Over-the-counter (OTC) medications are some of the most widely abused substances in the United States. The National Institute on Drug Abuse (NIDA) reports that after alcohol and marijuana, Americans age 14 and older abuse prescription and OTC medications more than any other substance.
DXM, or dextromethorphan, is a substance found in more than 100 cough and cold medications that are sold over the counter without a prescription. DXM is an antitussive substance that suppresses coughs and is found in common medications like Robitussin, Dimetapp, Mucinex, Theraflu, Coricidin, Triaminic, Tylenol Cough and Cold, and DayQuil/NyQuil.
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When used as directed, DXM-containing products are safe and effective for controlling and managing symptoms of the common cold. DXM has, however, become a drug of abuse. These medications are misused and used recreationally in much larger doses than are recommended. DXM abuse can be dangerous, bringing a range of potential adverse effects and risks.
The DEA reports that there were more than 45,000 case mentions of dextromethorphan to the American Association of Poison Control Centers (AAPCC) and six deaths related to the drug.
Use and Abuse
DXM is not labeled as a controlled substance by the Drug Enforcement Administration (DEA), which means that it is fairly easy to obtain in the form of OTC medications. NIDA publishes that DXM abuse is often called “candy,” “skittling,” “dex,” “triple C,” or “robo-tripping.”
Cold medicines containing DXM are often mixed with soda to make the substance taste better. Liquid or oral suspension DXM products are regularly misused, and these products also may be abused in pill or powder form.
DXM is popular with teenagers. The Monitoring the Future (MTF) study published by NIDA reports that more than 3.5 percent of high school sophomores abused a nonprescription cough medicine in 2016. Several states are working to make it harder for young people to obtain products containing DXM in an attempt to limit abuse of these products, Pharmacy Today publishes. Many states have put age restrictions in place that don’t allow minors under age 18 to purchase these products.
When taken in large amounts, DXM can have effects that are similar to dissociative drugs like ketamine and PCP. A dissociative drug causes feelings of detachment and depersonalization, and can distort the way people see and perceive themselves and the world around them. A dissociative drug can make people feel as if they are having an “out-of-body” experience.
The normal dosage of a DXM-containing cold medication is about 10 mg to 20 mg, given every four to six hours, or one 30 mg dose, given every six to eight hours, as directed for medical use. The Center for Substance Abuse Research (CESAR) reports that when misused, a person may take a dose of a DXM product in the range of 240 mg to 1500 mg at a time for recreational use, and heavy DXM use may mean a person drinks as many as three to four bottles every day.
In lower doses, DXM can cause stimulation and euphoria. When more is taken, a person can experience distorted visual perceptions, and with even higher doses, dissociative sedation may occur. Combining DXM with other central nervous system depressant drugs like benzodiazepines, opioids, or alcohol can amplify the effects of all substances involved. Visual hallucinations, a distorted sense of time, heightened senses, and excitability are all possible effects of DXM abuse.
When DXM is taken for a nonmedical reason and in a way or dose that is not medically necessary or recommended, this is a form of drug abuse. DXM generally is swallowed when abused; however, tablets may be crushed, and the drug may be injected or snorted as well.
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Recreational DXM use can have toxic effects and even lead to a potentially life-threatening overdose. The DEA reports that there were more than 45,000 case mentions of dextromethorphan to the American Association of Poison Control Centers (AAPCC) and six deaths related to the drug.
DXM can slow breathing and lead to respiratory distress, and a person can literally stop breathing as a result. DXM abuse also can cause hypoxic brain damage, as it can disrupt the flow of oxygen to the brain, cause seizures, and lead to an increased heart rate.
DXM is commonly combined with other medications in cold and cough preparations, and these substances can have health risks as well. For example, DXM is often mixed with acetaminophen, which can cause liver damage; with pseudoephedrine, which can heighten blood pressure; and with antihistamines, which can lead to cardiovascular toxicity, anticholinergic toxicity, and central nervous system toxicity. The combination of DXM with alcohol can be deadly, more quickly resulting in a possible overdose.
Generally speaking, the higher the dose of DXM, the worse the possible side effects. In lower amounts, DXM intoxication is similar to being drunk on alcohol, with effects like slurred speech, loss of motor control, and behavioral changes. Higher doses of DXM can cause aggression, violent outbursts, paranoia, delusions, and effects that are similar to other dissociative drugs, even so far as causing substance-induced psychosis, the journal the Psychopharmacology Bulletin warns.
There are additional potential side effects of DXM abuse. They are:
- Hot flashes
- Racing heart rate
- Increased blood pressure
- Panic attacks
- Rashes or redness of the skin
- Nystagmus (rapid and involuntary eye movement)
- Vision changes
- Stomach pain
- Trouble thinking clearly
- Impaired judgment
- Balance issues
DXM interferes with the way a person thinks and feels. It can, therefore, affect the way they act and behave.
The effects of DXM can last about six hours or so, during which time a person is liable to make poor decisions and not be able to think rationally or logically. Consequences of DXM abuse can include physical, social, emotional, and legal ramifications that can be long-lasting.
Another possible long-term side effect of repeated DXM abuse is toxic psychosis, which means a person can lose contact with reality and continually be confused mentally. It is not entirely clear exactly what the long-ranging effects of DXM may be, and whether or not these health issues are reversible. It acts in the brain in ways that are still being researched and are not fully understood.
Is DXM Addictive?
NIDA warns that DXM abuse can lead to addiction. Repeated use of DXM can cause the body to build up a tolerance to the drug, which will then cause a person to feel the need to take more and more of it for the drug to keep working the same way.
Physically, a person can struggle with drug dependence after taking DXM on a regular basis. This means that when DXM stops being active in the body, withdrawal symptoms can occur that can include insomnia, depression, anxiety, agitation, restlessness, stomach upset, diarrhea, vomiting, nausea, and weight loss. DXM withdrawal also may include cravings for the drug, which can be both physical and psychological. These cravings can make it difficult for a person to control their DXM use.
Compulsive and chronic drug use is a sign of addiction, which is considered to be a brain disease with far-reaching effects. When someone battles addiction, the person is unable to quit taking DXM even if they want to. Abuse of the drug begins to overshadow most other aspects of the person’s life. As a result of the addiction, the person will no longer keep up with school, family, and work obligations, and the individual will likely give up recreational and social events that were previously important. This substance abuse and addiction can lead to drastic changes in social circles, intentional isolation, weight fluctuations, interpersonal relationship issues, significant mood swings, and health issues.
Getting Help for Addiction
A lot of empty cough and cold medication bottles in the trash, unpredictable mood swings, lack of concern over personal hygiene, increased secrecy and isolation, appetite changes, and strange sleep patterns can all be signs of problematic DXM abuse and potential addiction involving the drug.
There are several options for addiction treatment that are provided in a variety of settings. Both outpatient and inpatient or residential treatment programs can be beneficial, and they offer a host of options to suit each individual seeking care. Families and loved ones can work closely with a care team to design a treatment plan that will be optimal for them.
Each person’s needs are individual, so the treatment plan should be individualized as well. A person who needs to continue to go to school or work, or take care of a family at home, may require an outpatient treatment program that can offer flexibility and the opportunity to schedule sessions and meetings around other obligations. Outpatient treatment programs can be helpful when there is not a high level of physical and psychological drug dependence, such as when DXM abuse has not been going on for very long.
Inpatient, or residential, addiction treatment programs are the most comprehensive, as they offer care and supervision 24/7 in a highly structured and supportive environment. When drug dependence is more significant, and addiction is more progressed, an inpatient treatment program is often ideal.
Medical, mental health, and substance abuse treatment providers can help families to determine the right level of care for each individual. In general, DXM addiction treatment programs will commonly include specific components.
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Since DXM abuse can lead to physical dependence and difficult withdrawal symptoms when the drug wears off, medical detox is often the optimal method for allowing the drug to process out of the system safely. A medical detox program usually lasts about a week, and it is provided in a structured and secure environment where a person can be continually monitored and supported around the clock.
Medications can be a useful component during detox to minimize drug cravings and withdrawal symptoms. Medical detox can provide a safe way for individuals to reach a level of physical stability before entering into an addiction treatment program.
Both group and individual therapy sessions are an integral part of any addiction treatment program. Behavioral therapies can help individuals to recognize negative thoughts and actions, develop healthy coping mechanisms, and improve self-confidence and self-reliance skills.
Family, group, and individual counseling sessions can work through existing issues and develop better communication skills and tools for minimizing relapse.
A peer support group, such as those in 12-step programs, can offer a safe place where individuals can develop healthy connections and learn how to manage cravings and live a sober life in recovery.
Alternative and adjunctive therapy options, such as meditation, massage therapy, yoga, creative expression therapies, fitness programs, nutritional planning, chiropractic care, and acupuncture, can all complement an addiction treatment program by providing a strengthened connection between body, mind, and soul.
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(September 2017). Dextromethorphan in Cough Syrup: The Poor Man’s Psychosis. Psychopharmacology Bulletin. Retrieved August 2018 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5601090/
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