Dextromethorphan: Why it’s not just cough medicine
While you may not have heard of abusing Dextromethorphan or DXM, it is a serious and relatively common act. Here's what you need to know.
Today's guest bloggers are John Pitsakis, PharmD Candidate, Jefferson School of Pharmacy; Gregory Heindel, PharmD, Pediatric Pharmacy Resident at Children's Hospital of Philadelphia; and Laura Modafferi, PharmD, Emergency Room Pharmacy Resident at Hospital of the University of Pennsylvania.
"It's just cough medicine! Why do you want to see my ID?" asked a frustrated customer at the pharmacy counter. The woman was quite annoyed when asked to provide identification to purchase medication that she had been using for cold symptoms since childhood. "It's not the stuff people use to make meth, right?" she questioned. She was correct. The product was not the over-the-counter (OTC) congestion relief medication (pseudoephedrine), which is an important ingredient in manufacturing methamphetamine, but rather the cough medicine dextromethorphan (DXM). DXM can also be abused but many people are unaware of the dangers related to misuse of DXM.
While you may not have heard of abusing DXM, it is a serious and relatively common act. DXM abuse is thought to have originated with blues musicians in Texas during the 1960s and use continued to grow until the mid-2000s. Males aged 15 to 19 are most commonly associated with DXM abuse. DXM is also called Skittles, Robo, Robotripping, Poor man's PCP, Sizzurp, Agent Lemon, or DXemon Juice and has been touted as a drug of choice by popular musicians such as Three Six Mafia's song, Sipping on Some Sizzurp.
So why are people chugging distasteful cough syrups that we all tried to avoid as children? Well, there are supposedly four plateaus or "levels" of effects that DXM produces. Doses between 100 and 600 mg (a normal dose for a cough is 20-30 mg) cause mild stimulation, euphoria, hallucinations, distorted visual perceptions and loss of motor control. However, DXM abusers are often seeking the "dissociative" effect, which occurs at much higher doses (500-1500 mg).
Similar to other drugs of abuse, excessive use of DXM can have several serious consequences. Patients abusing DXM commonly present with fever, high blood pressure, shallow breathing, head spasm, and psychosis. The most serious cases can result in coma, seizures, or even death. Use of long acting DXM preparations such as Delsym can be especially dangerous because it is a higher concentration and lasting effects.
There are also other concerns with DXM abuse not related to DXM. DXM is available in cough preparations which contain other drugs, such as guaifenesin, antihistamines, and acetaminophen. Each of these drugs have their own side effects ranging from upset stomach to liver failure. The DXM and chlorpheniramine preparations (such as Coricidin Cough and Cold, known as "Triple C") specifically has been associated with more adverse effects than the other combinations. But this still doesn't cover all the dangers of DXM. In fact, some of these serious consequences can happen to people not intending to abuse DXM, even when taking normal doses.
DXM can increase levels of a hormone called serotonin. High levels of serotonin can increase the risk for developing a potentially fatal adverse reaction, called serotonin syndrome. Some symptoms of serotonin syndrome include increased heart rate, sweating, vomiting, confusion, and tremor. At normal doses and by itself, dextromethorphan has not been shown to cause serotonin syndrome, but using it in combination with other serotonin increasing medications can increase the risk of serotonin syndrome.
Case reports describe dextromethorphan used in combination with certain medications, herbal supplements, or illicit drugs leading to the development of serotonin syndrome requiring hospital intervention for treatment. Signs and symptoms of serotonin syndrome commonly develop within hours of ingesting the medications and can become life threatening if left untreated. This emphasizes the importance of discussing your OTC and prescription medications with your pharmacist or doctor.
In the above scenario, the customer's probing questions about the ID check led to a conversation about the potential safety concerns with DXM and she was greatly appreciative after the pharmacist identified a serious potential drug interaction with one of her medications. It is important to take OTC cough syrups seriously. There are many potential dangers to abusing DXM, and even potential for serious drug-drug interactions if you aren't mindful. Certainly, DXM is not, "Just a cough medicine".
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