Dependence risk with chronic dextromethorphan abuse

Current Psychiatry. 2005 February;04(02):13-23

February 1, 2005|Psychiatry

Jeannie Melick-Shield;Lisw;Cacd;David Barloon, ARNP, MSW;Jill Liesveld, MD

‘Robo-ing’ patients may meet diagnostic criteria

DEXTROMETHORPHAN DEPENDENCE

Mr. E believes he is dependent on dextromethorphan, and his behavior meets DSM-IV-TR criteria for dependence (Table):

His persistent development of a culture of dextromethorphan use consumes much of his time.
He neglects family and work responsibilities.
He has tried repeatedly to cut down and stop his cough syrup use.
His use continues despite marital, work, and legal consequences.
He can tolerate daily dextromethorphan doses that would not be possible for the naive user.
He experiences physical and psychological withdrawal when he stops using dextromethorphan.

Table 1

DSM-IV-TR criteria for substance dependence

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
Tolerance, as defined by either of the following: Withdrawal, as manifested by either of the following: The substance is often taken in larger amounts or over a longer period than was intended There is persistent desire or unsuccessful efforts to cut down or control substance use. A great deal of time is spent in activities necessary to obtain the substance (eg, visiting multiple doctors or driving long distances), use the substance (eg, chain smoking), or recover from its effects Important social, occupational, or recreational activities are given up because of substance use The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
Source: Adapted and reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders (4th ed, text revision). Copyright 2000. American Psychiatric Association.

Box 2

Warning to parents: Signs of child or adolescent dextromethorphan abuse

Cough syrup bottle in home’s medicine cabinet looks more empty than expected
Child is using the Internet to learn about or attempt to purchase products containing dextromethorphan
Cough syrups or other products containing dextromethorphan are found in child’s possession
Child denies using common street drugs or alcohol but displays an unexplained altered state (confusion, ataxia, dizziness, euphoria, or slowed mental processing) or nausea, vomiting, or dizziness (from dextromethorphan withdrawal)
Child hangs out with peers in drug stores or supermarkets
Using cough syrup to get high has become a fad in child’s school or peer group

He claims that about one-third of his peer group has tried dextromethorphan to get high, although he believes

WHO ABUSES ‘DXM’?

The prevalence of dextromethorphan abuse is unclear.⁸ Abuse has been reported in Sweden, Canada, Australia, Germany, and the United States.¹ Sweden has allowed prescription-only sales as a deterrent to abuse since 1986.⁹

The literature and our experience in treating dextromethorphan abusers suggest that abuse often begins in late childhood or early adolescence but may continue as chronic behavior in adulthood.

Use by adolescents. Case reports note episodic or fad dextromethorphan use—usually by adolescents and young adults—that springs up in a region or within a group and then fades.⁸ An abuse epidemic by Utah adolescents in the 1980s led drug stores to voluntarily place dextromethorphan-containing products behind the pharmacy counter to monitor and deter purchases.¹⁰

In a study of 376 students in grades 4 through 12 in Albuquerque, New Mexico, many knew cough syrup could be used to “get high.” When shown a list of cough syrup brand names, they often could identify those containing dextromethorphan, including NyQuil, Robitussin-DM, and Vicks 44D. The rates at which the students knew these three common cough preparations could be abused were:

46%, 25%, and 16%, respectively, for high school students
20%, 10%, and 17% for middle schoolers.⁸

Because many youngsters know that dextromethorphan abuse can produce an altered state, clinicians need to educate parents to be alert for warning signs in their children (Box 2).

Use by adults. Substance abuse counselors at our agency all have worked with adults who use cough syrup for intoxication. Some adults say they use dextromethorphan to enjoy the high and others as an alternative to alcohol.

A ‘HIGH’ WITH 4 PLATEAUS

Many Internet sites carry information about dextromethorphan.^11-13 Its altered state is called a plateau, and four plateaus have been described.

Lower plateaus are considered “recreational.”¹³ According to the National Institute on Drug Abuse (NIDA), users experience a sense of dissociation and distortion of time and space at doses of about 2 ounces of medication containing 15 to 30 mg of dextromethorphan.¹⁴

Users are said to try to attain plateaus 1 or 2 to enhance and enjoy their surroundings. They describe music as being richer, colors more intense, and conversation more meaningful. The experience is said to be similar to a marijuana high or alcohol intoxication.

References