Tag: DXM

12/9/16

Channeling Your DXM Personality

5© ljupco | 123rf.com
5© ljupco | 123rf.com

June of 2016 was a confusing month for DXM. Alaska became the 11th state to limit the sale of products containing dextromethorphan (DXM) to individuals 18 and older. Representative Charisse Millett of Anchorage thanked her colleagues for passing a bill that will protect Alaska teens. On the other hand, there was a study published in the journal, Substance Abuse Treatment Prevention, and Policy by Spangler, Loyd and Skor that same month which said DXM was a safe, effective cough suppressant, available without a prescription since 1958. The article reported how the annual prevalence of DXM abuse has sharply decreased since 2010. So why would so many states be restricting the sale of a “safe, effective cough suppressant”?

Adding to the issue, there is H.R. 3250, The DXM Abuse Prevention Act, which was sent to both the House and Senate for consideration on April 27, 2016. H.R. 3250 seeks to prevent the abuse of DXM and would restrict its sale to individuals 18 and over. Civil penalties for retailers violating H.R. 3250 would range from a warning for a first offense up to $5,000 for four or more violations. If implemented, the federal law would take precedence over any existing state legislation.

The pro-drug website Erowid noted that while DXM is still unscheduled in the US, and legal to buy, possess and ingest without a prescription, it is becoming increasingly difficult to purchase. “Some pharmacies and mega-stores like WalMart have instituted voluntary procedures to reduce the sale of DXM-containing products to minors.” Erowid listed and commented on the legal status of DXM in 25 different states and was soliciting more information on its status in other states.

In 2007 the DEA requested that the FDA evaluate whether dextromethorphan should be scheduled as a controlled substance. Three years later the FDA held an Advisory Committee meeting on the matter. After hearing presentations on DXM and its abuse potential, the committee voted 15 to 9 against scheduling DXM. An Erowid assessment of the presenters was they did not believe that scheduling was warranted, but were concerned about abuse.

The DXM article by Spangler, Loyd and Skor said that to address reports of abuse, the Consumer Healthcare Products Association (CHPA) initiated a plan to raise awareness of the behavior and “address prevention by focusing on the factors that impact teen behavior.” All three authors were employees of the CHPA, “which represents manufacturers of over-the-counter medicines and dietary supplements.”  And funding for the research, collection of the data, analysis, interpretation, plan implementation, and writing of the manuscript was provided by CHPA member companies. They concluded:

It is noteworthy that the annual prevalence of over-the-counter cough medicine abuse has sharply decreased since 2010. While a true cause-and-effect relationship cannot be assured, the Consumer Healthcare Products Association and its member companies believe that the increased awareness of the issue since the 2010 Food and Drug Administration Advisory Committee meeting, and the subsequent implementation of a well-delivered and targeted abuse mitigation plan that addressed the levers influencing teen decisions is contributing to the observed reduction in abuse. During the period of 2010–2015, reported abuse of dextromethorphan by 8th, 10th, and 12th graders decreased 35 %. The authors believe this reduction supports the view of the Consumer Healthcare Products Association at the outset of the abuse mitigation plan effort and today: Controlled substance scheduling or prescription requirements would result in a reduction in the legitimate use of this medicine that has benefits that far outweigh its risks. Instead, there are more targeted, more effective, and less disruptive interventions to address dextromethorphan abuse.

Writing for The Fix, John Lavitt reported that one in 30 adolescents use DXM to get high because it is cheap and accessible. In 2014 there were six DXM-related deaths, according to the American Association of Poison Control Centers. Non-medical use of DXM leads to around 6,000 ER visits per year. Adolescents account for almost 50% of those visits. The effects range from mild stimulation to euphoria and hallucinations. There can be an out-of-body dissociative state, complete dissociation with unresponsiveness and even overdose.

Medline Plus lists some of the many products that contain DXM, including NyQuil, DayQuil, TheraFlu, Tylenol Cold, Dimetapp DM, Robitussin DM, Triaminic DM, and Alka-Seltzer Plus Cold and Cough.  Some of the symptoms of a DXM overdose listed included: breathing problems, bluish-colored fingernails and lips, blurred vision, coma, Convulsions, drowsiness, hallucinations, heart palpitations, nausea and vomiting, rapid heart beat.

Now here is some DXM history from Erowid. It was approved by the FDA in 1958. In the early 1960s, there were reports that beat poets like Allen Ginsberg and Peter Orlovsky and the author Jack Kerouac were using DXM in the form of Romilar tablets. Incidentally, Romilar was introduced as a replacement for codeine cough remedies in an attempt to cut down on abuse. In 1973, Romilar DXM tablets were removed from the market after an increase in recreational use was noted. DXM continued to be available as a syrup, with the thinking that consuming large quantities of syrup would be deterrent for recreational use. OTC DXM tablets have been back on the market now for number of years. In the late 1980s DXM use was prominent among the punk subculture.

By the way, codeine cough syrup is main ingredient in the concoction “Sizzurp” that sent rapper Lil Wayne to the hospital with multiple seizures. He even wrote a song about his love for Sizzurp, “Me and My Drank.”  Then there’s Justin Beiber and his street-racing-DUI-Sizzrup arrest. Teens and others without ready access to a codeine prescription cough formula can substitute OTC DXM formulas in their Sizzurp knockoff. Add some Jolly Ranchers to make the concoction more drinkable.

So while DXM may be safe and effective when used as recommended, it was being used as a recreational high almost from the time it came onto the market as a substitute for codeine. It has ebbed and flowed in its consideration for classification as a controlled substance. Currently it isn’t one. However, it does seem likely to face restricted sales to anyone under the age of 18. Eleven states have already passed legislation to that effect, and larger chains like WalMart, Walgreens, Target, Rite-Aid and others now require ID and limit sales to two DXM-containing products. And there is pending federal legislation that has a 38% of passing that would make it illegal to sell DXM products to minors. The last word on DXM is from Erowid.

Recreational DXM use continues. A number of deaths have been documented due to the recreational use of DXM although a majority of these have been the result of products (such as Coricidin Cough and Cold) that combine DXM with other substances that become dangerous in high doses.

So if you decide to try and contact your inner beat poet, or channel your punk rock personality through DXM, be careful.

03/25/16

A “God Moment” with DXM

© iofoto | 123rf.com
© iofoto | 123rf.com

One of the most coincidental encounters I’ve ever had in my experiences working with addicts and alcoholics involved someone intending to get high on DXM. One day when I was on my lunch break, I went to a local supermarket to get some hot food from their deli counter. When I was about fifty feet from the automatic doors, one of the individuals I knew from the treatment program exited the store and immediately made a left when he saw me. I called out a hello, which he answered as he just kept walking, saying he had just bought something to eat. Normally a friendly person, his behavior was unusual.

I wondered what could be going on as I went into the store. Then for some reason, I had the thought to go check the isle with the over-the-counter cold medications. The section was completely empty of cough suppressant capsules containing DXM, dextromethorphan. After I bought my lunch, I walked in the direction I has seen him hotfoot it away from me earlier and now saw him coming out of a sandwich shop. Hmm, I thought, he must be really hungry today.

I told him what I had found in the grocery store and then reminded him he had told me he bought something to eat there. Now he had some thing else from the sandwich shop. I also showed him a plastic bag with the grocery store’s logo that contained empty boxes of DXM cough suppressant. I told him that it had been on the top of a garbage can just outside the sandwich shop. He said he bought a drink in the grocery store before buying his sandwich and denied any knowledge of the empty DXM shelves in the grocery store. Of course he didn’t know how the empty DXM packets got there either. Then he left to meet the person giving him a ride home.

Back at the outpatient office, as I was telling the other staff members the above story, he walked in admitted that he had bought the DXM capsules. He said he hadn’t taken any and after I confronted him, he threw his baggy of capsules away. We talked of how close he had come to a lapse into active drug use and I encouraged him to not waste this pretty amazing intervention. We both agreed it seemed to be a “God moment” that put me in front of the store just as he was coming out. The last I heard, he was abstinent; but it took a few more tries at treatment before he got it.

Dextromethorphan (DXM) is a synthetic substance found in about 70 over-the-counter products mainly as a cough suppressant and expectorant. Other medical uses include the other symptoms from hayfever, colds, allergies and the flu: the temporary relief of sinus congestion, runny nose, cough, sneezing, itching of the nose and throat, and watery eyes. DXM was approved by the FDA in 1958 as a cough suppressant. As early as 1962, it was being used recreationally. Ironically it had been substituted for codeine in cough suppressant medications to cut down on abuse. When it became a popular recreational drug with “young heads,” DXM was temporarily removed from the OTC market in 1973.

By 1977 pharmaceutical companies reintroduced DXM cough syrup with an unpleasant taste when used in the large quantities necessary for a high. Within a short time those same manufacturers began to produce forms of DXM syrup with an “appealing flavoring.” Used as prescribed, DXM products do not lead to the altered states sought after by those who abuse it. Doses approximate 30 mg of DXM every four to six hours. A single recreational dose can range from 240 to 1500 mg. “Heavier users have been known to ingest up to 3 or 4 bottles a day.”

In high doses, DXM is a dissociative anesthetic with powerful psychedelic effects. Sometimes it is compared to PCP and ketamine, two other dissociative anesthetics. High dose DXM can lead to toxic psychosis and a host of other physiological and behavioral problems. See the link above and Medline Plus for further information and treatment for DXM overdose.

Dose dependent effects can vary from a mild stimulant effect with distorted visual perceptions to a sense of complete dissociation from your body. A bad DXM experience described on the pro-drug website Erowid said: “My DXM experience was even scarier than my shrooming experience when I thought that I’d lost my face and that I would never return from being completely and utterly confused.”

DXM abuse is largely done by teens looking for a cheap, accessible high. The guy I described above was in his early 20s. Katie McBride, writing for The Fix, described how one teenage boy named Nic had two nearly fatal DXM overdoses in “The Dangers of DXM.” She related information on the SAMHSA website from 2006 that reported an estimated 1 million people between the ages of 12 and 25 had abused OTC cough and cold medication in the previous year. I was not able to find more recent data on DXM or abuse of OTC cough and cold medication. Although there has been data gathered on nonprescription cold and cough medications, since 2006 it was not included in the annual National Surveys on Drug Use and Health (NSDUH).

Beginning in 2006 Monitoring the Future, an ongoing study of the behaviors, attitudes and values of American high school students, began tracking the use of DXM among 8th, 10th, and 12th grade students. Respondents were asked how often they used cough or cold medications to get high in the past year. All the surveyed grade levels reported decreased use from 2006 to 2014. The percentages in 2006 who had used DXM were as follows: 8th graders: 4.2%; 10th graders: 5.3%; 12th graders: 6.9%. By 2014, the percentages were: 8th graders: 2.0%; 10th graders: 3.7%; 12th graders: 4.1%.

The DXM Abuse Prevention Act of 2015 (H.R. 3250) has been introduced to amend the Federal Food, Drug and Cosmetic Act. H.R. 3250 would restrict the sale of DXM products to individuals under the age of 18, except with a valid prescription. Retailers would have to verify that they are not selling DXM to individuals under 18. It would also create a series of penalties for retailers violating the sales restrictions to under aged individuals. The FDA Law Blog reported:

In determining civil penalty amounts for violations, the bill would require consideration of whether the retailer “has taken appropriate steps to prevent subsequent violations,” including establishing a documented training program for all employees who sell dextromethorphan. The bill has received strong support by a number of anti-drug abuse, healthcare and industry organizations including the Consumer Healthcare Products Association, Drug Abuse Resistance Education (“D.A.R.E.”) and Partnership for Drug-Free Kids.”

According to the Monitoring the Future data, DXM use among teenagers has been decreasing. But we should keep in mind that 2% to 4.1% of high school students using DXM in the past year to get high is still a significant number. I’m not sure that H.R. 3250 will ever get out of committee and become law, but it has some good ideas, like restricting the sale of DXM products to individuals over 18, unless they have a prescription. The restrictions on pseudophedrine seem to work in keeping it out of the hands of wanna-be Walter Whites. Something similar should work with DXM products as well.