and coordination.
  • The fourth plateau: The effects at this plateau occur in individuals who take more than 600 mg of DXM. The effects include extreme sedation, hallucinations, and dissociative effects. Dissociative effects occur in individuals who have experiences where they feel that they are leaving their body or that things around them are not real.

Extremely high doses of DXM have been known to be potentially dangerous as a result of extreme sedation, extremely suppressed breathing rates, and the potential to develop a heart attack. Individuals who overdose on DXM are often given the opiate antagonist naloxone, which appears to have some utility for reducing the effects of DXM overdose.

In addition, individuals who use DXM in high doses are at risk for harm due to poor judgment, impulsive behavior, or as a result of the perceptual disturbances that occur with the drug. For instance, an individual driving a car under the influence of a heavy dose of DXM would be more likely to get in an accident as a result of visual distortions that interfere with the person’s ability to drive. The DEA reports a number of serious accidents due to younger individuals being under the influence of DXM.

The varying effects of DXM that occur by dosage indicate that the effects of DXM are similar to dissociative hallucinogenic drugs like ketamine and phencyclidine (PCP). These drugs are recognized as extremely dangerous drugs of abuse, and in high doses, DXM appears to produce similar effects and carry similar dangers.

The National Institute on Drug Abuse (NIDA) reports that chronic use and abuse of DXM can also result in:
  • An excess buildup of acid in the body fluids
  • Liver damage when DXM is consumed in medications that also contained acetaminophen
  • Damage to the brain and other organs as a result of decreased oxygen to the brain (hypoxia)
  • Respiratory issues associated with chronically decreased breathing rates
  • The development of a substance use disorder

The Substance Abuse and Mental Health Services Administration (SAMHSA), the DEA, and NIDA all report that while repetitive use of substances containing DXM can lead to significant tolerance for the drug, there is no reliable evidence indicating that individuals who chronically use or abuse DXM develop withdrawal syndromes. Based on the current evidence, it does not appear that individuals develop physical dependence on DXM. Individuals who repeatedly use substances for nonmedicinal purposes and suffer negative ramifications as a result of their drug use qualify for a potential diagnosis of a substance use disorder (the current clinical term to identify both substance abuse and addiction).

Statistics on DXM Abuse

The latest data available from SAMHSA indicates an increasing trend for abuse of antitussive agents for the period of 2004-2011.

The estimates of emergency room visits/admissions for these years are depicted below:
  • In 2004, there were 2,420 ER visits.
  • In 2005, there were 2,570 ER visits.
  • In 2006, there were 3,174 ER visits.
  • In 2007, there were 3,074 ER visits.
  • In 2008, there were 3,580 ER visits.
  • In 2009, there were 3,911 ER visits.
  • In 2010, there were 4,140 ER visits.
  • In 2011, there were 4,449 ER visits.

Again, the results indicate a general increasing trend over this time period. SAMHSA and the DEA report that the abuse of DXM can occur across all age groups, but it is primarily focused in younger individuals between the ages of 12 and 26. In addition, SAMHSA reports that younger females between the ages of 12 and 17 may be slightly more likely than younger males in the same age bracket to abuse these medications; however, younger males over the age of 18 are more likely than females in the same age bracket to abuse the drugs.

Recognizing Signs of DXM Abuse and Getting Help

According to NIDA, individuals who abuse DXM often take it in combination with alcohol, cannabis products, central nervous system depressants like narcotic medications or benzodiazepines, and stimulant medications. Of course, this can result in a complicated situation as polysubstance abuse can typically present with a number of mixed effects and very serious complications that result from combining different drugs.

Combining what is known about the abuse of DXM with the diagnostic criteria from the American Psychiatric Association (APA) for substance use disorders, some of the signs that may be present in an individual who is abusing DXM include the following:
  • Repetitive use of DXM for non-medicinal purposes
  • Frequent intense urges to use DXM, which can be triggered by stressful events, feeling happy, a desire to escape, a desire to socialize, etc.
  • Using DXM in situations or ways that are significantly dangerous, such as taking large amounts of the drug, mixing it with other drugs, using it while operating machinery, etc.
  • Spending significant amounts of time using DXM, recovering from its use, or trying to get it
  • Developing significant tolerance to DXM (DXM is not normally designed to be used for medicinal purposes for lengthy periods of time; thus, the development of tolerance suggests an abuse issue.)
  • Being unable to control or cut down on use of DXM even if one wishes to do so
  • Feeling as if one is leaving their body or that things are not real while displaying issues with walking or coordination
  • Seeming relatively hyperactive and presenting with visual hallucinations
  • Appearing somewhat sedated and having difficulty seeing certain obvious aspects of the environment.
  • Appearing intoxicated without the smell of alcohol

Because individuals who abuse DXM are often younger and may also be abusing other drugs in conjunction with DXM, whenever one is concerned that someone is abusing this drug, they should consult with a licensed mental health professional regarding the appropriate action to take. In some instances, attempting to put together a formal intervention may be appropriate. Loved ones can contact an organization like the Association of Intervention Specialists for professional advice on how to do this. An intervention occurs when concerned friends and family members of an individual who may have a substance abuse issue get together and attempt to convince that individual that they need treatment.

Treatment for DXM abuse will consist of a number of different components, such as initial inpatient admission, medically assisted treatments (e.g., medications for various symptoms), substance use disorder therapy (the foundation of treatment for any type of substance abuse issue), and participation in some form of social support. Some individuals will need additional treatments for co-occurring disorders and special interventions for specific needs, such as tutoring, job training, occupational therapy, speech therapy, etc.

Last Updated on June 17, 2019
Editorial Staff
Editorial Staff
The editorial staff of American Addiction Centers is made up of credentialed clinical reviewers with hands-on experience in or expert knowledge of addiction treatment.
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