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Dextromethorphan – DXM – Triple C

Columns - Pharm Report

Saturday, 31 May 2003

The next time you walk down the aisle of your local supermarket or pharmacy notice where the cold and cough remedies are displayed. Imagine you are a 14-year-old looking to purchase an over-the-counter (OTC) “high.” Look around and see how many possibilities you can find. The medicine aisle of your pharmacy or grocery store is becoming a favorite aisle for some. This affinity is not because they are sick but because they are looking to become intoxicated. The favored intoxicants are cough and cold pills, tablets and syrups containing the cough-suppressant dextromethorphan. These preparations are often labeled as “DX” or “Maximum Strength.”

For example, in Jacksonville, Florida, the incidence of dextromethorphan overdose doubled in 2001. The average age of those individuals was 15-years-old with a range of 12 to 26 (First Coast News, 2002). A New Mexico survey of 376 4th to 12th graders found that cold and cough medicines with dextromethorphan were ranked higher than those without in regard to “getting high.” The Cincinnati Drug and Poison Information Center reported a series of 19 Coricidin HBP Cough and Cold cases over a six-week period in 2000. In 2000, there were 25 cases of dextromethorphan overdose reported to the Maryland Poison Center. Of those, 18 involved use by adolescents and young adults. Sixteen were classified as intentional abuse and, strikingly, nine were involved in suspected suicide attempts (Hilmas, 2001).

Pre-teens, teenagers, and young adults are increasingly getting high by using OTC medications in ways they were not intended. These practices, called “pharming,” include drinking cough syrup and taking in pill or tablet form large amounts of OTC cough medicine (Forreal, 2003). Cough and cold medications containing the medication dextromethorphan (DXM), can have devastating effects on the user. In doses well beyond those recommended, DXM can act as a hallucinogen such as LSD or as a dissociative agent similar to PCP or Ketamine. In order to create the effect desired by the abuser, doses in excess of 100 mg are generally required. The recommended dose for therapeutic cough suppression for adults and children over 12 years of age is 10-20 mg every 4 hours or 30 mg every 6-8 hours, not to exceed 120 mg daily. The usual dosage for children 6 to 12 years of age is 5-10 mg every 4 hours or 15 mg every 6-8 hours not to exceed 60 mg daily. Due to increasing tolerance, the abuser may end up consuming doses of over 1,000 mg (Indiana Prevention Resource Center, 2001). Remember, OTC medications typically contain other substances such as acetaminophen and/or diphenhydramine that in high dose can have their own toxic effects.

An example of the practice of “pharming” is the use of Coricidin products. Coricidin Cough and Cold — “Triple C” — comes in tablet form and contains not only dextromethorphan but also chlorpheniramine maleate, an antihistamine with CNS depressant qualities similar to alcohol. By taking five, six, or more times the recommended dosage, these drugs can interact; adversely amplifying the impact of both drugs. Coricidin HBP Cough and Cold (a special formulation for those with high blood pressure) contains 4 mg of chlorpheniramine and 30 mg of dextromethorphan per tablet, equaling the largest amount of dextromethorphan per dosage unit currently on the market. Users can become intoxicated by taking large doses of cough syrup, a practice known as “robodosing” or “robo-tripping” (from the trade name Robitussin). They may take a large number of cold and cough suppressant pills or tablets called “skittles.” Other street names for dextromethorphan include “robo,” “Vitamin D,” “Red Devils,” “dex,” and “tussin.” Those who favor the use of cough syrup are often called “syrup heads.”

Unfortunately, there are web sites devoted to teaching individuals — especially adolescents — how to abuse dextromethorphan. For example, a teenager can find out how much DXM to take based on their calculated weight, how to obtain the drug in pure powder form, how to drink several bottles of cough syrup without vomiting and how to isolate the pure drug dextromethorphan from syrup.

Dextromethorphan (D-isomer of levorpahnol, a semisynthetic morphine derivative) produces its antitussive activity on the cough center in the medulla oblongata. It has no analgesic properties and is not considered a drug of addiction. Dextro-methorphan is generally considered a safe drug. Even at very high doses (over 10 mg/kg) death from DMX is rare unless it is combined with other chemicals such as antihistamines, MDMA, alcohol or antidepressant medications (Hilmas, 2001). There are over 140 non-prescription products containing dextromethorphan. Some of the more commonly known of these products include Nyquil, Robitussin DM, Triaminic DM, Rondec DM, Benylin DM, Drixoral, Delsym, Pertussin, Vicks 44, Contac and St. Joseph Cough Suppressant.

Abusers have described their experience as similar to the mind-altering impact caused by ingesting LSD. There have been accounts of dissociative “out of the body” experiences similar to those achieved by using the arylcyclohexylamines (PCP and Ketamine). Auditory and visual hallucinations can occur. At high doses mental changes start to occur along with tachycardia and hypertension. As the dose increases ataxia, lethargy, confusion, slurred speech, hallucinations, and seizures may be part of the clinical presentation. Vomiting may occur creating the danger of aspiration and asphyxiation.

Adverse effects

Decreased ability to regulate body temperature (possible “rave-related heat stroke”).
Dry itchy skin.
Dry mouth and loss of body fluids (anti-cholinergic effects).
Blurred vision, cognitive alterations, and dissociative states.
Hallucinations and delusions.
High blood pressure, redness of face, headache and numbness of fingers and toes.
Lack of muscle coordination.
Loss of consciousness.
Death (rarely and generally in combination with other substances).

Dextromethorphan overdose is generally diagnosed based on clinical presentation and collaborative data from others who may have observed the individual or are aware of their drug use history. There is a drug screen available to detect dextromethorphan. Generally, there is a six-hour turnaround time. Quest Diagnostics Laboratory offers this analysis based on blood serum evaluation.

Management of overdose consists primarily of supportive measures. In other words, monitoring of vital signs, maintenance of a clear airway and the use of IV solution if necessary. Activated charcoal (1 mg/kg) can bind dextromethorphan in the gastrointestinal system and reduce further absorption. Naloxone (0.4-2 mg IV repeated every 2-3 minutes up to a total dose of 10 mg) has been used with some success to reverse the respiratory depression and central nervous system effects of dextromethorphan (Hilmas, 2001).

Law enforcement agencies have discovered that clandestine labs are now manufacturing in different sizes, shapes, and colors pills that contain DXM. Anyone providing intoxicating doses to minors or to anyone unaware of the dangers can be subject to arrest based on laws designed to not only protect juveniles but the public at large.

Cardwell C. Nuckols, PhD, is President of Cardwell C. Nuckols & Assoc., LLC a national and international training and consulting organization. He can be reached at cnuckols
@elitecorp.org

References
First Coast News. (2002). “Triple-C” Becoming Popular Over–The–Counter High Among Teens. Retrieved on February 14, 2003 from http://www.firstcoastnews.com/ health/articles/2002-02-24/coricidan.asp
Forreal. (2003). Triple C: Part of the “Pharming” Phenomenon. Retrieved on February 14, 2003 from http://www.forreal.org/think/triplec.asp
Hilmas, Elora. (2001). “Maryland Poison Center Toxalert.” Adolescent Dextromethorphan Abuse. Volume 18, Issue 1.
Indiana Prevention Resource Center. (2001). Non-medical use of Dextromethorphan a/k/a “DXM.” Retrieved on February 14, 2003 from http://www.drugs.indiana. edu/publications/iprc/factline/dxm.html
Medline Plus Health Information. (2002). Dextromethorphan Overdose. Retrieved on February 14, 2003 from http://www.nlm.nih.gov/medlineplus/ency/ article/002628.htm
Neary, Susan Russell. (2002). From Poisons to Therapeutics: The Historical Origins of Contemporary Pharmacology. Retrieved on February 14, 2003 from http://www.medscape.com/viewarticle/439913

This article is published in Counselor, The Magazine for Addiction Professionals, June 2003, v.4, n.3, pp. 29-30.