DXM: A drug in plain sight

By Emily Weaver, Sharon J. Davis and David Saarnio

November 2020

We are writing this article to raise awareness among parents and counselors about a legal and easily accessible drug that is widely used by adolescents to get high: dextromethorphan (DXM). DXM is an ingredient found in certain medications meant to help us get better, so teens frequently abuse this drug without being aware of the potential consequences and dangers. Given the personal insights and experiences we have with the damaging effects of DXM, we are sharing this story in hopes of reaching a larger population and creating more efficient prevention strategies related to teen drug use.

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When co-author Sharon Davis’ son was 17, he began abusing over-the-counter (OTC) cough medicine. He had been using marijuana and K2 (synthetic marijuana) for a few years, but it was Coricidin — a cold medicine marketed as being for people with high blood pressure — that really damaged him.

Sharon’s son became a different person. He had always been a moody kid, but his moodiness turned to anger, mania and psychosis. Over a four-month period, his father and mother took him to the emergency room four times. It wasn’t until he attempted suicide that they really got him the help he needed and found out the full extent of his addiction.

He had been introduced to Coricidin through some friends. Soon he was using 30 pills at a time. Coricidin use led to cocaine use. Cocaine use led to methamphetamine use. Two years later, he is working on recovery, but his mind and mental health will never be the same.

According to the Partnership for Drug-Free Kids, 50% of American teenagers have misused a drug, and drug overdose is the fourth-leading cause of death among teens. Parents, counselors and other adults are well aware of the problem of teen drug use, and the nation’s opioid epidemic has brought the topic of medication misuse to the forefront of public attention. That attention is long overdue. However, that focus also misleads us because other critical concerns are being overlooked.

For example, our society is largely neglecting to talk about the large-scale problem of adolescent misuse of OTC medicine and its potential as a gateway to other drugs. In fact, OTC cough and cold medicine is one of the most popular drugs that youth use to get high. According to the Monitoring the Future survey funded by the National Institute on Drug Abuse, more teens got high from OTC medicine in 2019 than from prescription opioids.

Why OTC?

OTC cough medication is easy for teens to get. In some places, teens can purchase these medications from their local convenience stores. Furthermore, most stores have these medications out on the shelf where they are easy to steal. Teens can also get them from peers and even from parents. Because they don’t necessarily perceive these types of medications as “dangerous,” many parents will store them in an unlocked medicine cabinet, unknowingly allowing their teens easy access to them.

The psychoactive drug in OTC cough and cold medicine is DXM, which falls into a class of drugs known as dissociative hallucinogens. Other drugs in this category include PCP, ketamine and nitrous oxide. The Food and Drug Administration (FDA) approved DXM as a cough suppressant in 1958. It remains legal to buy and use in the U.S. DXM is a safe drug when used as directed, but when used in 10 times or more the recommended dose, it acts as a powerful dissociative, distorting reality. Currently, 85%-90% of OTC cough medications contain this effective antitussive (cough inhibitor). DXM is a synthetic opioid drug, but it activates different opioid receptors in the brain than prescription opioids do.

Teens typically misuse DXM to feel the euphoric, dreamlike experiences and hallucinations it causes. When individuals use DXM to get high, they experience various levels of inebriation, known as plateaus.

There are four plateaus associated with DXM. The first plateau involves mild intoxication and stimulant-like effects. The second plateau features increased intoxication and mild hallucinations. At the third plateau, the user enters a state of altered consciousness with impaired senses and psychosis. The fourth plateau involves a sense of derealization (in which the world appears unreal) and depersonalization (e.g., detachment from the self).

Users describe the higher plateaus as akin to being in other realms or alternate universes. Commonly, users feel an out-of-body sensation, like being transported to another dimension. They lose their sense of self and time. It is common for users to post videos or blogs about their experiences, including what they felt like and what they saw while high. The slang term robo-tripping is how many teens refer to being high on DXM. Slang terms for the drug itself include triple-C’s, robo, skittles, red hots and dex.

Why is DXM problematic?

DXM is a dangerous drug when used outside of therapeutic doses, yet little has been done to curb its misuse among teens. For decades, we have known about the consequences of misusing this drug, including seizures, hyperthermia, tachycardia, psychosis, mania and even death.

The opioid epidemic in this country is a national crisis. It is worthy of public attention and government funding to address. At the same time, DXM misuse among teens is also startling, and yet it is rarely highlighted. This drug is more popular than opioids among young people, and it is legal, inexpensive and easy to get.

It is imperative that prevention efforts and policies address this problem. For example, laws similar to those passed in 2005 that required pharmacies to move the popular methamphetamine-making drug pseudoephedrine behind the counter could make DXM less readily available. Some states already require purchasers of OTC cough and cold medications containing DXM to present an ID proving they are 18 or older. We believe this should become mandatory nationwide and that sellers of these drugs should be held accountable.

Furthermore, mass awareness campaigns targeting parents, teachers, law enforcement and counselors need to remind adults of the dangers of these drugs, whereas prevention programs for children and teens should increase their focus on the dangers of OTC medications. National campaigns and policy changes are called for, but these alone will not likely be enough to cause real change. True prevention efforts require work on multiple levels — from the policymakers in Washington to counselors and parents in local communities. Each of us has a part to play, and each can make a difference.

Where do teens hear about DXM?

In today’s era of prolific internet and social media use, teens have more access to the world than ever before. In past decades, peer pressure to use drugs was a huge concern. It was thought that susceptible teens would be influenced by their peers in the neighborhood and at school. This peer pressure occurred face to face.

Today’s teens still confront in-person peer pressure, but they now also face this pressure virtually. Peer influence can come not just from the local teens at school but from millions of teens across the world online. Many teens access the internet and find out about drugs of abuse, including how to get high on OTC cough and cold medications.

A quick search of popular sites such as YouTube can lead teens to videos that either warn of the dangers of DXM or encourage users to experience the high from it. Unfortunately, many websites include dosing recommendations and “tripping” suggestions for having a better experience of getting high.

For example, Reddit, one of the most popular social media sites around the world, has an estimated 430 million active users. Reddit consists of threads that allow its users to post about certain subjects and topics. These threads are like cybercommunities made up of members who hold similar interests. One of these threads, called “r/DXM,” has more than 31,500 users. This thread allows people a place to describe their DXM highs and the side effects. It also provides advice on how to minimize certain side effects such as nausea.

Other websites and cybercommunities such as Dextroverse.org and the Vaults of Erowid provide teens outlets to post about their DXM highs and get advice from other users on how to use the drug. The site DexCalc.com allows users to enter their weights and get a recommended dose for the “plateau” of high they want to achieve. Although many of these websites claim that their purpose is “harm reduction,” teens typically use these sites for suggestions and advice on the “safest” using pleasures. All of these websites are accessible to teens, and all of them are free to use.

Prevention efforts

Fifteen years ago, the FDA issued warning labels on OTC cough and cold medications aimed at making parents aware of the dangers of medicine abuse by teens. The Stop Medicine Abuse campaign launched nationwide in 2004, but clearly that campaign was not successful. More needs to be done to dissuade youth from abusing OTC drugs.

As counselors, we need to step to the front lines of true preventive efforts. This means that we need to know more about DXM (and other OTC medications), the reasons teens are using it, the ways teens are getting it and the most effective methods to prevent its misuse.

Getting parents involved is a good first step. Parents must know what to look for and how to talk to their teens about OTC drugs. Counselors need to get the message out to parents to be realistic and truthful when educating teens about DXM. Scare tactics do not work for many teens; in fact, they may make teens more curious about experiencing the outcomes for themselves. A better approach for prevention may be for parents, family members and other adults to increase the quality of their connection to and communication with youth.

Research shows that establishing consistent messages against drug misuse and having clear boundaries early on can be among the best prevention efforts for teen drug use. Simple steps, such as hiding medications and taking inventory, can also be effective. Most parents want to trust their teens, but having medications that contain DXM where teens can access them is not wise, and many parents are not aware of the dangers of DXM medications. OTC cough and cold medicine should be as securely stored as opioid prescriptions.

In addition, parents need to know what sites their teens are accessing online. A parallel line of defense involves checking browser histories and having clear rules about what teens can access online. Drug use is a leading cause of death among teens (resulting in more than 5,000 deaths per year according to figures from the National Institute on Drug Abuse). Parents wouldn’t want their teens searching for firearms or lethal poisons online, and no parent should want their teen searching for how to get high from DXM. Parents may not be comfortable with this advice. After all, it may feel like snooping, and teens are likely to resist as well. Even so, what teens access online can be one of the biggest telltale signs of drug use.

Establishing rules for computer/internet usage (e.g., allowing a teen to use the internet for two hours a day after completing homework), installing a firewall and setting locks or passwords for downloads can all be safety measures that contribute to prevention or, when needed, intervention. The earlier that parents establish household internet rules, the better. Proactive planning and putting rules in place before children reach their teen years may prove much easier than trying to establish new rules once teens are in late adolescence.

Talking to teens about drug use is often uncomfortable for parents. Many parents do not know where to begin. Some parents are worried that talking about drugs will increase their children’s curiosity about using. Other parents simply find the topic embarrassing or awkward. As counselors, we need to help parents develop communication skills with their children and teens, but especially starting in middle childhood. Counselors can provide parents with resources for where to find information about drugs of abuse, and we can intervene if a teen has already started using. It is almost a certainty that teens talk to other teens about getting high on OTC cough and cold medication. As counselors, we need to encourage parents to talk to their children about choosing not to get high on it.

If Sharon Davis, as both a counselor and parent, had recognized the signs of DXM abuse in her son, he might have gotten help sooner. The message we want parents and counselors to hear is that DXM is one of the most popular drugs for teens, and despite it being legal and easy to get, it is not safe when misused. Sharon was unable to prevent all the damage done to her son, but we hope that her story will help parents of children and teens across the country to protect their own sons and daughters.

Emily Weaver is a graduate student in the clinical mental health counseling program at Arkansas State University. She plans to graduate in the spring, become a licensed professional counselor and pursue a career in addictions counseling. Contact her at emily.weaver@smail.astate.edu.

Sharon J. Davis is a professor at Arkansas State University and a certified rehabilitation counselor. Contact her at sharondavis@astate.edu.

David Saarnio is a professor of psychology at Arkansas State University with a specialty in developmental psychology.

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