Evidence-Based Reviews

Dependence risk with chronic dextromethorphan abuse

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‘Robo-ing’ patients may meet diagnostic criteria


 

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Habitual users of dextromethorphan can develop symptoms that meet DSM-IV criteria for substance dependence. A common ingredient in nonprescription cough syrups, dextromethorphan is considered nonaddictive but is far from benign in excessive dosages.

To illustrate the risks of dextromethorphan abuse, this article:

  • presents the case of an adult with apparent dependence
  • provides evidence of psychiatric and medical consequences of chronic excessive use of this cough remedy
  • offers a glimpse at how dextromethorphan is described on the Internet, where information on its recreational use is readily available.1

Box 1

Dextromethorphan’s mechanism of action and metabolism

Dextromethorphan acts on the brain’s cough center, the medulla oblongata, raising the cough reflex threshold. It is well-absorbed by the GI tract, metabolized in the liver by the cytochrome P-450 2D6 isoenzyme, and excreted in the urine unchanged or as a demethylated metabolite.2,3

Interaction between dextromethorphan and MAOIs resulting in serotonergic syndrome has been well-documented.4

Dextromethorphan has a 15- to 30-minute onset of action and peaks in 2.5 hours. Duration of action is 3 to 6 hours.5 Though dextromethorphan is an opiate analog, it is regarded as having no analgesic or addictive properties.6 When taken in therapeutic dosages—one-sixth to one-third ounce of medication containing 15 to 30 mg dextromethorphan—it is considered highly effective and safe,1 with no analgesic, euphoric, or dependency-producing properties.3

Dextromethorphan has a wide margin of safety. Doses 100 times the recommended amount have not been fatal,1 although overdose deaths have occurred.3

WHY DEXTROMETHORPHAN?

Dextromethorphan is a antitussive (cough suppressant) developed in the 1950s as a nonopioid alternative to codeine. Considered safe and effective at therapeutic dosages (Box 1),1-6 it can cause dissociation and psychotic effects in overdose.

Dextromethorphan is an attractive drug of abuse because it:

  • produces the desired intoxicating effect
  • is inexpensive—usually less than $5 a bottle
  • is easy to purchase without prescription in >120 cough syrup preparations.7
On the other hand, dextromethorphan is not as accepted by drug users as are marijuana, alcohol, and cocaine. Our patients tell us:
  • persons who abuse cough syrup say it tastes terrible
  • the hallucinations and dissociation associated with dextromethorphan intoxication can be unpleasant, even frightening
  • cough syrup is seen as a drug for “losers.”
Those who use dextromethorphan chronically tend to do so in solitude, which suggests that many users may go unrecognized.

CASE: 11 YEARS OF ‘ROBO-ING’

Mr. E, age 26, presented to our clinic for a court-ordered evaluation of substance abuse after his third drunken driving arrest. A college senior and father of three, he denied abusing nonprescription medications but volunteered that his alcohol consumption was “under control.” He said he continued to “drink on occasion,” including “less than three” glasses of wine the night of his arrest.

At the counselor’s recommendation, Mr. E underwent intensive outpatient counseling. He accepted that he had a genetic predisposition to addiction, gained insight into his alcohol abuse, and began a 12-step recovery program. The day he was to be discharged from treatment, however, Mr. E asked for a session with his counselor and revealed that he had been abusing “DXM” (dextromethorphan) in cough syrup for 11 years. He admitted drinking two 6- to 8-oz bottles of Robitussin-DM-brand cough syrup daily for the last 5 years, an activity he called “Robo-ing.”

He claimed to be a “highly revered teacher.” He said he “championed DXM use” and that “everyone looked up to” him because he had introduced “hundreds of people to the high.”

He had taught others to camouflage the cough syrup’s taste by chewing gum or gulping soft drinks. Maintaining a steady DXM level in the body “enhances” any other drug or alcohol use, he said. Mr. E described his DXM use fondly, though now with some fear.

Mr. E begged for help. Because of DXM use, his marriage was failing, he had been fired from his job, he was struggling to pay his legal fines, and he had spent time in jail. He feared he had damaged his brain and worried that his DXM use might have contributed to birth defects in two of his children.

Mr. E continued outpatient psychotherapy for 5 months to address his DXM use triggers—seeing cough syrup in stores, any alcohol use, and stress. He researched DXM addiction and was amazed to find no 12-step programs or information on DXM and birth defects.

We met with him 7 months after discharge. He reported that his marriage “has never been better,” and his children seemed to have no developmental delays. He was graduating from college and returning to his hometown to work.

Two years later, he is back in treatment for dextromethorphan abuse.

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