Emma Troyer

Professor Andaluz

English 100

April 20, 2019

Dextromethorphan Abuse and its Implications

Dextromethorphan, otherwise known as DXM, is an ingredient found in many

antitussives (cough suppressants) sold over the counter. It is recommended for patients

who are experiencing acute symptoms due to minor throat and bronchial irritation

associated with the common cold or inhaled irritants. However,

dextromethorphan-containing syrup is of particular interest, as it is often abused for its

psychosis-inducing effects. This is a practice commonly referred to as “robo-tripping” or

“megadosing.” If one is not careful, misuse can lead to brain damage, loss of

consciousness, irregular heartbeat, seizures, and sometimes even death (Lexicomp,

2019). The analysis at hand seeks to understand the chemical properties of

dextromethorphan and the risks associated with its abuse.

It is typically used to treat a dry cough, and contrary to popular belief, it is not

indicated as an expectorant used for expelling mucus. There are more than 140

different brands containing dextromethorphan that can be purchased over the counter.

They include, but are not limited to, TheraFlu, Drixoral, Benylin DM, Creomulsion,

Delsym, Hold, Tylenol Cold, Robitussin DM, Scot-Tussin, Silphen, Goodsense Cough,

Nyquill, Alka-Seltzer Plus Cold and Cough, St. Joseph Cough Suppressant, ElixSure

Cough, and Buckleys Cough (Lexicomp 2019). The drug comes in many forms,
including syrups, tablets, sprays, and lozenges, which are often flavored with sweetener

to achieve a more desirable taste for the patient.

Syrups and capsules may contain additional ingredients like acetaminophen,

guaifenesin, chlorpheniramine maleate, and/or pseudoephedrine (Schwartz 2005).

Dextromethorphan can be sold in immediate release or extended release formulations,

and the recommended immediate release formulation dosing for adults is 10 to 20

milligrams every four hours or 20 to 30 milligrams every six to eight hours.

Recommended guidelines for extended release formulations are slightly different, with

60 mg twice daily as the typical dose. However, a patient should not exceed taking 120

milligrams in 24 hours, as the ramifications can be quite dire (Lexicomp 2019).

Dextromethorphan was first marketed in the 1950s as a non-addictive alternative

to codeine, but when it quickly became a significant drug of abuse due to its

hallucinogenic effects, it was pulled from the shelves. Manufacturers decided to give the

syrups a foul taste to try and deter people from abusing it, but this negatively impacted

revenue and sales, so the practice was halted (American Addiction Centers 2018).

Fortunately, as of 2017, fourteen states have passed legislation dictating that

dextromethorphan cannot be sold to minors (Naronon 2019).

A recent survey of the National Poison Data System confirmed that incidence of

dextromethorphan abuse could be pinpointed at 15.7 cases per 1 million citizens (Linn

et al. 2014). From 1999 to 2004, a tenfold increase in dextromethorphan abuse was

reported to the California Poison Control System. 0.23 cases per 1000 calls were

identified as dextromethorphan abuse cases in 1999, while 2.15 cases per 1000 calls
were made in 2004. Sadly, 74.5% of these cases occurred amongst adolescents

ranging from ages 9 to 17 (Bryner et al. 2006). These youth often do not have the life

experience necessary to understand the full ramifications of their actions, and they often

underestimate the long-term consequences of dextromethorphan abuse.

Unfortunately, due to lax regulations for its distribution and cheap economic cost,

it is very easy for teenagers and young adults to gain access to the drug. Whether they

purchase it at the drugstore, shoplift, or purchase dextromethorphan powder online, the

drug is probably the most easily accessible hallucinogen in existence. There are even

readily available directions online for the home manufacture of dextromethorphan

powder from Coricidin HBP Cough and Cold tablets (Schwartz 2005), and countless

internet forums exist to discuss drug use and abuse. There is definitely no shortage of

opportunities for young people to be exposed to dextromethorphan, which is why it is so

critical for parents to remain heavily involved in their children’s lives.

Youth are particularly at-risk for dextromethorphan abuse, and it is essential that

parents stay well-informed about the signs that may indicate their children are abusing

the drug. Parents are advised to monitor their teens for symptoms of drowsiness,

disorientation, inability to focus, sudden rashes, memory loss, muscle twitches, stomach

spasms, confusion, labored breathing, and numb extremities. Behavioral changes such

as depression, anger, avoidance of friends and family, abandonment of former friends,

isolation, antagonism, secretive behavior, negative changes in school performance, and

behavioral issues in school may also be indicative of dextromethorphan abuse

(Narconon 2019).
When taken as directed, dextromethorphan is a helpful antitussive that can help relieve

dry or hacking coughs. It typically does not result in any significant side effects, but on

the few occasions it does, those side effects may include nausea, constipation, mild

dizziness, drowsiness, and headache (American Addiction Centers, 2018).

Dextromethorphan is often associated with dry mouth, tachycardia, and diminished

concentration ability at higher dosage levels, but ingesting very large doses can have a

dissociate effect on the user. This is referred to as “megadosing”, which is defined as

taking five to ten times the recommended dose, or approximately 1500 milligrams each

day (Schwartz 2005). To fully understand the impacts of megadosing, one must first

understand the mechanism by which dextromethorphan induces hallucinations.

Dextromethorphan is produced from a derivative of morphine; however, it is not

at opioid and exhibits a different mechanism from drugs belonging to that class.

Dextromethorphan is an antagonist for N-methyl-D-aspartate excitatory transmitters and

inhibits the release of this neurotransmitter, which is how it effectively suppresses

coughing (American Addiction Centers 2018). However, it is believed that

hallucinogenic effects may be caused by the conversion of dextromethorphan to

dextrophan, which is the primary metabolite of the drug. As a putative

N-methyl-D-aspartate receptor antagonist, it has the potential to induce phencyclidine

(PCP)-like effects in its users. Because it is metabolized by the CYP2D6 system, fast

metabolizers may have a higher susceptibility to abuse – and those fast metabolizers

represent 85% of the general American population. It also has positive effects on
seizures, pain, stroke, traumatic brain injury, depression, and methotrexate neurotoxicity

(Szekely et al. 1991).

According to Martinak et al. (2017), the psychiatric symptoms induced by

dextromethorphan overuse have been classified into four dose-dependent levels. The

first level is achieved when the user takes 1.5-2.5 mg/kg of body weight, and this is

where MDMA-like effects take place. At 2.5-7.5 mg/kg, impairment of motor, cognitive,

and perceptual functioning is akin to the synergistic effects of alcohol and cannabis use.

7.5-15 mg/kg may result in dissociation and intense hallucinations, comparable to

low-dose ketamine use. At the highest level, which is 15 mg/kg, effects similar to that of

high-dose ketamine use can be observed, including violent behaviors, elevated

temperatures, complete psychophysical dissociation, and possible death.

Note that dying from dextromethorphan toxicity itself is relatively uncommon, as the

body will induce vomiting before the user can reach the point of overdose, but it can still

occur.

Approximately 5% of Europeans have difficulty metabolizing the drug properly,

which can exponentially increase the rate at which acute toxicity levels are achieved

(Schwartz 2005). However, such high doses have resulted in many accidental deaths,

which can occur when the user believes themselves to have abilities or be present in a

reality that does not actually exist. In such a state, people are more prone to jumping

from elevated heights or driving recklessly, which accounts for the increased risk of

death.
 Additionally, many cough suppressants contain ingredients other than

dextromethorphan that are harmful when consumed in high quantities, which tends to

go unacknowledged with regard to dextromethorphan discourse. Nevertheless, it is still

important to be discussed when addressing this topic. For example, acetaminophen,

guaifenesin, and chlorpheniramine can cause permanent liver damage, seizures, and

coma if not taken correctly. Even though these effects are not directly caused by

dextromethorphan, they are still pertinent to the discussion since they are often

consumed in unhealthy quantities by cough syrup users. Furthermore, combining

substances such as marijuana, alcohol, or other drugs with dextromethorphan can lead

to slowed breathing, extremely depressed blood pressure, and reduced heart rate

(Owens 2017).

According to Martinak (2017), if the drug abuse has been occurring for extended

periods of time, it may be difficult for the user to quit. However, the addictive properties

of dextromethorphan have not been researched quite as extensively as many other

addictive drugs. Despite this, recent studies indicate that 10% of all United States

adolescents have abused cough syrup with the goal of getting high – which would mean

more teens abuse dextromethorphan than cocaine, ecstasy, or crystal

methamphetamine (Owens, 2017).

This is an astonishing figure that can no longer be overlooked in good

conscience by our society. Tolerance is a common effect of addiction, and the user will

eventually require more and more of the drug to achieve the desired effect. Oftentimes,

when the body grows accustomed to ingesting certain quantities of the drug on a
regular basis, it needs the drug in order to function smoothly. This can lead to painful

physical withdrawals, for which the user will likely need rehabilitation.

During the first week of detoxification, the user will likely experience vomiting,

muscle aches, and diarrhea. The subsequent three weeks after tend to consist of

insomnia, anxiety, night sweats, and cold intolerance. Common management of

withdrawal symptoms includes the use of short-acting benzodiazepines and low-dose

antipsychotics. In one particular patient case, only the use of olanzapine combined with

the mood-stabilizing divalproex was able to alleviate symptoms of suffering (Martinak

2017). It is very important that the user remains completely abstinent from the drug to

live a healthy lifestyle, otherwise this will be a cycle that haunts the user until they end

their abuse.

Overall, dextromethorphan abuse is a widely ignored topic, yet addressing this

issue is critical to protecting our youth, as it can have devastating long-term implications

for those who abuse it.. “Robotripping” and “megadosing” has been known to cause

seizures, brain damage, loss of consciousness, grandiose delusions, and other

physiological complications in its users. Unfortunately, adolescents are the group most

susceptible to abusing dextromethorphan, and it is imperative that more research is

done to fully understand its biological mechanisms and epidemiological implications so

that we as a society are fully equipped to protect them to the best of our ability.
 Works Cited

Bryner, Jodi K et al. “Dextromethorphan abuse in adolescence: an increasing trend:

1999-2004.” ​Archives of pediatrics & adolescent medicine​ vol. 160,12 (2006): 1217-22.

doi:10.1001/archpedi.160.12.1217

Dextromethorphan. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL.

Available at http://online.lexi.com. Accessed April 22, 2019.

Linn, Kelly A et al. “"Robo-tripping": dextromethorphan abuse and its anesthetic

implications.” ​Anesthesiology and pain medicine​ vol. 4,5 e20990. 14 Nov. 2014,

doi:10.5812/aapm.20990

Martinak, Bridgette et al. “Dextromethorphan in Cough Syrup: The Poor Man’s

​ 7(4): 59-63. 2017.

Psychosis” ​Psychopharmacol Bull. 4

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5601090/

Owens, Livia. “Dextromethorphan (DXM) – Side Effects – Risks – Abuse & Addiction.”

[Podcast]. ​Addict Help.​ 2017.

https://www.addict-help.com/drugs/dextromethorphan-dxm/

Schwartz, RH. “Adolescent abuse of dextromethorphan​.​” ​Clin Pediatr.​ 44(7) 565-568.

2005. https://www.ncbi.nlm.nih.gov/pubmed/16151560

Staff, Reviewed by Editorial. “Dextromethorphan (DXM) Abuse and Addiction:

Treatment, Symptoms, and Signs.” ​American Addiction Centers​. 2018.

americanaddictioncenters.org/dextromethorphan-dxm/abuse
Staff, Reviewed by Editorial. “Effects of Dextromethorphan Abuse.” ​Narconn.​ 2019.

americanaddictioncenters.org/dextromethorphan-dxm/abuse

Szekely JI et al. “Induction of phencyclidine-like behavior in rats by dextrophan but not

dextromethorphan.” ​Pharmcol Biochem Behav.​ 40(2): 381-386. 1991.

https://www.ncbi.nlm.nih.gov/pubmed/1805242