Since their introduction, preparations containing the over-the-counter drug dextromethorphan (DXM) have been used in a manner inconsistent with their labeling, often as a recreational drug or for spiritual experiences. Dextromethorphan has little to no dissociative/hallucinogenic effect at medically approved dosages, which range from about 5-60 milligrams. Dextromethorphan's dissociative properties are typically exhibited at dosages above about 150 mgs. As described by William White and some recreational users of the drug, dextromethorphan's dissociative are spread out over a series of plateaus, differentiated by range of dosages.
People who study the specific effects of psychotropic substances classify DXM as a dissociative drug, a major subclass of hallucinogenic drugs. It generally does not produce withdrawal symptoms characteristic of physically addictive substances, but psychological addiction has been reported by some users.
In 1958 the Food and Drug Administration (FDA) approved the use of dextromethorphan as an antitussive, in response to the rampant recreational use of, and addiction to, the now DEA-scheduled codeine that was present in cough medicines at the time. The perceived advantages of dextromethorphan in comparison to codeine were the lack of physical addiction, no abuse potential and the absence of a sedative-like effect from a normal dosage. Two years after its approval, dextromethorphan was finally marketed in the United States as Romilar, a dextromethorphan-only pill, which touted itself as the safe cough medicine alternative to the heavily abused codeine. While it did produce few side effects, it did not take long for a few users to discover dextromethorphan's non-medical use potential. This most likely came from users of codeine based cough medicine who wondered if the new medicine had any recreational use potential.
The removal of Romilar from shelves in 1973 left many wondering if dextromethorphan would be phased out in favor of a new compound less susceptible to abuse that could alleviate coughs as well as codeine and dextromethorphan. Manufacturers instead re-released dextromethorphan to the public in syrup form, which is theoretically harder to misuse. While some allege that reports of abuse went down mainly because of the unattractive delivery agent, William White, a dextromethorphan researcher, suggests the plunge in DXM abuse cases was mainly due to the availability of more appealing hallucinogens such as LSD, and psilocybin.
The 1980s saw recreational dextromethorphan use remain localized in small groups of users, notably the hardcore punk community. While many now regard DXM's potential for abuse as common knowledge, in the 1980s due to the lack of widespread Internet access and sources for reputable information on drugs, many were left in the dark about its psychoactive properties.
The early 90s trend of DXM use followed closely to the 80s due to the War on Drugs, and the lack of information about dextromethorphan. The Internet began to take shape around the world at this time allowing many to communicate with a defined topic at hand. Much of the early (and current) dissemination of knowledge on DXM was conducted on Usenet, calling attention to an obscure psychoactive drug. As the availability of access to the Internet became more common, dedicated websites with more accurate (and more scientific) information concerning DXM appeared, and were easily found by many. This flow of information has only increased with time. The growth of the Internet and the ease of spreading information also led to deaths from DXM coming to light. There are now websites largely focusing on documenting the circumstances of these deaths.
Late 1990s - present
As of the late 1990s, dextromethorphan became available in pure powder form from various grey-market chemical retailers. As the United States Drug Enforcement Administration became increasingly aware of online research chemical sales, it launched Operation Web Tryp, which completed on July 21, 2004. The operation resulted in ten arrests and the shutdown of several websites selling research chemicals. Because many of the online vendors also sold DXM in pure powder form, this affected the recreational DXM community by making DXM powder significantly harder to find, forcing some users to use over-the-counter medical products instead.
Dextromethorphan is most frequently consumed in the form of over-the-counter cough medicine preparations. Commonly used brands worldwide are Robitussin, Romilar, Coricidin, Zicam and Delsym. Slang terms for DXM often relate to the brands, such as "tussin" or "robo", "Red Baron", "dex," "skittles," (in reference to the physical appearance of Coricidin). Colloquially, use of DXM for its psychoactive effects is frequently referred to as "dexing," "tussing," "robofrying," "robotripping," or "doing the robot".
It should be noted that Coricidin, a popular preparation of DXM, is extremely dangerous at recreational doses because it also contains Chlorpheniramine Maleate, which is potentially fatal at high doses (see Preparations and their Risks)
William White's DXM FAQ
The plateau model of DXM effects seems to have emerged largely from the Internet drug culture of the mid-1990s, especially William White's FAQ. This document, which was little known outside the online drug community, details DXM's effects, chemistry and dangers in lengthy detail. Using science, history and hands-on reports from individual users, White's FAQ acted as a virtual manual for the interested dextromethorphan user. At first, White presented DXM as a generally benign drug, but in 2002, researcher J. W. Olney found a connection between dissociative use in rats with lesions of the brain. These became known as Olney's lesions, and White, upon receiving various reports from users reporting apparent long-term effects, changed his introduction to warn users more vigorously of possible brain damage. Olney's claims have since been contested, and William White has concluded that due to the lack of information and research on the occurrence of Olney's lesions in humans, no clear conclusions can be made about the risk of brain damage from DXM abuse.
While the maximum FDA approved dose of dextromethorphan is 30 mg, in significantly higher doses of 150 mg to 2000 mg, dextromethorphan is recreationally used as a dissociative drug that can cause depersonalization, euphoria, dissociation, dreamlike mental effects, visual and aural hallucinations, and in sufficiently high doses, out of body experiences. Some use high doses for spiritual purposes or to attain a greater self-knowledge. The recreational effects of dextromethorphan typically last between 4-8 hours, although the duration may increase with higher doses (12-48 hours) and may be greatly extended in individuals with a variant CYP2D6 allele (approximately 6-10% of the white population).
The author of the DXM FAQ, William White, opined that the levels of the DXM experience come in dose-dependent stages, or "plateaus," with each plateau possessing different characteristic effects. Some users observe distinctive differences between each plateau. Further information on DXM and DXM's plateaus may be found in Erowid's DXM Vault. This system for distinguishing doses is very popular within the DXM community. It is common to see the plateau system discussed (with varying accuracy to the original specification) on DXM web sites and news articles.
Lower plateau doses of dextromethorphan are characterized by a mild intoxication and euphoria similar to a combination of MDA and alcohol, due to its serotonin and dopamine reuptake inhibition. Often, audio intake is altered, leaving the user with an altered perception of sound. This alteration causes the brain to process sounds slower, making music sound more defined and bold. Frequent users of dextromethorphan frequently emphasize how much music often adds to the pleasure of a DXM 'experience'.
Moderate doses tend to decrease agility, coordination and affect the user's perception of time. Many users of the substance report that the coordinative effects of dextromethorphan create the feeling that one is a 'thick fluid.' Sound may take on a flanging effect and the user may have difficulty distinguishing distances between objects. Dissociative cognitive effects become apparent, resulting in the user feeling "detached" or "disconnected" from reality. Closed eye hallucinations may be observable.
High dose effects have been compared to the effects of ketamine, a dissociative anaesthetic frequently used in veterinary treatment as well as extramedically. The higher dosages can also exhibit a significant depersonalization and dissociation, bizarre thought patterns, and the user often feeling completely disconnected from external reality. Users may also feel as if they are part of an object or universe. Marked changes in sensory perception are unescapable and can include lilliputian hallucinations. Coordination is significantly impaired, and many users are unable to move comfortably. Possibly linked to this significant coordinative impairment, a 'chaotic blindness' may be experienced by some, in which the brain may be so confused and overloaded with sensory information that it has a significantly difficult time processing visuals. Out of body experiences and religious experiences are common. Extending the duration of the DXM trip through pre-dosing (taking multiple "booster" doses throughout the day before the main dose) may bring about a separation from reality which has much in common with forms of psychosis: extreme schizophrenic hallucinations, such as hearing voices or music, seeing entities with eyes open, and experiencing a total breakdown of reality. Reliving or viewing of past memories is also common. Dextromethorphan becomes toxic at 20 - 30 mg per kg of bodyweight, producing vomiting, fever, and possibly coma or death.
Neutral effects of using DXM include "robo-walk" (when a user on DXM walks like a robot due to loss of coordination), discoordination, trismus and bruxia (clenched jaw, teeth-grinding), vertigo, and pupil dilation.
Negative effects can include fever, diarrhea, vomiting, and severe nausea. Using DXM can also cause hangovers on the following day, and is extremely dangerous when used in combination with alcohol. The effects of long term use are widely speculated.
Some DXM mixtures have the active ingredient listed 'dextromethorphan polystirex' on the bottle. This merely extends the DXM's half-life to 10-12 hours, resulting in a longer trip.
While antitussive preparations containing DXM are legal to purchase from most pharmacies worldwide, it may be illegal to purchase bulk DXM that is intended for laboratory use if one intends to use it recreationally.
In the United States, 2003 saw Texas and North Dakota vote against bills that would prohibit the sale of products containing DXM to minors. In 2004 California also followed suit and voted against a bill similar to the ones proposed in Texas and North Dakota. Although these three states have been unable to pass these bills, New York in 2004 passed legislation making the distribution of two or more dextromethorphan-containing products to a minor a misdemeanor (Bill Summary - S06244). This variation in States’ decision to restrict the availability of dextromethorphan to minors is a contested matter.
In 2005, the Virginia General Assembly considered HB 2045, a bill to make distribution of DXM to minors a Class 1 misdemeanor.
During the 2006 legislative session Oklahoma introduced HB2485, by Rep Nance, author of the landmark pseudoephedrine act, to ban the sale of DXM to individuals under the age of 18, and to limit the quantities sold to adults. The bill was stripped of language and resulted in the Governor's Task Force on the Abuse of Household Products. As of Oct 2006 this task force is meeting to discuss effective restrictions on DXM products.
A few pharmacies around the United States have started to put DXM-containing products behind the counter and putting an age limit of 18 on purchasing them (notably Coricidin brand products). It is possible that this stems from concerns regarding shoplifting rather than recreational use.
DXM is specifically excluded from regulation under the Schedules of the Single Convention on Narcotic Drugs.
DXM appears to be available over the counter in most countries other than Hong Kong and Thailand.
Preparations and their risks
Most over-the-counter cough medicines contain other drugs besides dextromethorphan that can be quite dangerous when taken in high doses. These ingredients include acetaminophen (Also referred to as paracetamol or APAP) and chlorpheniramine maleate (an anticholinergic antihistamine contained in Coricidin Cough & Cold which can cause severe and life-threatening symptoms including: seizures, shortness of breath or troubled breathing, weakness, loss of consciousness, severe dry mouth, nose, or throat, bleeding from skin, mouth, eyes, rectum, and vagina, and possibly death). It is likely that brompheniramine, another antihistamine, would cause the same complications as chlorpheniramine maleate. Some cough medications also often contain guaifenesin (an expectorant), which can cause nausea and vomiting in high doses. Pseudoephedrine (a decongestant) may cause other complications as well, such as dangerous hypertension potentially leading to coma or death, if enough is ingested.
Coricidin Cough & Cold (CCC) in particular is a common source of DXM in the United States for uninformed users. There have been reports of deaths resulting from overdose of dextromethorphan combined with chlorpheniramine maleate, an antihistamine found in CCC. Taking Coricidin in excessive amounts, such as those required for recreational dextromethorphan use, is generally considered to be extremely dangerous, thus Coricidin is not under any circumstances to be considered a safe source of DXM. Nonetheless, among many users it has remained a popular choice, possibly due to ignorance, or that it contains more DXM than most products at 30mg a pill. Dextromethorphan can be extracted from Coricidin tablets in cold water, but this procedure is not widely used or known, and has never been scientifically proven to work.
Some users have extracted Dextromethorphan from cough medicine using ammonia, naphtha (or lighter fuel) and lemon juice (or simply citric acid), in a process typically called the "Agent Lemon extraction." The extraction, when properly performed, is said to remove most of the hydrobromic acid ions and guaifenesin (if the preparation contains it) from the cough syrup. However, it does not remove other ingredients such as pseudoephedrine or paracetamol, which are toxic in high doses. Some brands, however, contain no active ingredients apart from dextromethorphan (such as those described earlier). In such cases, the agent lemon extraction is only intended to remove the sugars and other ingredients in the syrup itself, and thus reduce the amount of extraneous (and often foul tasting) material the user has to consume.
Erowid.org has compiled a list of some DXM-containing products and their other active ingredients, available here.
There have been a small number of dextromethorphan overdose deaths documented in medical and media reports. Even when used alone, dextromethorphan overdoses have been fatal, although all fatalities that have been reported only occurred at very high doses. Lethal toxicity starts at approximately 20mg/kg, which is about 1360mg for a 150lb (68kg) person.
With dextromethorphan, as with most other drugs, concurrent use of other medications is not recommended. Many medications can be substrates or inhibitors of the liver enzyme used in the metabolism of dextromethorphan, CYP2D6. Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs that inhibit the cytochrome P450-2D6 enzyme responsible for metabolizing DXM down into dextrorphan (DXO). This inhibition can cause brain serotonin to build to dangerous levels, which can lead to serotonin syndrome. The condition is typically mild in most people, although it causes generally discomforting symptoms. The syndrome is frequently seen with the antidepressant SSRIs, which raise levels of serotonin in the brain to a desired level. It is highly unlikely that one should experience the syndrome from the therapeutic, medicinal doses of over the counter medicines, and typically the syndrome will subside within 2 days to a week if proper action is taken such as seeing a psychiatrist or discontinuation of the pharmaceutical source of the syndrome.
Monoamine oxidase inhibitors interact with many medications, including dextromethorphan.
Approximately 5% of caucasians have a functional deficiency in the enzyme CYP2D6, which metabolizes DXM and many other drugs (such as the opioids). Enzyme-deficient individuals can overdose very easily, potentially leading to hospitalization. Thus, those who choose to use DXM recreationally are cautioned to start with a low dose of appoximately 5mg of DXM per kilogram of body weight.
William E. White published a paper on Usenet claiming that high doses of disassociatives (including Dextromethorphan) may cause brain damage in the form of NMDA neurotoxicity (NAN or Olney's lesions). A researcher named John Olney demonstrated that high doses of NMDA antagonists, the class of drugs to which dextromethorphan belongs, produced small lesions in the brains of lab rats, which are now known as Olney's lesions. The doses required to produce damage are far in excess of human recreational doses, but there have not been studies on long-term, lower-dose use. However, White's article has been challenged by one Cliff Anderson in his paper, The Bad News Isn't In. White later retracted his original claims in a response to Cliff Anderson's paper though he still warns of possible long term damage from using DXM.