Dextromethorphan abuse and poisoning: Clinical features and diagnosis
- Chris Rosenbaum, MD, MSc, FACEP
Chris Rosenbaum, MD, MSc, FACEP
- Assistant Clinical Professor of Emergency Medicine
- Tufts University Medical School
- Director of Medical Toxicology
- Newton-Wellesley Hospital
- Edward W Boyer, MD, PhD
Edward W Boyer, MD, PhD
- Director of Academic Development
- Department of Emergency Medicine
- Brigham and Women's Hospital
- Associate Professor of Emergency Medicine
- Harvard Medical School
- Section Editors
- Michele M Burns, MD, MPH
Michele M Burns, MD, MPH
- Section Editor — Pediatric Toxicology
- Assistant Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
- Stephen J Traub, MD
Stephen J Traub, MD
- Section Editor — Toxicology
- Associate Professor of Emergency Medicine
- Mayo Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The epidemiology, pertinent pharmacology, and clinical features of dextromethorphan poisoning will be reviewed here. The treatment of dextromethorphan poisoning is discussed separately. (See "Dextromethorphan poisoning: Treatment".)
Approximately one million United States youth and young adults (age 12 to 25 years) misuse over-the-counter (OTC) cough and cold medicines that contain dextromethorphan each year . Nonmedical use of dextromethorphan (DXM) results in approximately 6000 emergency department (ED) visits annually in the United States . Adolescents (age 12 to 20 years) account for almost 50 percent of ED visits. Coingestion of ethanol is frequently seen. Reports from other countries suggest that DXM abuse is prevalent outside of the United States as well [3,4].
Initially introduced in tablet form during the late 1950s as the OTC cough suppressant Romilar, DXM has a long history of abuse. Because of diversion to recreational use, Romilar was removed from the OTC market in 1973 [5,6]. Subsequently, pharmaceutical companies introduced liquid formulations that were designed to reduce abuse by creating an unpleasant taste if ingested in large amounts . Before geltabs became more widely available, it took approximately one bottle of cough syrup to achieve a euphoric effect .
DXM abuse is known as "going pharming," "Dexing," "Robodosing," or "Robotripping" among adolescent and adult users [8-10]. Myriad slang terms exist for DXM based upon tablet appearance and their similarities with popular candies (table 1) [8,9].
In 2006, Coricidin, Nyquil, and Robitussin formulations accounted for almost 66 percent of reported instances of dextromethorphan misuse among United States persons between the ages of 12 to 25 years . These cough medicines often combine DXM with acetaminophen, antihistamines, or decongestants [7,8,11-15]. In order to extract DXM from unwanted products in combination cold preparations, abusers sometimes perform a two-phase acid base extraction technique using common household products ("Agent Lemon" technique) . This technique was applied quantitatively to 295 mL of a combination cough and flu medication and found to markedly reduce the amount of acetaminophen and pseudoephedrine in the final product while yielding significant quantities of dextromethorphan and doxylamine . Some DXM abusers prefer a single phase acid base extraction technique that results in a substance known as "Crystal Dex" .
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- PHARMACOLOGY AND CELLULAR TOXICOLOGY
- Toxic dose
- Mechanism of action
- CLINICAL FEATURES
- - Youth and adults
- - Children
- Physical examination
- - Acute overdose
- - Coingestant findings
- - Signs of chronic use
- Ancillary studies
- - Acetaminophen level
- - Other studies
- - Dextromethorphan testing
- DIFFERENTIAL DIAGNOSIS
- ADDITIONAL RESOURCES