An Update on Dextromethorphan, the Addictive Cough Medicine Ingredient

Dextromethorphan is the key ingredient in many over-the-counter cough medications that are available in any pharmacy in the country. However, just because it is readily available doesn’t mean that it is harmless or safe. In fact, it is addictive and can cause serious effects and even death.

Because dextromethorphan is not an illicit drug and only occasionally causes deaths, the situation of dextromethorphan abuse and addiction gets little attention. Because it is so readily available, it is unfortunately popular with young people. At least 21 states in the U.S. have restricted the sale of medications with dextromethorphan to anyone under 18, with pharmacies being required to check the buyer’s identification.

What is dextromethorphan (DXM)?

It is a drug similar in chemical composition to codeine. In the body, it has a function more similar to ketamine or phencyclidine, a hallucinogenic drug commonly called PCP. At a low dosage, it suppresses coughing.

Who is abusing dextromethorphan?

While adults can and do abuse and become addicted to products with dextromethorphan, the biggest abuse problem is experienced among teens and young adults. The annual Monitoring the Future survey provides insight into the scope of this problem.

The Monitoring the Future survey collects information on drug abuse patterns of 8th, 10th and 12th-grade students. According to the short summary published for 2023, these were the percentages of students abusing dextromethorphan:

• 4% of 8th-grade students
• 3% of 10th-grade students
• 2.4 % of 12th-grade students

As is typical, more male students abused dextromethorphan than female students, but not by a large margin. These numbers come from the more detailed 2022 survey.

Male students

• 3.4% of 8th-grade students
• 4.3% of 10th-grade students
• 2.6 % of 12th-grade students

Female students

• 3.2% of 8th-grade students
• 3% of 10th-grade students
• 1.8 % of 12th-grade students

In rural areas or small towns, the rate of use is even higher:

• 5.6% of 8th-grade students
• 4% of 10th-grade students
• 3.3% of 12th-grade students

The number of 8th-grade students misusing this drug made a jump between 2022 and 2023. In 2022, only 3.2% of 8th grade students abused dextromethorphan. In 2023, this number increased to 4%. However, in 2020, the number of 8th-grade students abusing this drug was significantly higher, at 4.6%.

One of the reasons dextromethorphan may appeal to teens is that this drug is not detectable in routine drug tests.

How is dextromethorphan abused?

It is abused by consuming far more than a therapeutic dose. Some people may drink an entire bottle of liquid cough medicine or swallow a large number of pills. Per the product packaging, the maximum recommended dose is 120 milligrams of dextromethorphan in a cough preparation. A person intent on getting high may take 25 times this amount, which could require them to drink more than one bottle of liquid cough medicine or swallow more than one bottle of pills.

What are the effects of DXM?

The most common effects are:

• Stomachache
• Confusion
• Blurred vision
• Double vision
• Slurred speech
• Poor physical coordination
• Fast heartbeat
• Increased blood pressure
• Sleepiness
• Numb fingers and toes
• Perceptual changes
• Disorientation
• Dizziness
• Loss of normal cognitive functions

The effects depend on the dosage. Higher dosages can cause:

• Delusions
• Hallucinations
• Euphoria
• Agitation
• Coma
• Paranoia
• Dissociation

These more serious symptoms can lead to violence, assault, homicide or suicide.

Even higher doses can cause elevated body temperature and even death from cardiac or respiratory arrest. Very high doses can also cause shock and convulsions.
When a teen hears how “fun” it is to abuse DXM, they are unlikely to ever hear about the serious effects that are possible from using this drug.

Special hazards associated with DXM abuse

Many drug users will down DXM while drinking alcohol or taking pills. Polydrug use (the use of multiple drugs at once or in quick succession) is extremely common. Mixing DXM with alcohol or other drugs, even prescribed drugs, can be deadly. Mixing dextromethorphan with certain prescription drugs can trigger a life-threatening syndrome with the following symptoms:

• Agitation
• Confusion
• Headache
• Very fast heart rate
• Low blood pressure
• Seizures
• Irregular heartbeat
• Unconsciousness

Mixing dextromethorphan with amphetamine, ecstasy (MDMA), or cocaine could also trigger this syndrome.

Additionally, as many as 10% of Caucasians break down a drug like DXM slowly. This means that the level of DXM in their blood could climb dangerously high because it is not being broken down and carried out of the body. So two people could consume the same amount of DXM and one could come out of it fine while the other one has a deadly experience. This also means that individuals who can’t break down DXM could experience symptoms similar to DXM abusers while they are only taking a therapeutic dose.

Is dextromethorphan addictive?

Yes, it is definitely addictive. Many studies and case reports document the inability of some people to stop using the drug, even if it is seriously harming their lives. There are also withdrawal symptoms suffered by a person who has discontinued their DXM abuse[8]:

In the first week:

• Severe vomiting
• Muscle aches and pain
• Diarrhea

For the following three weeks:

• Night sweats
• Insomnia
• Intolerance to cold
• Anxiety

When a person can’t stop using a drug despite the harm being caused to their health, work, relationships or mental status, this is a definite sign of addiction. A medical guide to determining addiction lays out the signs:

• Strong desire or compulsion to take dextromethorphan

• Reduced ability to control the onset and termination of substance taking, and the amount taken

• The occurrence of physical withdrawal symptoms on attempting to end or reduce substance use and their reduction when use is resumed

• The development of tolerance

• Neglect of other areas of life in favor of substance consumption

How to identify when a person is abusing dextromethorphan

Most people who are abusing drugs keep their habit a secret unless they are abusing these drugs in the company of others doing the same.

Parents, spouses and friends may have to get clever to detect the signs that a person is misusing DXM. They should look for these signs:

• Empty bottles or blister packs of cold medication

• Cough medicine bottles in their possession when there is no illness

• Cough medicine missing from the home medicine cabinets

• Loss of interest in friends, school, hobbies

• Changes in sleep or eating habits

• Poor personal hygiene

• Poor performance at school or work

• Hostility, antagonism and secrecy

A person abusing this drug may use slang terms like skittles, skittling, tussin, robo-tripping, robo, CCC, triple Cs or dexing.

Why are dextromethorphan products legal?

That’s a good question. With more than 20 states having outlawed cough medicines with DXM to those under 18, one could wonder why other states have not yet followed suit.

Additionally, anyone aged 18 or older could buy these medications and share them with younger individuals. Perhaps the only way to improve the situation is to make DXM-containing medications prescription-only, which would increase the control of this drug. Families who are educated on the hazards of dextromethorphan can take steps to keep DMX products in their homes out of young hands.

Recovering from DXM addiction

Fortunately, it is possible to recover from DXM addiction. It requires good support while a person is going through withdrawal and then an effective program to help the person create a new sober life for themselves.

A person misusing DXM is often trying to escape from their problems or the stresses of life. They must become capable of dealing with these stresses or problems so they are not tempted to escape into euphoria or delusions. For most people, this means that they must improve their life skills and become capable of confronting and resolving conflicts or losses. Sobriety is possible and it is worth the work to get clean and productive once more.

Sources:

• Ohio Becomes 21st State to Adopt Age-18 Sales Law for Cough Medicine. Consumer Healthcare Products Association, 2023. CHPA

• National Survey Results on Drug Use, 1975-2023: Overview and Detailed Results for Secondary School Students. Monitoring the Future, 2024. MTF

• National Survey Results on Drug Use, 1975-2022: Secondary School Students. Monitoring the Future, 2023. MTF

• Why DXM? Stop Medicine Abuse, undated. Stop Medicine Abuse

• Dextromethorphan in Cough Syrup: The Poor Man’s Psychosis. National Library of Medicine, 2017. NLM

• Dextromethorphan. National Library of Medicine, 2023. NLM

• Dextromethorphan. American College of Medical Toxicology, undated. ACMT

• Dextromethorphan Withdrawal and Dependence Syndrome. National Library of Medicine, 2010. NLM