Dextromethorphan Abuse

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

Dextromethorphan (DXM) was approvedby the FDA in 1954 as a safeand effective, nonaddictive cough suppressantwhen used appropriately. Itis available in various forms, includingliquid, capsule, liquid gelatin capsule,lozenge, and tablet. Unfortunately, thiscommonly used cough suppressant,used by millions of individuals for coughrelief, is often abused by teens becauseof its phencyclidine-like euphoric effect,and the abuse of this agent also may beassociated with psychosis and mania.¹The abuse of DXM can cause seriousadverse events, such as brain damage,seizure, loss of consciousness, irregularheartbeat, and even death.²

In 2005, the FDA issued a warningregarding DXM abuse to address thisserious issue and increase awarenessabout this growing trend.² This warningwas in response to reported deathsamong teens that may have been relatedto the use of raw DXM purchasedover the Internet.^2,3 Currently >100 OTCcough and cold products containingDXM are available, either as a single-entityproduct or in combination withother active ingredients. Many manufacturersof cough and cold products containingDXM have included warningsand information on their product Websites to increase awareness about thedangers of DXM abuse.

According to a 2006 survey conductedby the National Survey on Drug Useand Health (NSDUH), an estimated 3.¹million individuals aged 12 to 25 haveused a nonprescription cough and coldmedication to get high.⁴ In addition,young women between the ages of 12and 17 were more likely than young menof the same age group to misuse a nonprescriptioncough and cold product;men aged 18 to 25 were more likely tomisuse these products when comparedwith women in this age group, however.4 Furthermore, statistics from thePartnership for a Drug-Free Americareport that an estimated 10% of teenagersintentionally take excessive doses ofDXM to get high.³

Awareness Among Parents

Increased awareness is needed to combatthis growing trend. According to arecent survey by the Community Anti-Drug Coalitions of America (CADCA)and the Consumer Healthcare ProductsAssociation (CHPA), only 8% of parentssurveyed knew about cough medicineabuse, and 75% of these parentsnever talked to their teenagers aboutcough medicine abuse.⁵ Results fromanother study showed that only 45% ofteens believe that cough syrup abuseis risky.⁵

According to the CHPA, teens abuseDXM by ingesting large doses of OTCproducts containing DXM or by purchasingthe raw form of DXM from theInternet and mixing this raw form withalcohol or other illegal drugs.⁶ Since2002, the CHPA has been dedicated toeducating pharmacists, other healthcare professionals, retailers, parents,educators, and teens about the dangersof OTC cough medicine abuse. Lastfall, the US House of Representativespassed HR 970, the DextromethorphanDistribution Act of 2007. This legislationwould prohibit the distributionof raw DXM to any person other than FDA-registered drugmanufacturers.⁶

It is important for parents and caregivers to familiarizethemselves with the slang used for DXM. According to the USSubstance Abuse and Mental Health Services Administration,slang names for DXM include "C-C-C (triple C), Dex, DM, RedDevils, Drex, Robo, Skittles, Velvet, and Vitamin D."^5,7 DXMabuse may be referred to as "dexing, robodosing, robofizzing,and robotripping."^5,7

For more information on dextromethorphan please visit the following Web sites:

• www.doseofprevention.org/tools Healthcare.html
• www.chpa-info.org
• www.StopMedicineAbuse.org
• www.fivemoms.com
• www.cadca.org
• www.dareamerica.org/home/default.asp

The normal dose of DXM is 15 to 30 mg; mind-alteringeffects can occur at doses as low as 100 mg; however, manyusers consume enough pills or syrup to equal 240 to 360 mg.⁵Some individuals consume as much as 600 mg of DXM.

Depending upon the dose of DXM taken, the effects experiencedmay vary, and abuse of this agent may create bothdepressant and hallucinogenic effects.^1,5 Users report variousadverse effects, including impaired judgment and mentalperformance, loss of coordination, slurred speech, nausea,dizziness, dissociation, and hallucinations.⁵ In addition, otheradverse events reported following high doses of DXM includetachycardia, hypertension, agitation, ataxia, and psychosis.⁸

Knowing the Signs

In 2006, the CHPA and the Partnership for a Drug-FreeAmerica launched a national media campaign to increaseawareness and educateboth parents andteenagers about thedangers of prescriptionand OTC drugabuse. Groups such asthe CHPA also provideeducational resourcesfor pharmacists andother health care professionals,as well asresources that can beused to assist patientsin understanding thedangers associatedwith DXM abuse.

It is important thatparents and caregiverseducate themselves and their children about the growingtrend of DXM abuse. Parents should be familiar with the warningsigns. Examples include the presence of empty cough andcold medicine bottles or boxes, declining grades, changes indisposition, loss of interest in hobbies, or medicinal smells onthe teen or in the bedroom.³ Parents also should be aware ofthe slang terms associated with DXM abuse and be encouragedto have open discussions with their children about thisform of abuse, as well as drug abuse in general.

References

• Tietze, Karen. Cough. In: Berardi R, Newton G, McDermoot JH, et al, eds. Handbook of Nonprescription Drugs. 15th ed. Washington, DC: American Pharmacists Association; 2006:232..
• FDA Warns Against Abuse of Dextromethorphan (DXM). FDA Web site. www.fda.gov/bbs/topics/ANSWERS/2005/ANS01360.html.
• FAQS About Dextromethorphan. Consumer Healthcare Products Association Web site. www.chpa-info.org/content.aspx?id=105&pid=93&cc=4#5.
• National Survey on Drug Use and Health. Misuse of Over-the-Counter Cough and Cold Medications among Persons Aged 12 to 25. Washington, DC: US Substance Abuse and Mental Health Administration; January 10, 2008. www.oas.samhsa.gov/2k8/cough/cough.htm.
• A Dose of Prevention: Tools for Healthcare Providers. www.doseofprevention.org/toolsHealthcare.html.
• Dextromethorphan and Stopping Cough Medicine Abuse Overview. Consumer Healthcare Products Association Web site.www.chpa-info.org/content.aspx?id=103.
• Legal but Lethal: The Dangers of Abusing Over-the-Counter Drugs. US Substance Abuse and Mental Health Services Administration Web site. www.family.samhsa.gov/get/otcdrugs.aspx.
• Bryner JK, Wang UK, Hui JW, Bedodo M, MacDougall C, Anderson IB. Dextromethorphan Abuse in Adolescence. Arch Pediatr Adolesc Med. 2006;160(12):1217-1222.archpedi.ama-assn.org/cgi/content/full/160/12/1217