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" .
- Substance Abuse and Mental Health Services Administration. Office of Applied Studies. The NSDUH report: misuse of over-the-counter cough and cold medications among persons aged 12 to 25. http://www.oas.samhsa.gov/2k8/cough/cough.cfm (Accessed on December 16, 2008).
- Ball JK, Albright V. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Emergency department visits involving dextromethorphan. The New DAWN report 2006; 32:1. http://www.oas.samhsa.gov/DAWN/dextromethorphan.cfm (Accessed on December 16, 2008).
- Abanades S, Peiró AM, Farré M. [Club drugs: old medicines as new party drugs]. Med Clin (Barc) 2004; 123:305.
- Chung H, Park M, Hahn E, et al. Recent trends of drug abuse and drug-associated deaths in Korea. Ann N Y Acad Sci 2004; 1025:458.
- Shulgin AT. Drugs of abuse in the future. Clin Toxicol 1975; 8:405.
- Wolfe TR, Caravati EM. Massive dextromethorphan ingestion and abuse. Am J Emerg Med 1995; 13:174.
- Banerji S, Anderson IB. Abuse of Coricidin HBP cough & cold tablets: episodes recorded by a poison center. Am J Health Syst Pharm 2001; 58:1811.
- Kirages TJ, Sulé HP, Mycyk MB. Severe manifestations of coricidin intoxication. Am J Emerg Med 2003; 21:473.
- Desai S, Aldea D, Daneels E, et al. Chronic addiction to dextromethorphan cough syrup: a case report. J Am Board Fam Med 2006; 19:320.
- Department of Health and Human Services. Trouble in the medicine chest (I): Rx drug abuse growing. http://ncadi.samhsa.gov/govpubs/prevalert/v6/4.aspx (Accessed on January 29, 2008).
- Watson, W. Toxic exposure surveillance system dextromethorphan data. American Association of Poison Control Centers, Washington, DC 2003.
- Drug Abuse Warning Network. Emergency department visits involving dextromethorphan, 2006 http://www.oas.samhsa.gov (Accessed on January 29, 2008).
- National Survey on Drug Use and Health. Misuse of Over-the-Counter Cough and Cold Medications among Persons Aged 12 to 25, 2008. http://www.oas.samhsa.gov (Accessed on January 29, 2008).
- Boyer EW. 2003 Poisoning Data: Massachusetts Poison Control Center, 2003.
- Simone K, Bottei, E, Siegel, E, et al. Coricidin abuse in Ohio teens and young adults. J Toxicol Clin Toxicol 2000; 38:532.
- Hendrickson RG, Cloutier RL. "Crystal dex:" free-base dextromethorphan. J Emerg Med 2007; 32:393.
- Hendrickson RG. "DXemon juice:" analytical evaluation of an extraction process for the purification and freebasing of dextromethorphan from cold preparations. J Med Toxicol 2008; 4:309.
- Boyer EW. Dextromethorphan abuse. Pediatr Emerg Care 2004; 20:858.
- O'Brien M. Emerging trends in drug use. Community Epidemiology Working Group Annual Conference. National Institutes on Drug Abuse. Atlanta 2003.
- Boyer E. Dissociative agents: Phencyclidine, ketamine, and dextromethorphan. In: Haddad adn Winchester's Clinical Management of Poisoning and Drug Overdose, 4th, Shannon MW, Borron SW, Burns MJ (Eds), Saunders, Philadelphia 2007. p.776.
- White, W. DXM FAQ, 1995. http://www.erowid.org (Accessed on January 29, 2008).
- Logan BK, Yeakel JK, Goldfogel G, et al. Dextromethorphan abuse leading to assault, suicide, or homicide. J Forensic Sci 2012; 57:1388.
- Siu A, Drachtman R. Dextromethorphan: a review of N-methyl-d-aspartate receptor antagonist in the management of pain. CNS Drug Rev 2007; 13:96.
- Kim HS, Park IS, Lim HK, Choi HS. NMDA receptor antagonists enhance 5-HT2 receptor-mediated behavior, head-twitch response, in PCPA-treated mice. Arch Pharm Res 1999; 22:113.
- Ganetsky M, Babu KM, Boyer EW. Serotonin syndrome in dextromethorphan ingestion responsive to propofol therapy. Pediatr Emerg Care 2007; 23:829.
- Kamei J, Mori T, Igarashi H, Kasuya Y. Serotonin release in nucleus of the solitary tract and its modulation by antitussive drugs. Res Commun Chem Pathol Pharmacol 1992; 76:371.
- Steinmiller CL, Maisonneuve IM, Glick SD. Effects of dextromethorphan on dopamine release in the nucleus accumbens: Interactions with morphine. Pharmacol Biochem Behav 2003; 74:803.
- Graudins A, Fern RP. Acute dystonia in a child associated with therapeutic ingestion of a dextromethorphan containing cough and cold syrup. J Toxicol Clin Toxicol 1996; 34:351.
- Warden CR, Diekema DS, Robertson WO. Dystonic reaction associated with dextromethorphan ingestion in a toddler. Pediatr Emerg Care 1997; 13:214.
- Barnhart JW, Massad EN. Determination of dextromethorphan in serum by gas chromatography. J Chromatogr 1979; 163:390.
- Silvasti M, Karttunen P, Tukiainen H, et al. Pharmacokinetics of dextromethorphan and dextrorphan: a single dose comparison of three preparations in human volunteers. Int J Clin Pharmacol Ther Toxicol 1987; 25:493.
- Baselt R, Cravey R. Disposition of Toxic Drugs and Chemicals in Man, Yearbook, Chicago 1989.
- Schadel M, Wu D, Otton SV, et al. Pharmacokinetics of dextromethorphan and metabolites in humans: influence of the CYP2D6 phenotype and quinidine inhibition. J Clin Psychopharmacol 1995; 15:263.
- Pharmacokinetic data. In: Goodman & Gilman's The Pharmacologic Basis of Therapeutics, 11th, Brunton LL, Lazo JS, Parker KL (Eds), McGraw HIll, New York 2006. p.1816.
- LoVecchio F, Pizon A, Matesick L, O'Patry S. Accidental dextromethorphan ingestions in children less than 5 years old. J Med Toxicol 2008; 4:251.
- Paul IM, Reynolds KM, Kauffman RE, et al. Adverse events associated with pediatric exposures to dextromethorphan. Clin Toxicol (Phila) 2017; 55:25.
- Bowdle TA. Adverse effects of opioid agonists and agonist-antagonists in anaesthesia. Drug Saf 1998; 19:173.
- Shaul WL, Wandell M, Robertson WO. Dextromethorphan toxicity: reversal by naloxone. Pediatrics 1977; 59:117.
- Henretig FM. Special considerations in the poisoned pediatric patient. Emerg Med Clin North Am 1994; 12:549.
- Helfer J, Kim OM. Psychoactive abuse potential of Robitussin-DM. Am J Psychiatry 1990; 147:672.
- Hinsberger A, Sharma V, Mazmanian D. Cognitive deterioration from long-term abuse of dextromethorphan: a case report. J Psychiatry Neurosci 1994; 19:375.
- Fleming PM. Dependence on dextromethorphan hydrobromide. Br Med J (Clin Res Ed) 1986; 293:597.
- Dodds, A. Toxic psychosis due to dextromethorphan. Med J Aust 1967; 2:231.
- Schadel M, Sellers EM. Psychosis with Vicks Formula 44-D abuse. CMAJ 1992; 147:843.
- Nicholson KL, Hayes BA, Balster RL. Evaluation of the reinforcing properties and phencyclidine-like discriminative stimulus effects of dextromethorphan and dextrorphan in rats and rhesus monkeys. Psychopharmacology (Berl) 1999; 146:49.
- Ng YY, Lin WL, Chen TW, et al. Spurious hyperchloremia and decreased anion gap in a patient with dextromethorphan bromide. Am J Nephrol 1992; 12:268.
- Horowitz BZ. Bromism from excessive cola consumption. J Toxicol Clin Toxicol 1997; 35:315.
- Liebelt EL, Francis PD, Woolf AD. ECG lead aVR versus QRS interval in predicting seizures and arrhythmias in acute tricyclic antidepressant toxicity. Ann Emerg Med 1995; 26:195.
- Darboe MN, Keenan GR Jr, Richards TK. The abuse of dextromethorphan-based cough syrup: a pilot study of the community of Waynesboro, Pennsylvania. Adolescence 1996; 31:633.
- Schier J. Avoid unfavorable consequences: dextromethorpan can bring about a false-positive phencyclidine urine drug screen. J Emerg Med 2000; 18:379.
- Williams JF, Kokotailo PK. Abuse of proprietary (over-the-counter) drugs. Adolesc Med Clin 2006; 17:733.
- 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
- SOCIETY GUIDELINE LINKS