Dextromethorphan, which sometimes is referred to as DXM or DM, is an over-the-counter medication that can temporarily alleviate coughing due to a cold, flu, or other ailments. Dextromethorphan belongs to the medication class known as antitussives. It is available alone or in combination products with other medications such as antihistamines and decongestants. Some dextromethorphan-only products include Delsym, Robitussin 12 Hour Cough Relief, and Vicks DayQuil Cough. Several brands (e.g. Mucinex, Tylenol, Sudafed, Theraflu, Vicks, and Robitussin) have multiple products that contain dextromethorphan combined with various other medications.
In 1958, dextromethorphan was approved by the FDA as an over-the-counter cough suppressant under the brand name Romilar. Romilar was removed from the market in 1973 due to concerns about misuse, but other cough syrups that had dextromethorphan in them were still available because it was thought that they were less likely to be abused.
Dextromethorphan is a synthetic drug that is a D-isomer of levomethorphan, an opioid analgesic. It is thought that dextromethorphan may work in the medullary cough center by triggering sigma opioid receptors. Although related to other opioids, dextromethorphan does not produce analgesia and has little sedative effect.
Dextromethorphan’s main metabolite functions as an antagonist for the N-methyl-D-aspartate (NDMA) receptor, so, in high doses, DXM’s effects are similar to drugs like ketamine and phencyclidine (PCP). Dextromethorphan is often abused for its euphoric and hallucinogenic effects. There are a number of street names associated with dextromethorphan, including dex, skittles, robo, triple C, and poor man’s PCP. Misuse of DXM is sometimes referred to as “robo-tripping” or “skittling”.
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Effects of Recommended Use Compared to Excessive Use
Dextromethorphan is available in various oral formulations. Dosing for both syrup and liquid formulations is either 10 to 20 mg every 4 hours or 30 mg every 6 to 8 hours. For extended-release dextromethorphan, 60 mg can be taken every 12 hours. Dosing for both oral strip and oral gel formulations is 30 mg every 6 to 8 hours. For the lozenges, 5 to 15 mg can be taken every 1 to 4 hours. Regardless of formulation, an adult should never take more than 120 mg of dextromethorphan in a day, and maximum daily doses are even lower for some children.
Dextromethorphan’s medicinal effects typically begin after 15 and 30 minutes, reach their maximum around 2 to 3 hours, and end at or before 6 hours. Like any medication, there are potential side effects, including constipation, drowsiness, nausea, vomiting, dizziness, sedation, nervousness, and confusion.
According to the United States Drug Enforcement Administration (DEA), there are four levels of “plateaus”, based on dose, reported by individuals who abuse dextromethorphan.
- The first plateau is between 100 mg and 200 mg. At this level of abuse, the effect is a mild stimulation.
- The next plateau occurs between 200 mg and 400 mg. Individuals taking the drug at this level will likely experience hallucinations and euphoria.
- The third plateau occurs between 300 mg and 600 mg. Individuals at this plateau will likely experience issues with motor coordination and distorted visual perceptions.
- The highest plateau is between 500 mg and 1500 mg. At this level, individuals can experience dissociative sedation.
Signs of Robotripping
The DEA reports that dextromethorphan abuse spans all ages but is especially concerning in teenagers and young adults. According to one study, among reviewed cases of dextromethorphan abuse reported to the California Poison Control System (CPCS), 74.5% involved 9- to 17-year-olds and the median age was 16 years old.
Signs that suggest that an individual may be suffering from a substance use disorder include:
- Using the drug more or in larger amounts than intended
- Spending a lot of time obtaining, using, or recovering from the drug
- Craving the drug
- Doing risky activities to obtain the drug and/or while under the influence of the drug
- Continuing drug use despite significant consequences, such as trouble with relationships or health problems
- Having trouble fulfilling important responsibilities at school, work, or home due to regular drug use
- Stopping or decreasing other activities because of drug use
- Experiencing tolerance and/or withdrawal
- Unsuccessfully trying to stop drug use
Signs of dextromethorphan misuse may include:
- Purchasing large amounts of the drug
- Using dextromethorphan in significantly higher amounts or significantly more often than directed by the label
- Using dextromethorphan in the absence of a cough or using combination products in the absence of indicated conditions
Individuals who take more than recommended amounts of the drug are at risk of overdosing. Signs that an individual may have overdosed on DXM include the following:
- Rapid heartbeat
- Trouble breathing
- Vision changes
Individuals who take excessive doses of combination products containing dextromethorphan may also overdose on the other medication(s) in the product as well as DXM or even before they would overdose on DXM. If you think that you or someone else may have overdosed on dextromethorphan or another medication, call the poison control helpline at 1-800-222-1222 or call 911. In an emergency, always call 911.
Dextromethorphan overdose is mainly treated with supportive care. Use of activated charcoal may be beneficial by binding dextromethorphan and its primary metabolite. According to one study, it is unclear whether it is valuable to administer naloxone to individuals suffering from dextromethorphan poisoning. A more recent study asserts that because it is not clearly beneficial, naloxone use is not generally recommended for treating dextromethorphan overdose.
Treatment for Continued Robotripping
Anyone who may be struggling with a substance use disorder, whether that involves dextromethorphan, other drugs, or both, should be evaluated by a health care professional. Addiction is a chronic disease that, if left unaddressed, can lead to disability or death. Other drugs are often misused along with dextromethorphan, which can make diagnosis and treatment more complex. Research-based treatment for addiction can help individuals learn to manage their illness and avoid relapse.
Some individuals who abuse dextromethorphan may also have co-occurring mental illnesses, such as depression, anxiety disorders, or other mental health issues. It is extremely important that all individuals starting treatment for a substance use disorder receive thorough assessments to evaluate for any co-occurring disorders. Individuals with both a mental illness and a substance use disorder frequently have more severe and persistent symptoms that are more resistant to treatment than individuals who just have one or the other. Any comorbid mental illnesses should be treated concurrently with the individual’s substance use disorder.