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Kentucky News: Dextromethorphan: Friend or Foe
Published in the June 2006 Kentucky Board of Pharmacy Newsletter
In this age of substance abuse, there are a multitude of compounds being consumed by various populations. No longer are we only concerned about “street drugs” and access to prescription drugs for abuse, but also OTC drugs. In recent years there has been a flurry of media coverage over the use of pseudoephedrine in the synthesis of methamphetamine, as well as a host of new laws governing the sale of the decongestant. Meanwhile, a drug of choice is slipping under the radar. The newest party accessory for adolescents is much less expensive than fashionable clothes and shoes and it can be found on pharmacy shelves, grocery shelves, convenient store shelves, and various other retailers.
Dextromethorphan (DXM) is a cough suppressant found in as many as 70 OTC cough and cold formulations. Typically, this drug is used to relieve non-productive coughs; however, it has become one of the latest sources of a “high” amongst young people nationwide. Currently there are no laws governing the sale of products containing DXM, despite the fact that it is a chemical related to morphine. It lacks narcotic properties, except in the instance of overdose.
DXM acts centrally to elevate the threshold for coughing. At recommended doses the drug is safe and effective; however, at higher doses it produces dissociative effects similar to those of phencyclidine, also known as PCP, and ketamine. The positive effects of DXM use include: euphoria, enhanced awareness, dissociation of the mind from the body, creative dreamlike experiences, and warm feelings toward others. These are the effects that are sought by those using this drug recreationally. The negative, and often disregarded, effects of DXM use include: tachycardia, fever, nausea and/or vomiting, diarrhea, and dizziness. Over consumption of this drug can lead to seizures, psychosis, brain damage, coma, and death.
As with any drug of abuse, there is a certain language that is used in connection with DXM use. Some of the most common phrases are: Orange Crush, Triple Cs, Red Devils, Skittles, DXM, Dex, Vitamin D, Robo, Robo-trippin, and Robo-dos¬ing. The “Robo-” terminology relates to the widely recognized source of DXM, Robitussin® products. Two terms that may not be as familiar are “Skittles” and “Red Devils,” which relate to Coricidin, which are small, round, red tablets. Hence, the term “skittling” refers to someone that is under the influence of DXM. These tablets look so much like little red candies that teens have reported consuming these tablets while in school without anyone realizing it.
Prolonged use of DXM may result in tolerance and physical dependence. It is believed by clinicians that there is also a strong psychological component of DXM addiction. Withdrawal symptoms include: restlessness, muscle or bone aches, insomnia, diarrhea, vomiting, and cold flashes with goose bumps (“cold turkey”). It may take months for some of these symptoms to dissipate.
Not only is there concern over the possibility that adolescents will overdose on DXM, but also other ingredients in the DXM source. Many cold and cough preparations also contain active ingredients such as acetaminophen, antihistamines, and pseudoephedrine. FDA has determined that acetaminophen overdoses lead to more than 56,000 emergency room visits a year. Coupled with the other ingredients in the cold medications, adolescents abusing DXM are at increased risk of requiring hospitalization.
While not currently regulated by the government, there are many steps that the pharmacy profession can take to control the sale of DXM containing products. The most logical step is to move these products behind the counter, especially those that contain DXM as the sole ingredient. This would also help to decrease the theft of these products. Another deterrent to adolescent DXM abuse is to make it a “store policy” that sales are made to adults only. While these may seem obvious, these are just a few things pharmacists can do to help lessen abuse of DXM by today’s youth.
