DXM Misuse: Signs, Effects & Addiction Treatment
DXM (dextromethorphan) is a cough suppressant medication (antitussive) that has been on the market for many years. Originally released in the 1950s, it became highly abused and was removed from the consumer market. Because DXM is an efficient cough-suppressing agent, several companies began to reintroduce the drug in a form that was unpleasant tasting to reduce abuse of the drug. Because the unpleasant taste led to poor sales, manufacturers then began to reintroduce medicines that were better tasting, and the drug was reestablished as a significant drug of abuse.
Currently, DXM is available over the counter in numerous medications (over 100 different products). Its major medicinal use is to suppress coughing associated with the common cold, bronchitis, influenza, allergies, and other conditions or infections. It is available in well-known medications, such as Vicks Formula 44, Robitussin, and Nyquil. The drug is often referred to by abusers as DXM, robo, triple C, skittles, red devil, etc. The term robotripping refers to its abuse in cough syrups (robo used as a term to signify Robitussin).
How Does DXM Work?
DXM is not a controlled substance. It is produced from a derivative of the drug morphine, but it is not classified as an opiate drug. DXM is an NDMA antagonist, which means that its major action is to inhibit the release of the excitatory neurotransmitter N-methyl-D-aspartate (opiate drugs have a mechanism of action that is entirely different from DXM). This mechanism of action accounts for its ability to control coughing.
When the drug is used according to its instructions, it produces a rather benign side effect profile that can include:
- Possible nausea, stomach cramps, or constipation
- Mild issues with drowsiness, dizziness, or mild headache
Dangers of DXM Misuse
DXM taken for medicinal purposes is most often taken in doses that range between 15 mg and 30 mg every four hours. Using the medication in this manner does not produce any significant psychoactive effects, and its ability to suppress coughing effectively typically lasts throughout the four-hour time period. Abusers of the drug often take the substance in much higher quantities and at more frequent intervals.
Abuse of DXM produces similar effects to a category of drugs known as dissociative hallucinogenic drugs, which includes phencyclidine (PCP) and ketamine. Chronic misuse of DXM can result in similar effects to chronic abuse of these drugs. The United States Drug Enforcement Administration (DEA) has established a dose-dependent schedule that outlines the effects of DXM abuse. Because the drug has significant differing effects at different dosages, the DEA list DXM as a significant drug of concern, but it is not a controlled substance.
The four levels (plateaus) of DXM misuse recognized by the DEA are:
- Plateau 1: Misuse of DXM in the first plateau occurs when individuals take between 100 mg and 200 mg. Taking these doses of the drug results in feelings of euphoria and stimulation.
- Plateau 2: The second plateau of DXM misuse occurs when a person takes a dosage between 200 mg and 400 mg. Feelings of stimulation, euphoria, and hallucinations (mostly visual hallucinations) are associated with these dosages.
- Plateau 3: At this plateau, individuals will take 300-600 mg of DXM. The effects include euphoria, hallucinations, significant impairments in motor coordination, and visual perceptual distortions. One’s visual perception of objects in the environment is significantly altered, and this places the person at risk if they are operating a motor vehicle, moving quickly, etc.
- Plateau 4: Any single dose of DXM beyond 600 mg qualifies for the final plateau. At this plateau, individuals experience hallucinations, visual distortions, extreme sedation (and even lethargy and unconsciousness), and dissociative effects, such as feeling as if they are not real, leaving their body, or that the environment is not real.
The DEA lists numerous cases where individuals under the influence of high levels of DXM were involved in serious accidents. In addition to the above effects, high doses of DXM are associated with poor judgment, impulsive behavior, and risk-taking that increase the risk of potential mishaps. A person using extremely high amounts of DXM is also vulnerable to serious health issues that result from significantly depressed breathing and cardiovascular issues, such as heart attack. The DEA reports that naloxone, an opioid antagonist drug used for individuals who overdose on opiate drugs, can be beneficial in reversing the effects of an overdose on DXM.
According to the National Institute on Drug Abuse (NIDA), chronic misuse of DXM may also produce:
- Liver damage, especially when DXM is consumed in medications that contain acetaminophen
- Respiratory issues associated with long-term suppressed respiration
- Dangerous buildup of excess acid in one’s bodily fluids
- Organ damage as a result of hypoxia (decreased oxygen flow) that can include damage to the heart, lungs, and brain
- A significant substance use disorder (substance abuse or addiction)
Major organizations, such as the DEA, NIDA, and the Substance Abuse and Mental Health Services Administration (SAMHSA), indicate that chronic use of DXM can lead to significant tolerance (needing more DXM to get effects that were once achieved at lower doses); however, there is not sufficient evidence to indicate that repeated use of DXM is associated with the development of a withdrawal syndrome. Thus, it appears doubtful that individuals can develop significant physical dependence on DXM, although some individuals may develop significant psychological issues when they discontinue DXM (e.g., issues with depression, motivation, significant cravings, etc.). However, the diagnosis of a substance use disorder does not require that an individual develop physical dependence on any substance.
SAMHSA reports that DXM abuse can be found across all age groups but that the drug is primarily abused by younger individuals. People 12-26 years old are the most likely individuals to abuse DXM, and in the majority of cases, these are males, especially when the misuse occurs in individuals over the age of 18. In the past, SAMHSA also collected information regarding emergency room visits associated with specific drugs of misuse. The data indicated an increasing trend in the rise of ER visits associated with the abuse of products containing DXM, such that the number of cases doubled between 2004 and 2011 (the last year that SAMHSA actively reported this type of data). The DEA and SAMHSA also report that there has been a decline in DXM abuse in recent years; however, it is still a significant drug of concern, especially for younger people.
It appears doubtful that individuals can develop significant physical dependence on DXM, although some individuals may develop significant psychological issues when they discontinue DXM.
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Signs of DXM Misuse
NIDA reports that abuse of DXM is often accompanied by concurrent use or abuse of alcohol, marijuana, and prescription medications, such as prescription pain medications or benzodiazepines. In some instances, individuals use stimulant drugs to counter the effects of DMX. Consistently abusing multiple drugs can result in development of a serious issue with polysubstance abuse and a complicated substance use disorder profile. The American Psychiatric Association (APA) lists the diagnostic criteria for substance use disorders; information from NIDA and SAMHSA along with these diagnostic indicators suggests some telling signs that may represent the abuse of DXM.
- Consistent use of the drug for it psychoactive effects and not for its medical uses
- Frequent cravings to use DXM
- Frequent use of the drug in situations where it is dangerous to do so that can include using large amounts of the drug while operating machinery (e.g., driving an automobile), taking the drug in conjunction with other drugs, or using significantly large amounts of the drug in a single setting
- Expressing behaviors that indicate one is having difficulty controlling use of the drug, including repetitively using more DXM than originally intended, recognizing that DXM use is causing significant problems but still using it, using DXM for longer periods of time than originally intended, failing to meet important obligations as a result of use of DXM, or abandoning cherished activities in favor of DXM use
- Investing a significant proportion of time using DXM, trying to get the drug, or recovering from its use or abuse
- Displaying or admitting to having dissociative-type experiences
- Displaying issues with hallucinations, visual acuity, or judgment in the context of appearing rather sedated
- Appearing intoxicated but not smelling of alcohol
- Developing tolerance to DXM (The use of DXM for medicinal reasons is typically not a long-term endeavor because most individuals use it for very acute situations, such as a cold, influenza, etc. Any person who develops tolerance to DXM should be suspected of abusing the drug unless they are using it under the supervision of a physician.)
Treatment for DXM Misuse
The main demographic factors associated with DXM abuse are being male and being relatively young. Because these individuals will often deny that they are abusing the drug or that they have lost control of their use of the drug, attempts to approach them that use confrontation are often ineffective. Instead, a more professional approach should be considered, such as enrolling the aid of a professional mental health worker with experience in the treatment of addictive behaviors or a professional interventionist.
A professional interventionist helps concerned individuals to organize a formal substance use disorder intervention to allow friends and family of the person to express their concerns about their drug use and to convince the individual to consider treatment. More information about professional interventionists and substance use disorder interventions can be found at the website for the Association of Intervention Specialists, a professional organization that trains interventionists.
Formal treatment for abuse of DXM may or may not include an initial physician-assisted withdrawal management program. The use of medications to help an individual cope with psychological issues and cravings in the initial stages of abstinence is done on a case-by-case basis. People who have developed severe substance use disorder issues as a result of polysubstance abuse may be more likely to be enrolled in this type of program than individuals who just abuse DXM; however, again, after an initial assessment is performed, it can be decided whether or not they should be enrolled in a withdrawal management program.
Formal treatment should include targeted interventions for any co-occurring mental health conditions as well as participation in substance use disorder therapy (group therapy, individual therapy, or both), participation in social support groups (e.g., 12-Step groups or other social support groups), medical management of conditions as appropriate in the individual case, and any other interventions or supports that are needed in the specific case. For instance, younger individuals may require tutoring services or vocational rehabilitation services. Family therapy may be an important addition to the treatment program for younger individuals who have issues with their family members or who need special support from family members.
For younger individuals, peer support is crucial. Because peer pressure is an important risk factor in the use and abuse of drugs, younger individuals in recovery often need to rearrange or even change their peer contacts. This can be successfully accomplished by enrolling the person in group therapy where the group members are primarily in the same age range or having the individual attend social support groups that are frequented by younger individuals. For most individuals, psychoeducation regarding drug abuse, mental illness, and relapse prevention is also crucial, and this can be provided in formal therapy and in support groups.
An important consideration for younger individuals recovering from some substance use disorder issue (and for anyone addressing a substance use disorder) is to understand that simply becoming abstinent or completing a withdrawal management program is not sufficient to promote long-term recovery. Most individuals will need to spend significant amounts of time involved in therapy, recovery groups, and social support groups to deal with issues regarding potential relapses of DXM abuse or to avoid engaging in the use of other potential drugs of abuse. While there is no definite boundary identified for the length of time one needs to remain in some form of substance use disorder treatment, it is generally considered that individuals who remain in treatment and remain abstinent for minimum periods of 5-7 years are on the road to long-term recovery.
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