DXM Drug of the Month: download
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And now it’s time for the Drug of the Month, where we take a closer look at the background, science, history, and recent trends in a different drug each month. For our last drug of the month, we talked about Kratom, a drug that was a relatively obscure plant until recently, when a proposal to add it to Schedule 1 of the Controlled Substances Act sparked nationwide outrage. This month, we’re returning to the world of completely legal drugs that are often used recreationally in off-label ways. November’s Drug of the Month is Dextromethorphan, also known as DXM or DM.
Dextromethorphan is a drug of the morphinan class with sedative, dissociative, and stimulant properties (at higher doses). It is a cough suppressant and an ingredient in many over-the-counter cold and cough medicines. It is best known by its trade name Robitussin, but is also frequently included in other cold and cough medicines like NyQuil, Benylin DM or DimeTapp DM. Basically anytime a cough or cold medicine includes the letters DM after its name, it means detromethorphan was added to the product. It is sold in syrup, tablet, spray, and lozenge or capsule forms. In its pure form, dextromethorphan occurs as a white powder.
DXM is a synthetic substance that doesn’t exist alone in nature. It was entirely created by scientists doing science-y things in a lab. DXM was first successfully tested in 1954 as part of US Navy and CIA-funded research on non-addictive substitutes for codeine. In 1958, DXM was approved by the FDA for over-the-counter sales after research supported its legitimacy and effectiveness as a cough suppressant. As researchers had initially hoped, DXM was a solution for some of the problems associated with the use of codeine, such as heavy sedation and the risk of developing opiate dependence, but like other dissociative anesthetics like PCP and ketamine, DXM later became popular for its non-medical use.
DXM is also used recreationally. When exceeding recommended therapeutic dosages, dextromethorphan acts as a dissociative anesthetic. At doses much higher than medically recommended, DXM and its major metabolite, dextrorphan, act as an NMDA receptor antagonist, which produces effects similar to, yet distinct from, the dissociative hallucinogenic states created by other dissociative anaesthetics such as ketamine and phencyclidine. It may produce distortions of the visual field – feelings of dissociation, distorted bodily perception, and excitement, as well as a loss of sense of time. Dextromethorphan usually provides its recreational effects in a non-linear fashion, so that they are experienced in significantly varied stages. These stages are commonly referred to as “plateaus”. Teens tend to have a higher likelihood of using DXM-related drugs as it is easier to access through over-the-counter sales. The recreational use of DXM or Robitussin is often referred to as Robo-Tripping. This should not be confused with purple drank or sizzurp, another cough-medicine based drug that was popularized in the hip-hop community in the 1990s, but purple drank is made from a mixture of codeine.
So I did actually have a personal experience robotripping by accident once. For our long-time listeners, you may remember I spent a week in Peru last summer, hiking the Inca Trail to Machu Picchu. On the last day of the hike, it was raining like crazy and even hailed on us, so after hiking wet all day and sleeping in a semi-wet tent all night, I got the flu. And then the next day, when we arrived at Machu Picchu, it was super super hot and sunny again, and I had a heatstroke. Long story short, I was super sick and had a hideous fever and we were in this tiny mountain town near Machu Picchu, and the friends I was traveling with had to go a Peruvian pharmacy and in broken Spanish, try and find me medicine. Thanks to worldwide access to the Internet and Google translate, they ended up buying me basically Peruvian Robutussin. But I misread the label and took like five times too much, and ended up waking up, hallucinating that there were people in a painting that weren’t there, not walking straight, not making sense, and just feeling generally really loopy. My partner was really worried that I had something worse than the flu like some crazy jungle virus or something, but the next day, when we read the label on the bottle again, he was like, “Oh, no. You were just robotripping.”
For people intentionally robotripping, depending on their body weight, they may need to ingest 2-4 or more times what I used in order to feel the dissociative effects. In over-the-counter formulations, DXM is often combined with acetaminophen for fever reduction and pain relief. However, to achieve DXM’s dissociative effects, the maximum daily therapeutic dose of 4000 mg of acetaminophen is often exceeded, potentially causing acute or chronic liver failure, and making abuse and subsequent tolerance of products which contain both DXM and APAP potentially fatal.
At normal doses, side effects may include Nausea, Vomiting, Drowsiness, Dizziness, Constipation, Diarrhea, Sedation, Confusion, Nervousness, Closed-eye hallucination. At doses three to 10 times the recommended therapeutic dose, additional side effects may include euphoria, increased energy, increased confidence, mild nausea, restlessness, insomnia, rapid speech, feelings of increased strength, enlarged pupils or glazed eyes. At dosages 15 to 75 times the recommended therapeutic dose, side effects include hallucinations, dissociation, vomiting, blurred vision and/or double vision, bloodshot eyes, dilated pupils, sweating, and fever.
Here in the United States, DXM is not included in any schedule of the Controlled Substances Act. That means the government considers it less dangerous than any of the substances that do appear in the Controlled Substances Act, including cannabis, which is in Schedule I, the most restrictive schedule, or codeine, which is in Schedule V, the least restrictive . And that’s why DXM is available over-the-counter, without a prescription. As of January 1, 2012, dextromethorphan is prohibited for sale to minors in California, except with a doctor’s prescription. In a number of other states including New York, Nebraska, Virginia, Alabama, and Mississippi, sales to minors under a certain age are also prohibited. Other states may require DXM or DXM-containing products to be kept behind the counter, requiring interaction with a pharmacist.
In 2014, the National Agency of Drug and Food Control of Indoniesia prohibited single-component dextromethorphan drug sales with or without prescription. Indonesia is the only country in the world that makes single-component dextromethorphan illegal even by prescription.
So that’s all for today’s introduction to the Drug of the Month, dextromethorphan or DXM. Next week, Sam will be back to chat about the Science of DXM and how it interacts with the human body.
Now it’s time for the drug of the month, where we introduce and dive into the science, history, and recent trends in a different drug every month. For November, that drug is Dextromethorphan, also known as DXM. As Rachelle explained last week, this drug is a common component of cough syrups like Robitussin, and can also be used recreationally in what’s known as robo-tripping. For this, the second installment, I’ll be explaining the science of dextromethorphan: methods of administration, how long it stays in the body, and some of its positive and negative effects.
DXM has the chemical formula C18H25NO and has the properties of a sedative, dissociative, and even a stimulant at various dosages. As Rachelle said, dextromethorphan is a synthetic drug that in its pure form, like many other drugs, is a white powder. While it is not sold this way in American stores, a quick Google search shows that it can be purchased in powder form from Alibaba.com, which is basically the Chinese equivalent of Amazon. However, people in DXM forums have also told stories of receiving incorrectly labeled drugs from Chinese suppliers, so it’s very important to do independent testing of any raw chemical you purchase online. And of course, like with caffeine or any other powdered form of a drug, careful measuring is a must. Offline, stores typically sell Dextromethorphan as a major ingredient in cough medications, namely syrups, tablets, sprays, lozenges, or capsules. Again, and as Rachelle’s personal story made clear last week, those using DXM for medical purposes should also be careful not to consume too much and usher in some of the drug’s more intense effects.
Once inside your body, Dextromethorphan is quickly absorbed by your gastrointestinal tract, where it enters the bloodstream and crosses the blood–brain barrier. Contrary to what a normal person may assume, while it’s used as a cough suppressant, DXM actually does not do anything to your lungs, and instead works solely in your brain, raising your threshold for the amount of discomfort required to cough. Because of this, many cough-relieving medications will also include an expectorant like guaifenesin to actually reduce the blockages in your respiratory system.
And, similar to diamorphine being turned into morphine in your body, DXM is actually a prodrug, meaning that the human body metabolizes it into another drug that has a bigger impact. For Dextromethorphan, a lot of it is metabolized into Dextrorphan which is about ten times stronger, though some of the DXM sticks around and also has an effect – it’s believe that the responsibility for the psychoactive effects is shared by these two similar but distinct drugs.
As we said, the effects of Dextromethorphan vary widely based on dosage. A typical medical dose is about 20 to 30 milligrams, with recommendations to take an additional dose if needed. The International Society for the Study of Cough recommends adults using one dose of 60 milligrams without re-dosing. At these levels, in addition to its cough suppressant properties, DXM can cause nausea, vomiting, drowsiness, sedation, and confusion, among other things. Some even report closed-eye hallucinations at this dosage.
Outside of medical use and into the realm of recreation and psychonauts, the DXM community talks about there being various “plateaus” of effects, with the idea being kind of like electrons around an atom: the effect isn’t a linear progression, but instead has certain types of effects it can have that stay about the same until enough has been ingested to increase the effect to the next level. A typical threshold dose for recreation is about 100 milligrams, though some do up to about 300 milligrams for what’s considered the first plateau. In these amounts, DXM can cause euphoria and feelings of increased confidence and strength, and people will often speak very fast, so behaving rather like a stimulant. The negatives of this can include insomnia and nausea.
The next plateau begins at roughly 300 milligrams, though this varies from person to person based on body weight, body chemistry, and tolerance. At this level, for which people sometimes take 600 milligrams or even more, Dextromethorphan causes strong dissociation and many report vivid hallucinations and confusion, including a lost or distorted sense of time. People who are a fan of robo-tripping almost always do this at home or in another safe space; unlike hallucinogens like LSD, there doesn’t seem to be much interest in consuming DXM at large social events, but people instead treat it more as an introspective and quiet activity. At this and higher doses, DXM has a range of side effects that include blackouts, the inability to focus visually, and serious confusion that can cause paranoia. In my research for this drug of the month segment, I even came across many reports of people consuming up to 2 grams – meaning 2,000 milligrams, which is 100 times the medical dose – although they almost universally reported terrible experiences, and this dosage is certainly an outlier and not recommended by anyone.
Dextromethorphan does come with a small risk of overdose, but only in giant doses like the ones I just described. In rats, the LD-50 for DXM is 116 mg/kg, and in mice it’s nearly double, at 210 mg/kg. There is no set number for humans, but there are some reports of people dying from high doses of DXM alone. However, much more common is dying from a mix of DXM and other substances – one thing prospective recreational users should be aware of is that many over-the-counter formulations of cough syrup that have DXM also contain acetaminophen, which can be very toxic at high doses and cause serious liver damage. So if someone is choosing to use DXM, they should not only calculate the dosage of the Dextromethorphan, but everything in the formulation and make sure that they are all well within the safety range.
While it does certainly carry risks, DXM is not considered to be physically addictive. Active robo-trippers tend not to use it more than once a month, but of course, like any drug it can also be psychologically addictive, particularly if someone is having other problems that they are seeking to disassociate from. Because of this, it’s wise to be mindful of set and setting, and only consume higher doses of DXM when in a positive state of mind, as people report it magnifying negative feelings and worries rather than alleviating them.
One other serious risk from Dextromethorphan is that sometimes, people consume it unknowingly – according to the harm reduction organization DanceSafe, it’s somewhat common for people seeking to purchase MDMA receive tablets of DXM instead, from dealers seeking to take advantage of people operating with limited knowledge. If used in an environment like a concert or festival, DXM can actually be quite dangerous, as it inhibits your body’s ability to regulate its temperature, increasing the risk of heatstroke. It is particularly dangerous when used along with MDMA, which could happen if someone consumes drugs from two sources and one of them was from an honest dealer while the other was not. In order to help mitigate this risk, the testing kits sold by DanceSafe are able to identify pills which contain DXM.
So that’s all for the science of Dextromethorphan, one of a wide range of drugs used primarily as medicine but also taken for other purposes as well. Next week, we’ll be back with the history of DXM: when it was first created, and how its use and legality have changed over time.
And now it’s time for Drug of the Month, where we take a closer look at a different drug each month. For November, we’ve been learning more about Dextromethorphan, also known as DXM or Robitussin. Last week, Sam talked about the Science behind DXM and how it interacts with the human body. On today’s episode, I’ll be discussing the history of DXM, the origins of its use, and how attitudes towards it have changed over time.
As I mentioned in the Intro episode, DXM was first synthesized in a lab in 1954, as part of government-funded research to replace codeine with a less addictive alternative. It was approved in 1958 by the FDA as a cough suppressant and made available for over-the-counter sales. Initially, DXM was sold in tablets under the brand name Romilar. As early as 1962, recreational use of DXM was reported in pop cultural writings, and was apparently particularly popular among Beat writers, such as Allen Ginsberg, Jack Kerouac, and Peter Orlovsky. The Beats were so well-known for their use of Romilar during their time in Ibiza that they were known among locals as the Romilar army. In 1967, the first case of “toxic psychosis” induced by an overdose of Romilar was reported. The case report states: [QUOTE] “A 23 year-old male, a well-known drug addict, recently presented with a toxic psychosis due to taking 20 tablets of “Romilar” (dextromethorphan), which he bought from a chemist. This was characterized by hyperactive behavior, extreme pressure of thought, marked visual and auditory hallucinations, and association of sounds with colours (synaesthesia). This experience was likened to that experienced when he was under the influence of L.S.D.” [END QUOTE]
By the late 1960s, recreational use or abuse of DXM had reached such levels that manufacturers began including ingredients in their cough medicines solely designed to induce nausea, in order to discourage over-consumption. As one writer described it, “while drinking a bottle became a stomach-churning adventure, the psychedelic trip was undiminished.” In 1973, Romilar DXM tablets were removed from the market altogether. However, DXM continued to be available in cough syrups, with manufacturers developing more formulations designed to deter abuse by ensuring the syrups were unpleasant to consume in large quantities due their foul, medicinal taste. Within a few short years, however, the call of the market demands was too strong, and those same manufacturers began releasing formulas with “some appealing flavoring.” This led at least one researcher in 1975 to suggest that the cycle of recreational abuse may be repeated.
While the potential for abuse of DXM was already well-established in 1970, when the Controlled Substances Act was originally passed by Congress and signed into law by Nixon, dextromethorphan was specifically excluded from being scheduled, under Section 201(g)(2). To my knowledge, dextromethorphan is the only substance that is explicitly named in the Controlled Substances Act to be not included. Section 201(g)(1) states that: “The Attorney General shall by regulation exclude any non-narcotic drug which contains a controlled substance from the application of this subchapter and subchapter II of this chapter if such drug may, under the Federal Food, Drug, and Cosmetic Act [21 U.S.C. 301 et seq.], be lawfully sold over the counter without a prescription.” “Narcotic drug” is then defined as opium, opiates and its derivatives, poppy straw, and coca leaves, cocaine and its derivatives. Therefore, dextromethorphan did not fit the definition of narcotic drug, and was also approved by the FDA for non-prescription OTC sales. It’s unclear based on the legislative history why DXM was specifically exempted, when many substances with similar chemical structure and psychoactive effects have been scheduled, even in Schedule I or II. It appears to come down to either the government’s conviction that DXM has a very low potential for abuse, or the influence of Big Pharma.
At a minimum, dextromethorphan is regulated as an OTC Category I substance, which means it’s “Generally Recognized As Safe and Effective.” In contrast to the Controlled Substances Act, OTC regulations apply to over 800 active ingredients, including acne and weight loss products.
In the 1980s, with the backlash against the drug culture of the ‘60s and ‘70s and the accompanying War on Drugs ushered in by Reagan, psychedelics became generally less available, especially in rural areas or smaller towns. DXM, which was still easily available over-the-counter in any drug store, saw renewed popularity within the counterculture, especially among the hardcore punk community. One writer speculates that its widespread popularity within the hardcore scene may be related to a brief mention in the seminal countercultural guide, The Anarchist Cookbook. People within the subculture would use DXM primarily in group environments, in people’s homes and in the warehouses where many of them lived. Often a theme was chosen for the DXM trip (although the term “vacation” was sometimes preferred to “trip”). Themes included locations, historic times, fantasy environments, emotions, and abstract concepts. DXM was almost never a solitary activity. In contrast, many DXM users today regard it as a solo experience. The recreational use of DXM within this scene diminished as the hardcore punk community itself began to dwindle.
In the 1990s, with the advent of widespread Internet access, recreational use of DXM re-emerged into the mainstream. As early as 1996, DXM Hydrobromide powder could be purchased in bulk from online retailers, allowing users to avoid consuming DXM in syrup preparations. As Sam mentioned in last week’s episode, while DXM is not available for purchase in its powder form in American stores, it is still easily available online through such websites as alibaba.com, Chinese Amazon.
The rapid rise of recreational DXM use enabled by Internet chat rooms and drug use forums prompted the DEA to convene two Drug Abuse Advisory Committee Meetings in the 1990s. The first, in 1990, was prompted by concerned citizen petitions from Pennsylvania and Utah. The objectives for the 1990 meeting were to: (1) help FDA identify and better define the extent of the problem, (2) develop a strategy for assessing the problem, and (3) identify and discuss the pros and cons of possible solutions. The committee concluded that more data would be needed, specifically regarding toxicity in higher dose ranges. They agreed to follow up in the next six months or whenever appropriate. Two years later, in 1992, the advisory committee reconvened. The meeting concluded, once again, with no clear consensus on the extent of the problem or what actions should be taken to control it, and a vague idea that more studies would be needed to focus attention on the specific geographic regions where “outbreaks” of DXM use were occurring.
More recently, in 2005, five male teenagers (between the ages of 17 and 19) in three separate incidents in Washington state, Florida, and Virginia died following ingestion of DXM. In four out of the five cases, the individuals tested positive for other drugs, in particular, cannabinoids and diphenhydramine, which is the active ingredient in Benadryl. All five overdose victims had obtained the DXM from “Chemical API,” a chemical resale company in Indianapolis that purchased powdered DXM from India, repackaged the substance and resold it over the Internet. This leads me, personally, to suspect that the deaths may have been related to the purity of the product (but I assume an issue like that would have shown up in the drug tests if that’s something they were looking for). In the Florida case report, one male youth ingested the same amounts of DXM and diphenhydramine as his two friends who fatally overdosed. It is likely that he survived because he became ill and vomited from the ingestion. In addition, he weighed about 70 pounds more than his friends who did not survive.
In conclusion, DXM’s history of use as a recreational drug is as long as its existence. Despite widespread knowledge of this, the government has deemed DXM sufficiently safe and unlikely to lead to abuse that it is still available over-the-counter. And while a number of fatal overdoses may have occurred as recently as 2005, this does not appear to be a regular or even likely occurrence over decades of close scrutiny.
So that’s all for this week’s segment of Drug of the Month, where we went over the History of Dextromethorphan and how society’s attitudes towards have changed over time. Next week, Sam will be back with some recent news and trends.
And now it’s time for the drug the month, where we give an introduction and dive into the science, history, and trends in a different drug each month of the year. For November 2016, that drug has been Dextromethorphan, also known as DXM, which is the active ingredient in products like Robitussin and, when taken in large enough doses, the compound responsible for what’s known as Robo-tripping. For this, our fourth and final installment, I’ll be talking about some recent news items and trends in the use and regulation of Dextromethorphan.
Unfortunately, while robo-tripping has become enough of a phenomenon that the average teenager has probably heard of it, it’s not likely they understand exactly what drug they’re taking or how it works. Because of this, surveys will usually avoid asking a question like, “have you consumed large quantities of Dextromethorphan for fun?” and instead ask the simpler, “Have you consumed large quantities of over the counter cough syrup for fun?” While this makes more sense to a casual user, it loses a bit of accuracy, since it could also include people abusing cough syrups with different formulations.
Despite this one problem, we do have some pretty good data on DXM usage and trends in that use. Monitoring the Future, one of the major drug surveys of American youth, started asking about over-the-counter cough syrup in 2006, and at that time, 5.4% of high schoolers said that they had used it at least once in the past year. In 2015, the latest year for which data is available, that decreased to 3.1%, a substantial drop that applied across all grade levels.
While impossible to quantify, some of that drop is probably due to the natural cycles of drug fads, since recreational drug consumption is a very social phenomenon, and many drugs have come in and out of style over the year, independent of their availability. It may well be that robo-tripping became popular as a curiosity, but that it was not enjoyable enough for very many people to become regular users, so it dropped off as more people tried it and didn’t like it. Surges are also fueled by sensationalist media reports, and those were commonplace for DXM in the early 2000s, just like we’ve seen more recently with other drugs such as salvia divinorum.
But aside from it simply going out of style, some of that decrease in use can certainly be attributed to both voluntary and government responses to the recreational use of DXM. As Rachelle explained in the history segment, DXM was not included in the controlled substances act, but in 2005 the FDA issued a warning on it after five deaths that were attributed to DXM overdose. It’s no coincidence that Monitoring the Future started asking about DXM usage the next year.
In 2007, the DEA asked the FDA to conduct research on DXM and provide a recommendation for whether it should be scheduled. The FDA concluded that it should not, but that it was monitoring the situation and could change its recommendation if abuse increased.
Despite the lack of federal scheduling, some states took matters into their own hands and heightened restrictions on DXM products. In 2012, California became the first state to put Dextromethorphan products behind the counter and require an ID proving customers were 18 years old before selling it to them. New York followed the next year, and as of this recording, ten states have passed such restrictions, the most recent being Florida, which just passed its age requirement law this year and will have it go into effect in 2017.
Some are pushing for the federal government to implement these age requirements nationwide, and last year a bill called the DXM Abuse Prevention Act of 2015 was introduced to by Congressman Bill Johnson, a Republican from Ohio. With only 21 sponsors, the bill did not get much traction. But it’s unclear if it would actually do much to reduce DXM use, since the downward trend in robo-tripping was already happening when they started measuring it in 2006, far before any state had passed such requirements.
While there has been a push for more regulation in the US, concerns over robo-tripping are more of a minor concern than a national hysteria. But that was not the case in Indonesia, where they didn’t just add age requirements, but went much further and outright banned Dextromethorphan in 2014. This was fueled by some serious hysteria, with one official justifying the ban by saying DXM is even more dangerous than morphine and that people addicted to it cannot be rehabilitated.
That’s all for this segment on news and trends surrounding Dextromethorphan, our drug of the month for November. Of course, we’ll be staying on top of current events in our weekly news segment, and will be sure to cover any additional age restrictions or bans on DXM if they continue to be introduced and passed. We’ll be back next week with the introduction for December’s drug of the month.