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A Guide to DXM Abuse & Treatment
What Is Dextromethorphan?
Dextromethorphan, or DXM, is the primary cough suppressant drug found in several over-the-counter (OTC) cough medicines. DXM is considered a legal substance by the FDA, and it does not require a prescription to obtain medicines that contain it. In recommended medicinal doses, DXM has few risks. In high doses, however, it can have psychoactive effects similar to PCP and ketamine, with many potential health consequences.1
Common street names for DXM include CCC, Triple C, Skittles, Tussin, and Robo (short for Robitussin). Illicit use of DXM is sometimes referred to as “skittling” or “Robo-tripping.” It is most often acquired through OTC cough medicines but can also be purchased in powder form online.
The typical medicinal dose is 15–30 mg, but abuse of DXM tends to involve doses ranging between 100 and 1500 mg, depending on the desired effects.1,2 These high doses can produce the psychoactive effects that characterize a DXM trip, but can also cause serious harm to the user.
Research into the effects and dangers of DXM is extremely limited and mainly centered around case studies, which cannot be generalized to the wider public. As more and more information is uncovered, it is becoming increasingly clear that abusing DXM can have very bad consequences for the user.
What Are the Effects?
DXM can have euphoric, hallucinogenic effects when abused. Many users report heightened senses, disruptions in time perception, and visual hallucinations. These effects depend largely on the dose. At medicinal doses, the user will simply experience the intended medical benefit of reduced coughing. As the dose increases, however, the psychoactive effects come into play. Many users describe these trip phases as effect “plateaus” with particular symptoms for each stage:1,3
- Plateau 1, 100–200 mg: Mild stimulation, restlessness, some euphoria.
- Plateau 2, 200–400 mg: Hallucinations begin, exaggerated senses, euphoric feelings, imbalance.
- Plateau 3, 300–600 mg: Poor motor coordination, vision/hearing is distorted, slow reaction times, mania, panic, some mild dissociation.
- Plateau 4, 500–1500 mg: Extreme sedation, hallucinations, delusions, loss of body control, complete dissociation.
These effects represent the desired high from abusing DXM, but there is also an ugly side. DXM intoxication also typically involves exhaustion, slurred speech, sweating, abnormally high blood pressure, loss of body control, and being hyper reactive to stimuli.2 The effects generally last 5–6 hours, but this amount of time can vary depending on the dose and use of other substances.1,2
The DXM high can include other disturbing side effects, such as:2
- Panic attack.
- High blood pressure.
- Impaired mental performance.
- Hot flashes.
- Rapid heart rate.
- Loss of the sense of self (complete dissociation).
These side effects reflect the adverse interaction between DXM and several physiological processes that impact both the body and brain of the user. These effects may even give rise to acute psychological issues if the DXM trip gets too intense. Complete dissociation means that the user completely loses their sense of self, which can easily turn into a terrifying trip.
Is It Safe?
Just because DXM is available in OTC cough medicines does not make it safe. When abused regularly, DXM may actually cause insomnia and general unhappiness.2 When taken in doses that exceed medicinal benefit, DXM can put the user in a very vulnerable state of confusion, dissociation, and drowsiness. They may end up accidentally hurting themselves or others.
On top of the risk of side effects and accidental injury, DXM abuse has a hidden danger that may be one of the biggest threats to the user: other ingredients. Many of the DXM-based cough medicines have a number of other medicinal ingredients to help alleviate other cold symptoms, which come with their own serious risks when taken in high doses:2,4
- Acetaminophen (pain reducer): Liver damage
- Antihistamines (allergy relief): Poor coordination, heart problems, seizures, coma
- Pseudoephedrine (stuffy nose and sinus relief): Increased blood pressure
- Guaifenesin (mucous clearing): Severe vomiting
In high doses, these other ingredients can cause serious, long-lasting damage. In the event of complications such as liver damage and cardiovascular injury, these chronic issues may need to be managed for the rest of the person’s life. Taking DXM in high doses is simply not safe. In fact, it can be downright dangerous.
Dangers of Mixing
Some users mix DXM with other substances, such as alcohol or MDMA (ecstasy or “Molly). This is particularly dangerous when it comes to DXM abuse. Most deaths related to DXM use involved co-abuse of DXM and other substances.4 Taking high doses of DXM in combination with alcohol or other drugs can synergize their effects, meaning the respective effects of each substance, including the dangerous ones, can be amplified by the presence of the other substances in the body.2
Taking high doses of DXM with alcohol can result in breathing problems, or even stopped breathing in some cases, which can be deadly.5 Combining DXM cough medications and alcohol can also result in extensive liver damage due to the compounded effects of alcohol and substances like acetaminophen that are damaging to this vital organ.
When combined with a drug that affects serotonin activity in the brain, such as MDMA or certain antidepressant medications, high doses of DXM can cause a very dangerous set of symptoms—collectively known as serotonin syndrome.3 Serotonin syndrome can be life-threatening, with extreme situations having the potential to result in coma or death. Symptoms include:6
- Body trembling.
- Muscle rigidity.
- High blood pressure.
- Abnormally high heart rate.
- High body temperature.
Mixing DXM with other drugs can be extremely risky, especially considering the other ingredients that often accompany DXM in cough medicines. The dangerous effects of each drug may be amplified by the other, resulting in potentially long-standing health consequences, including death.
Can You Overdose?
Deaths due to DXM use alone are very rare but not unheard of. When DXM is part of a diverse formulation of many other drugs, as it often is with cough medicines, assessing overdose risks is a complicated task. Many of the added medications in cold and cough formulations can induce vomiting in high doses. Some people seeking a DXM high use these OTC cough medicines in high doses, which can unintentionally cause them to vomit. This gets rid of a lot of the DXM before it can be metabolized, which can help prevent an overdose situation.4
Around 5–10% of Caucasians have a hard time metabolizing DXM, which can increase their risk of suffering a deadly overdose.
Most DXM-related deaths have more to do with other substances: either other ingredients in OTC cough medicines or other recreational drugs taken at the same time. Some of the other ingredients present in OTC cough medications, like acetaminophen, can cause all kinds of damage to the user’s body. In high doses, these medicinal substances can turn deadly, causing organ damage, heart attack, or even a stroke.2 Around 5–10% of Caucasians have a hard time metabolizing DXM, which can increase their risk of suffering a deadly overdose.1
Taking DXM with other drugs, like alcohol, MDMA, or certain antidepressant medications, can induce life-threatening symptoms, including serotonin syndrome.2,4 Other drugs can interact with DXM in the body to produce symptoms that are even more dangerous than either substance on its own.2
In addition to direct symptom dangers, a person high on DXM may be so intoxicated and out of touch with reality that they end up accidentally injuring or killing themselves or others. If a person gets high on DXM and tries to drive, for example, they could end up getting in a serious vehicle accident. DXM has powerful effects on a person’s visual and auditory perception, putting the user in an extremely vulnerable state that could unknowingly lead them into a dangerous situation.
The long-term effects of DXM abuse have not been exhaustively investigated.5 There isn’t much information on what kinds of consequences a long-term user may suffer, but available case studies point to both physical and mental health disturbances. Regular abuse of DXM has been found to cause insomnia and dysphoria, or a general dissatisfaction with life.2
Frequent use of high doses of DXM can lead to a condition known as toxic psychosis.2 Toxic psychosis generally involves the loss of contact with reality, with the person in a constant state of confusion.2 This constant state of psychosis can be both disturbing and dangerous for the person suffering it.
On top of these potential consequences, frequent DXM users may find themselves falling into a pattern of abuse and dependence.2 DXM has been found to have some addictive qualities, with chronic users reporting tolerance and mild dependence.
Is It Addictive?
Frequent high-dose DXM users have reported moderate physical dependence and tolerance to the drug.2 Tolerance means that the user needs higher and higher doses in order to get the same effects. Dependence means that the user’s body has gotten so used to the presence of DXM that it struggles to function normally without it. Both tolerance and dependence are risk factors for developing an addiction.
Another aspect of dependence is the presence of withdrawal symptoms when a person stops using the drug. Chronic DXM users have reported that withdrawal symptoms typically begin within 3 days after stopping DXM use and resolve within 2 days after onset.3 DXM withdrawal symptoms can include:2,3,7
- Upset stomach.
- Extreme weight loss.
- Muscle aches.
- Cold intolerance.
A substance use disorder involving a substance like DXM can impact every aspect of the user’s life, from work and school performance to social and interpersonal functioning. When diagnosing a substance use disorder, addiction professionals will consider whether the person:8
- Takes the drug in higher doses or for a longer period of time than intended.
- Wants to reduce or stop using the drug but is unable to do so.
- Spends a lot of time trying to get, use, or recover from the drug.
- Experiences cravings or has a strong desire to use the drug.
- Repeatedly fails to fulfill major obligations at home, school, or work because of drug use.
- Continues to use despite persistent or recurring interpersonal or social problems caused or made worse by drug use.
- Reduces or stops important occupational, social, or recreational activities because of drug use.
- Repeatedly uses the drug in physically dangerous situations, like driving.
- Continues to use the drug despite the persistent or recurring psychological or physical difficulties related to drug use.
- Develops a tolerance to the drug’s effects, meaning either needing more of the drug to get the same effects or finding that the same amount does not have the same effect.
- Experiences withdrawal symptoms when not using the drug, or uses the drug to avoid withdrawal symptoms.
Meeting 2–3 of the above criteria within a 12-month period could be indicative of a mild substance use disorder; 4–5 meets diagnostic criteria for moderate, and 6–7 for severe substance use disorder.8 Meeting any of these criteria is a bad sign, and it is very important to get professional help for a DXM abuse problem as soon as possible.
The first stage of addiction treatment involves clearing the body of all the drugs in its system, a process known as detox. This is done through sustained abstinence, which can be a difficult task once withdrawal symptoms start to arise. Working with a professional treatment program can ensure that you have the best care throughout this phase. A medical detox may even provide pharmaceutical support to help alleviate some of the withdrawal symptoms so you will be as safe and comfortable as possible throughout detox.
Once your body is DXM-free, you can begin the formal treatment process, where you will learn how to live your life without the maladaptive supports of DXM or any other abused substance. Treatment will help you identify high-risk relapse situations and teach you skills to cope with cravings so that you can maintain abstinence long-term. There are many different types of treatment programs, with each employing somewhat different therapeutic approaches. The first thing you’ll want to consider is whether you want to be in an inpatient program or an outpatient program.
An inpatient program is when you stay at the treatment facility for the duration of your treatment plan. This escape from daily life allows you to focus entirely on recovery in a 100% sober environment. Inpatient programs provide 24-hour medical and psychological support, though they often will cost more than outpatient programs.
An outpatient program is when you continue to live and sleep at home for the duration of treatment. These require that you check in on a regular basis for treatment sessions and medical check-ups. Some outpatient programs also perform regular urine tests to check that you are maintaining sobriety throughout the program. Outpatient programs are an excellent option for a person who has strong internal and external motivation to get clean, but they may pose a challenge for someone who is not fully committed to recovery.
Whichever program you choose, inpatient or outpatient, you will probably work through group and individual counseling and therapy. Therapy sessions can utilize many different approaches, depending on your own individual needs. What works for one person won’t necessarily work for another. It is important that the program you choose adapt your treatment plan to your particular situation. Some common therapy approaches in addiction treatment include:
- Cognitive behavioral therapy: Learn how to identify and avoid relapse triggers, as well as develop a better understanding of your own substance use motivations.
- Motivational interviewing: You will work with the therapist to explore and resolve any ambivalence you have when it comes to recovery.
- Contingency management: Also known as motivational incentives, this approach offers you rewards for meeting recovery goals.
Treatment will help you identify high-risk relapse situations and teach you skills to cope with cravings.
Once you complete a formal addiction treatment program, you may want to consider exploring various aftercare options to help you maintain abstinence. Many treatment programs will help you in setting up an aftercare plan so that you can resist relapse. Aftercare can involve many different things, depending on what works for you. Some aftercare options are:
- Continuing group or individual therapy to help bolster your abstinence skills.
- Support groups, including 12-step options, which are a free option for building a sober community and reinforcing the lessons you learned in treatment.
- Sober living, which could entail halfway housing or other form of sober residence with other peers in recovery where you can avoid relapse temptations as much as possible.
No matter which path you choose, the most important thing is that you avoid returning to your substance use problem. DXM abuse can have many negative consequences, but there is always help available to motivate your abstinence.
Recovering from DXM abuse is possible; all you have to do is reach out for help. If you can commit yourself to getting clean and leaving your DXM addiction behind you, you will find a satisfying life in recovery. Don’t wait until it’s too late to get help for your DXM problem. Find help today.
- Drug Enforcement Administration. (2014). Dextromethorphan.
- Center for Substance Abuse Research. (2013). Dextromethorphan (DXM).
- Antoniou, T., Juurlink, D. (2014). Dextromethorphan abuse. CMAJ, 186(16), E631.
- National Drug Intelligence Center. (2004). Intelligence Bulletin: DXM (Dextromethorphan).
- National Institute on Drug Abuse. (2015). Hallucinogens and Dissociative Drugs: What Are the Effects of Common Dissociative Drugs on the Brain and Body?
- Volpi-Abadie, J., Kaye, A. M., Kaye, A. D. (2013). Serotonin syndrome. Ochsner J, 13(4). 533–540.
- Martinak, B., Bolis, R., Black, J., et. al. (2017). Dextromethorphan in Cough Syrup: The Poor Man’s Psychosis. Psychopharmacological Bulletin, 47(4). 59–63.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.