A young man’s ‘trips’ to heaven and hell

¹³ Numerous factors explain this increase:

• Most people do not know that dextromethorphan-laced medications are dangerous if misused.
  
• These preparations can be purchased at many stores or snatched from the medicine chest.
  
• Several Web sites describe how to “safely” abuse dextromethorphan.¹³
  

Further, some pediatricians, family physicians, emergency physicians, and psychiatrists do not suspect “robo” abuse, in part because ordinary urine drug screens do not detect dextromethorphan.

medical consequences

Many dextromethorphan-laced preparations contain other active compounds—such as pseudoephedrine, acetaminophen, chlorpheniramine, guaifenesin, or bromide—that can cause serious adverse effects at above-normal doses. Abuse of medications containing both chlorpheniramine and dextromethorphan leads to hallucinogenic euphoria and dissociation, followed by hours of intense somnolence.

Dextromethorphan can cause serotonin syndrome when taken with serotonergic drugs such as amphetamines, cocaine, monoamine oxidase inhibitors, or selective serotonin reuptake inhibitors. Symptoms include tachycardia, hypertension, diaphoresis, mydriasis, myoclonus, agitation, and seizures.

Box 2

The authors’ observations

Physical and psychiatric symptoms, patient history, and collateral information together can confirm dextromethorphan abuse in patients who present with mainly visual and tactile hallucinations. The signs are easy to miss in patients with schizophrenia because schizophrenia is believed to be causing the psychosis.

Psychiatric/physical symptoms. Psychiatric symptoms of “robo” intoxication include euphoria, altered time perception, disorientation, and tactile, visual and auditory hallucinations.⁷ Physical symptoms include excitation, nystagmus, tachycardia, hypertension, hyperthermia, vomiting, urinary retention, drowsiness, and rash. Extreme dextromethorphan withdrawal can cause dysphoria, insomnia, vomiting, diaphoresis, abdominal pain, and diarrhea.⁷

Psychiatric symptoms of intoxication with dextromethorphan or phencyclidine are similar, but phencyclidine-intoxicated patients typically present with fluctuating behavior and motor symptoms including tremor, dystonic reactions, and catalepsy.

Also watch for dermatitis on the forehead, nose, or cheeks, which can result from chronic abuse of preparations containing dextromethorphan plus bromide or chlorpheniramine.

Patient history. Has the patient abused dextromethorphan before? If so, how often? When was he last treated for decompensation after cold medication abuse?

Also check for abuse of other substances, and ask teenage patients if their friends use cold preparations recreationally.

Collateral information. Ask family members to search the patient’s room for supplies of cold medicine and for empty boxes and capsule cards, check the medicine chest regularly to see if cold medications are missing, and check the patient’s jacket or coat pockets for cold tablets or cough syrup.

Treating ‘robo’ abuse

Convincing the patient and family that dextromethorphan abuse can cause severe harm is critical to promoting a positive outcome. Referral to a substance abuse rehabilitation program or 12-step group can help.

Related resources

• U.S. Department of Justice, National Drug Intelligence Center. Intelligence bulletin: DXM (dextromethorphan). www.usdoj.gov/ndic/pubs11/11563/index.htm.
  
• Partnership for a Drug-Free America. Resource for parents. www.drugfree.org/Parent. Click on “Cough Medicine Abuse” under “Special Drug Reports.”
  
• U.S. Food and Drug Administraton. FDA warns against abuse of dextromethorphan (DXM). www.fda.gov, enter “dextromethorphan” in search field.
  

Drug brand names

• Risperidone • Risperdal
  

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.