Dextromethorphan (DXM), which goes by a number of street names including D, dex, skittles, red devil, DM, tussin (e.g., for Robitussin), triple C, and Robo (Robitussin again), is the active ingredient in many nonprescription medications designed to treat chronic or problematic coughing. These medications include very familiar names, such as NyQuil, Robitussin, and Vicks Formula 44.

DXM drug was developed in the 1950s and initially approved under the brand name Romilar. Its abuse had become significant by 1970, and the drug was removed from the market. Since the drug was not included as a controlled substance in the Controlled Substances Act, and it was effective as a cough suppressant, it was reintroduced to the market. This time the manufacturers made the drug extremely unpleasant to taste, hoping that this would deter abuse; however, its unpleasant taste also resulted in it being unpopular with consumers. In order to increase sales, more palatable forms of the drug were developed, again opening the opportunity for individuals to abuse it.

DXM, D, dex, skittles, red devil, DM, tussin

DXM is produced from a morphine derivative, but it is a synthetic drug that does not have the same action as drugs in the opioid class. Most opioids attached to endogenous opioid receptors for endorphins and enkephalins that naturally suppress pain, whereas DXM works on a different neurotransmitter set. DXM functions to suppress the action of an excitatory neurotransmitter in the central nervous system (N-methyl-d-aspartate, often abbreviated as NDMA). When DXM is taken as directed, this suppression of NDMA results for its effectiveness as a cough suppressant. In addition, when taken as directed, there are few complications associated with the drug’s use.

DXM remains a very common drug in nonprescription medications. It is included in over 100 different products designed to treat the common cold, symptoms of influenza, allergies, and other conditions that produce coughing and cold or flulike symptoms.

Effects of Using and Abusing DXM

The dosages that are suggested when using dextromethorphan as a cough suppressant range from 15 mg to 30 mg. At these dosages, a person can safely take the drug several times a day; most often, individuals are able to take the drug 3-4 times daily when using it in this fashion. The effects of the drug are listed as lasting 4-6 hours when taken within its suggested dosage. Taken medicinally, there very few untoward side effects associated with its use, but some issues do occur in some individuals, including mild sedation, nausea, headache, and constipation. The drug is typically taken orally.

In high doses that are significantly greater than the suggested recommended medicinal doses, DXM produces effects that are very similar to dangerous drugs, such as phencyclidine (PCP) and ketamine. These drugs are a dissociative hallucinogens and produce feelings of detachment from reality, euphoria, and visual and auditory hallucinations.

The United States Drug Enforcement Administration has released a guideline for the abuse of DXM. The effects vary greatly by dosage. According to the DEA:

  • At the lowest level of abuse described, the dosage taken is between 100 mg and 200 mg. At this dosage, the effects are feelings of stimulation.
  • The next highest level of abuse involves dosages between 200 mg and 400 mg. Taking the drug at this level will result in the experience of euphoria and visual hallucinations.
  • At levels of 300 mg to 600 mg, individuals will experience euphoria, hallucinations, impaired motor functioning, and distortions in visual perception of objects.
  • Above 600 mg, there is an added dissociative hallucination and sedative effect. People often feel as if they are detached from their bodies or as if things are not real. In addition, very high doses can result in potential fatalities associated with extreme sedation and suppressed breathing or cardiac arrest.

Naloxone, which is often used to reverse the symptoms of overdose on opioid drugs, including heroin and OxyContin, may have utility for reducing and addressing the issues associated with an overdose of DXM.

Recognizing DXM Abuse

Abuse of DXM most commonly occurs in younger individuals from late adolescence to early adulthood. The term robotripping refers to the ingestion of high doses of over-the-counter cough medicines in an attempt to experience the psychoactive effects of these drugs. Many of these medications are combined with other drugs, such as alcohol, cannabis, other central nervous system depressants, and stimulant medications. In addition, a number of sources provide individuals with methods to extract the DXM from over-the-counter medications, resulting in an individual taking extremely high doses of the drug. Combining large amounts of DXM with other drugs or taking the drug an extremely high doses is very dangerous and significantly increases the risk of serious health hazards and even potential fatal effects.

Signs and symptoms of DXM abuse can include:

  • Repeated use of DXM in the absence of the symptoms it is designed to treat (e.g., coughing or having an illness such as a cold or influenza)
  • Finding out that the person is researching DXM online or purchasing the drug online
  • Noting that the person spends a significant amount of time using the drug, recovering from its use, or even trying to procure sources of the drug
  • Continued use, even though the person has expressed a desire to stop using DXM or cut down on use
  • Using DXM with other drugs
  • Using it to cope with normal life stressors
  • Failing to fulfill important obligations as a result of use
  • Displaying issues with coordination, like trouble with balance, walking with a noticeable stagger that resembles someone who is intoxicated, or difficulty performing routine tasks
  • Appearing lethargic or sleepy
  • Slurred speech in the absence of alcohol use
  • Rashes
  • Extreme sweating for the situation
  • Visual difficulties or seeing or hearing things that are not there
  • An irregular heartbeat or high blood pressure without a history of either
  • Anxious behaviors or panic attacks along with hallucinations
  • Feeling detached from one’s body or from reality
  • Using higher doses of DXM over time

There does not appear to be a significant risk for physical dependence on CXM (displaying both tolerance and withdrawal). However, tolerance does appear to occur rather rapidly in chronic abusers.

Getting Help

People who present with polydrug abuse may require formal withdrawal management participation, depending on the substances that are also abused with DXM. Planning for these issues early in the initial phases of treatment and recovery is extremely important to avoid potential issues with relapse. In addition, potential complications, such as feelings of worthlessness and the tendency to become depressed and even suicidal, can result in potentially dangerous complications, and the person should be monitored very closely.

A person who has abused DXM for a significant period of time or who suffers from polydrug abuse will require long-term formal treatment. As the majority of individuals who abuse DXM are younger, it is advantageous to engage these individuals in a group therapy program with at least some individuals in their own peer group. This allows them to identify with people who are successful in recovery or beginning recovery.

Individual therapy can also be used in conjunction with group therapy. The preferred form of therapy is some form of Cognitive Behavioral Therapy (CBT) that addresses the person’s belief system and dysfunctional thought processes, challenges these dysfunctional beliefs and thoughts, and helps the person readjust their thinking to more productive and realistic tendencies. CBT can be performed in both group and individual therapy. Because DXM abusers tend to be younger and often have complicated issues with family, family therapy can be extremely useful.

In addition to formal therapy and medical management of co-occurring conditions, the person should also become involved in a social support groups, such as Narcotics Anonymous. There are a number of other 12-Step programs that may be appropriate for the individual case, including Alcoholics Anonymous and Pills Anonymous (for prescription drugs). There are various 12-Step groups that family members can attend, such as Al-Anon, Alateen, or Nar-Anon.

Twelve-Step groups and other social support groups are not formal therapy groups because they are not typically run by licensed therapists; they are run by individuals who suffer from the same issue as members, but group leaders have generally had a substantial amount of time in recovery. These types of groups are extremely helpful, as they allow for identification with other individuals who have similar issues and experiences, offer a structured program of recovery that is compatible with formal therapy, and are ongoing. Again, if possible, younger individuals should seek out social support groups that have younger members in them in order to better identify with and learn from peers in recovery.

Getting an individual into treatment is often a difficult task because many individuals will be resistant and may not even see their substance use as problematic. Younger individuals will often shut down and become reactive when approached by family members regarding substance abuse issues. The best course of action before discussing treatment with a person who is abusing DXM is to call a mental health professional who specializes in the treatment of addiction. In addition, rehab centers can connect individuals with local interventionists who can assist in the conversation.