Download Dextromethorphan – DXM – Triple C By Cardwell C. Nuckols, PhD

Dextromethorphan – DXM – Triple C By Cardwell C. Nuckols, PhD
The next time you walk down the aisle of your local supermarket or pharmacy notice where the
cold and cough remedies are displayed. Imagine you are a 14-year-old looking to purchase an
over-the-counter (OTC) “high.” Look around and see how many possibilities you can find. The
medicine aisle of your pharmacy or grocery store is becoming a favorite aisle for some. This
affinity is not because they are sick but because they are looking to become intoxicated. The
favored intoxicants are cough and cold pills, tablets and syrups containing the cough-suppressant
dextromethorphan. These preparations are often labeled as “DX” or “Maximum Strength.”
For example, in Jacksonville, Florida, the incidence of dextromethorphan overdose doubled in
2001. The average age of those individuals was 15-years-old with a range of 12 to 26 (First Coast
News, 2002). A New Mexico survey of 376 4th to 12th graders found that cold and cough
medicines with dextromethorphan were ranked higher than those without in regard to “getting
high.” The Cincinnati Drug and Poison Information Center reported a series of 19 Coricidin HBP
Cough and Cold cases over a six-week period in 2000. In 2000, there were 25 cases of
dextromethorphan overdose reported to the Maryland Poison Center. Of those, 18 involved use
by adolescents and young adults. Sixteen were classified as intentional abuse and, strikingly,
nine were involved in suspected suicide attempts (Hilmas, 2001).
Pre-teens, teenagers, and young adults are increasingly getting high by using OTC medications
in ways they were not intended. These practices, called “pharming,” include drinking cough syrup
and taking in pill or tablet form large amounts of OTC cough medicine (Forreal, 2003). Cough and
cold medications containing the medication dextromethorphan (DXM), can have devastating
effects on the user. In doses well beyond those recommended, DXM can act as a hallucinogen
such as LSD or as a dissociative agent similar to PCP or Ketamine. In order to create the effect
desired by the abuser, doses in excess of 100 mg are generally required. The recommended
dose for therapeutic cough suppression for adults and children over 12 years of age is 10-20 mg
every 4 hours or 30 mg every 6-8 hours, not to exceed 120 mg daily. The usual dosage for
children 6 to 12 years of age is 5-10 mg every 4 hours or 15 mg every 6-8 hours not to exceed 60
mg daily. Due to increasing tolerance, the abuser may end up consuming doses of over 1,000 mg
(Indiana Prevention Resource Center, 2001). Remember, OTC medications typically contain
other substances such as acetaminophen and/or diphenhydramine that in high dose can have
their own toxic effects.
An example of the practice of “pharming” is the use of Coricidin products. Coricidin Cough and
Cold — “Triple C” — comes in tablet form and contains not only dextromethorphan but also
chlorpheniramine maleate, an antihistamine with CNS depressant qualities similar to alcohol. By
taking five, six, or more times the recommended dosage, these drugs can interact; adversely
amplifying the impact of both drugs. Coricidin HBP Cough and Cold (a special formulation for
those with high blood pressure) contains 4 mg of chlorpheniramine and 30 mg of
dextromethorphan per tablet, equaling the largest amount of dextromethorphan per dosage unit
currently on the market. Users can become intoxicated by taking large doses of cough syrup, a
practice known as “robodosing” or “robo-tripping” (from the trade name Robitussin). They may
take a large number of cold and cough suppressant pills or tablets called “skittles.” Other street
names for dextromethorphan include “robo,” “Vitamin D,” “Red Devils,” “dex,” and “tussin.” Those
who favor the use of cough syrup are often called “syrup heads.”
Unfortunately, there are web sites devoted to teaching individuals — especially adolescents —
how to abuse dextromethorphan. For example, a teenager can find out how much DXM to take
based on their calculated weight, how to obtain the drug in pure powder form, how to drink
several bottles of cough syrup without vomiting and how to isolate the pure drug
dextromethorphan from syrup.
Dextromethorphan (D-isomer of levorpahnol, a semisynthetic morphine derivative) produces its
antitussive activity on the cough center in the medulla oblongata. It has no analgesic properties
1
and is not considered a drug of addiction. Dextro-methorphan is generally considered a safe
drug. Even at very high doses (over 10 mg/kg) death from DMX is rare unless it is combined with
other chemicals such as antihistamines, MDMA, alcohol or antidepressant medications (Hilmas,
2001). There are over 140 non-prescription products containing dextromethorphan. Some of the
more commonly known of these products include Nyquil, Robitussin DM, Triaminic DM, Rondec
DM, Benylin DM, Drixoral, Delsym, Pertussin, Vicks 44, Contac and St. Joseph Cough
Suppressant. Abusers have described their experience as similar to the mind-altering impact
caused by ingesting LSD. There have been accounts of dissociative “out of the body”
experiences similar to those achieved by using the arylcyclohexylamines (PCP and Ketamine).
Auditory and visual hallucinations can occur. At high doses mental changes start to occur along
with tachycardia and hypertension. As the dose increases ataxia, lethargy, confusion, slurred
speech, hallucinations, and seizures may be part of the clinical presentation. Vomiting may occur
creating the danger of aspiration and asphyxiation.
Adverse effects









Decreased ability to regulate body temperature (possible “rave-related heat stroke”).
Dry itchy skin.
Dry mouth and loss of body fluids (anti-cholinergic effects).
Blurred vision, cognitive alterations, and dissociative states.
Hallucinations and delusions.
High blood pressure, redness of face, headache and numbness of fingers and toes.
Lack of muscle coordination.
Loss of consciousness.
Death (rarely and generally in combination with other substances).
Dextromethorphan overdose is generally diagnosed based on clinical presentation and
collaborative data from others who may have observed the individual or are aware of their drug
use history. There is a drug screen available to detect dextromethorphan. Generally, there is a
six-hour turnaround time. Quest Diagnostics Laboratory offers this analysis based on blood
serum evaluation.
Management of overdose consists primarily of supportive measures. In other words, monitoring of
vital signs, maintenance of a clear airway and the use of IV solution if necessary. Activated
charcoal (1 mg/kg) can bind dextromethorphan in the gastrointestinal system and reduce further
absorption. Naloxone (0.4-2 mg IV repeated every 2-3 minutes up to a total dose of 10 mg) has
been used with some success to reverse the respiratory depression and central nervous system
effects of dextromethorphan (Hilmas, 2001).
Law enforcement agencies have discovered that clandestine labs are now manufacturing in
different sizes, shapes, and colors pills that contain DXM. Anyone providing intoxicating doses to
minors or to anyone unaware of the dangers can be subject to arrest based on laws designed to
not only protect juveniles but the public at large.
References
First Coast News. (2002). “Triple-C” Becoming Popular Over–The–Counter High Among Teens. Retrieved on February 14, 2003
from http://www.firstcoastnews.com/ health/articles/2002-02-24/coricidan.asp
Forreal. (2003). Triple C: Part of the “Pharming” Phenomenon. Retrieved on February 14, 2003 from
http://www.forreal.org/think/triplec.asp
Hilmas, Elora. (2001). “Maryland Poison Center Toxalert.” Adolescent Dextromethorphan Abuse. Volume 18, Issue 1.
Indiana Prevention Resource Center. (2001). Non-medical use of Dextromethorphan a/k/a “DXM.” Retrieved on February 14,
2003 from http://www.drugs.indiana. edu/publications/iprc/factline/dxm.html
Medline Plus Health Information. (2002). Dextromethorphan Overdose. Retrieved on February 14, 2003 from
http://www.nlm.nih.gov/medlineplus/ency/ article/002628.htm
Neary, Susan Russell. (2002). From Poisons to Therapeutics: The Historical Origins of Contemporary Pharmacology. Retrieved
on February 14, 2003 from http://www.medscape.com/viewarticle/439913
This article is published in Counselor, The Magazine for Addiction Professionals, June 2003, v.4,
n.3, pp. 29-30.
2