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Cough and Cold Medicine
(DXM and Codeine Syrup) Abuse

What is DXM?

Overview: Dextromethorphan (DXM) is a cough suppressor found in more than 120 over-the-counter (OTC) cold medications, either alone or in combination with other drugs such as analgesics (e.g., acetaminophen), antihistamines (e.g.,chlorpheniramine), decongestants (e.g., pseudophedrine), and/or expectorants (e.g., guaifenesin). The typical adult dose for cough is 15 or 30 mg taken three to four times daily. The cough-suppressing effects of DXM persist for 5 to 6 hours after ingestion. When taken as directed, side-effects are rarely observed.


Street Names: CCC, Dex, DXM, Poor Man's PCP, Robo, Skittles, Triple C, Velvet.


Looks Like: DXM can come in the form of: cough syrup, tablets, capsules, or powder.


Methods of Abuse: DXM is abused in high doses to experience euphoria and visual and auditory hallucinations. Abusers take various amounts depending on their body weight and the effect they are attempting to achieve. Some abusers ingest 250 to 1,500 milligrams in a single dosage, far more than the recommended therapeutic dosages prescribed above. Illicit use of DXM is referred to on the street as "Robotripping," "skittling," or "dexing." The first two terms are derived fom the products that are most commonly abused, Robitussin and Coricidin HBP. DX abuse has traditionally involved drinking large volumes of the OTC liquid cough preparations. More recently, however, abuse of tablet andgel capsule preparations has increased. These newer, high-dose DXM products have particular appeal for abusers. They are much easier to consume, eliminate the need to drink large volumes of unpleasant-tasting syrup, and are easily portable and concealed, allowing an abuser to continue to abuse DXM throughout the day, whether at school or work. DXM powder, sold over the Internet, is also a source of DXM for abuse. (The powdered form of DXM poses additional risks to the abuser due to the uncertainty of composition and dose.) DXM is also distributed in illicitly manufactured tablets containing only DXM or mixed with other drugs such as pseudophedrine and/or methamphetamine. DXM is abused by individuals of all ages, but its abuse by teenagers and young adults is of particular concern. This abuse is fueled by DXM's OTC availability and extensive "how to" abuse information on various web sites.


Affect on Mind: Some of the many psychoactive effects associated with high-dose DXM include: confusion, inappropriate laughter, agitation, paranoia, and hallucinations. Other sensory changes, including the feeling of floating and changes in hearing and touch. Long-term abuse of DXM is associated with severe psychological dependence. Abusers of DXM describe the following four dose dependent "plateaus": Plateau Dose (mg) Behavioral Effects 1st 100-200 Mild stimulation 2nd 200-400 Euphoria and hallucinations 3rd 300-600 Distorted visual perceptions Loss of motor coordination 4th 500-1500 Out-of-body sensations.


Affect on Body: DXM intoxication involves: over-excitability, lethargy, loss of coordination, slurred speech, sweating, hypertension, and involuntary spasmodic movement of the eyeballs. The use of high doses of DXM in combination with alcohol or other drugs is particularly dangerous, and deaths have been reported, Approximately 5-10% of Caucasians are poor DXM metabolizers and at increased risk for overdoses and deaths. DXM taken with antidepressants can be life threatening. OTC products that contain DXM often contain other ingredients such as acetaminophen, chlorpheniramine, and guaifenesin that have their own effects, such as: liver damage, rapid heart rate, lack of coordination, vomiting, seizures, and coma. To circumvent the many side effects associated with these other ingredients, a simple chemical extraction procedure has been developed and published on the Internet that removes most of those other ingredients in cough syrup.


Drugs Causing Similar Effects: Depending on the dose, DXM can have effects similar to marijuana or Ecstasy. In high doses its out-of-body effects are similar to those of Ketamine or PCP.


Overdose Effects: DXM overdose can be treated in an emergency room setting and generally does not result in severe medical consequences or death. Most DXM-related deaths are caused by ingesting the drug in combination with other drugs. DXM-related deaths also occur from impairment of the senses, which can lead to accidents. In 2003, a 14-year-old boy in Colorado who abused DXM died when he was hit by two cars as he attempted to cross a highway. State law enforcement investigators suspect that the drug affected the boy's depth perception and caused him to misjudge the distance and speed of the oncoming vehicles.


*Above information and image below courtesy of the Drug Enforcement Administration (www.dea.gov)

What is Codeine Syrup?

Overview: Promethazine-codeine cough syrup. These prescription medications contain an opioid drug called codeine, which stops coughs, but when taken in higher doses produces euphoria.


Street Names: Sizzurp or Syrup


Methods of Abuse: Cough and cold medicines are usually sold in liquid syrup, capsule, or pill form. They may also come in a powder. Young people are more likely to abuse cough and cold medicines containing DXM because these medicines can be purchased without a prescription. Some people mix promethazine-codeine cough syrup with soda or alcohol and flavor the mixture by adding hard candies. [Codeine syrup is commonly mixed with Sprite and Jolly Rancher candies, popularized by well-known rappers and hiphop artists]


Affect on Mind: Codeine attaches to the same cell receptors as opioids like heroin. High doses of promethazine-codeine cough syrup can produce euphoria similar to that produced by other opioid drugs. Also, both codeine and promethazine depress activities in the central nervous system (brain and spinal cord), which produces calming effects. Both codeine and DXM cause an increase in the amount of dopamine in the brain’s reward pathway. Extra amounts of dopamine increase the feeling of pleasure and at the same time cause important messages to get lost, causing a range of effects from lack of motivation to serious health problems. Repeatedly seeking to experience that feeling can lead to addiction.


Other Effects: Slowed heart rate and slowed breathing. Also, cough and cold medicines are even more dangerous when taken with alcohol or other drugs.


Overdose Effects: Abuse of promethazine-codeine cough syrup slows down the central nervous system, which can slow or stop the heart and lungs. Mixing it with alcohol greatly increases this risk.*

* "Cough and Cold Medicine (DXM and Codeine Syrup)." NIDA for Teens. National Institute on Drug Abuse. Web. 15 Oct. 2015. <https://teens.drugabuse.gov/drug-facts/cough-and-cold-medicine-dxm-and-codeine-syrup>.