DXM (Dextromethorphan) Misuse and Treatment

The cough syrup on the pharmacy shelf is not usually the thing anyone worries about. But dextromethorphan - DXM - is the active ingredient in a huge share of over-the-counter cough and cold products, and at ten times the labeled dose it stops being a cough medicine and starts acting like something closer to a hallucinogen. Most people who reach that dose do it on purpose, looking for the high; some are teenagers who found a how-to page. Either way, DXM misuse is real, it can be dangerous, and there is a way to get help for it.

If someone is hard to wake, breathing slowly, or has swallowed a large amount, call 911 or Poison Control at 1-800-222-1222 right now. For a mental health crisis, call or text 988.

What DXM is, and where it hides

DXM is a cough suppressant. Used as the label directs, it is safe and effective, which is exactly why it sits unguarded in medicine cabinets and corner stores. The Drug Enforcement Administration counts it in more than 100 over-the-counter cold medications. The National Institute on Drug Abuse notes that the most commonly misused forms are "extra-strength" cough syrups, tablets, and gel capsules - and that those products often also contain antihistamines and decongestants.

That last detail matters. People chasing the DXM effect take the whole product, not just the DXM, so they get a full dose of everything else in the bottle. Many contain acetaminophen, which can damage the liver in large amounts. Common street names - robo-tripping, skittling, dexing - come from the syrups and gelcaps people use.

Why a cough medicine can get you high

DXM does two things that explain its misuse. It is chemically related to opioids, but NIDA describes it as an opioid that does not relieve pain and does not act on the opioid receptors. At large doses it produces a depressant effect and sometimes a hallucinogenic effect, similar to PCP and ketamine. That is what the plateau descriptions people trade online are describing.

NIDA is direct that repeatedly seeking that feeling can lead to addiction - continued use despite damage to health, work, or relationships. Believing a medicine is "safe because it's legal" is the mistake that makes DXM easy to underestimate.

The interaction that turns a bad night into an emergency

The most serious DXM risk is not the DXM alone - it is what it is mixed with. The FDA label for a prescription medicine that contains dextromethorphan warns that combining dextromethorphan with SSRI antidepressants (like fluoxetine) or tricyclic antidepressants raises the risk of serotonin syndrome, and that the risk is increased by an overdose, especially when other serotonergic drugs are involved. Serotonin syndrome can cause:

• agitation, restlessness, and confusion
• a fast heartbeat and high blood pressure
• high fever, heavy sweating, and shivering
• muscle rigidity and twitching (myoclonus) or overactive reflexes

The standard OTC Drug Facts label adds a second warning: do not use DXM with an MAOI antidepressant, or for two weeks after stopping one, because the combination can be fatal. If you take any antidepressant, that interaction is worth a conversation with a pharmacist before you take a cough medicine at all - and if someone shows the signs above after mixing the two, call 911.

When it is more than a cough

Cough medicine misuse tends to hide, because the product is legal and cheap. Some signs it has crossed into a problem:

• using DXM for the feeling rather than for a cough, and using it alone
• going through bottles or boxes fast, or finding empty packaging stashed away
• wanting more of the same cough medicine right after finishing one
• mixing it with alcohol or other drugs to intensify the effect
• hiding how much is being used from family

Misuse of a common cold medicine carries a particular kind of shame, and that shame is what keeps people from saying anything. It is also the reason it keeps going. Naming it out loud - to a clinician, a counselor, or a person you trust - is the first real step. If low mood or hopelessness is underneath the use, 988 is a place to say that too.

How treatment for DXM misuse works

There is no medication approved specifically to treat DXM misuse, so care looks like the care for substance use generally: an assessment, then behavioral therapy. Cognitive behavioral therapy helps a person see the triggers and thinking that lead back to use, and contingency management - rewards tied to confirmed drug-free tests - has strong evidence for substance use more broadly, per NIDA's treatment approaches overview. A clinician can also evaluate what else is going on: depression, anxiety, or sleep problems that the cough medicine may have been self-treating.

The starting points:

• A primary care doctor or an addiction medicine clinician, who can assess and refer.
• The SAMHSA treatment locator or SAMHSA's National Helpline at 1-800-662-HELP (4357), free and confidential, 24/7.
• Call or text (800) 653-9376 to speak with a treatment specialist who can check coverage and find an opening.

What to do tonight

1. If someone took too much, is unresponsive, or is struggling to breathe, call 911. For a suspected poisoning, Poison Control is 1-800-222-1222.
2. If you take an SSRI, SNRI, tricyclic, or MAOI antidepressant, do not take a DXM cough medicine without asking a pharmacist first.
3. Clear the shelf. If DXM use has become a problem in your home, count what is there and lock or remove it the way you would any other drug.
4. Keep naloxone on hand anyway. It reverses opioid overdoses, not DXM, but polysubstance use is common and naloxone costs nothing to have.
5. Call or text (800) 653-9376, or search findtreatment.gov, to set up an assessment. A cough-syrup habit is a substance use problem, and it answers to the same treatment as any other.

Calling is free; the referral service is paid for by treatment providers, and we check your benefits before you commit.

This page is general health information, not medical advice. For DXM specifically, the label on the product and a pharmacist or clinician are your best guides.

Additional Resources

Sources cited on this page:

• NIDA - Over-the-Counter Medicines DrugFacts
• DEA - The Facts About Dextromethorphan (DXM) Fact Card
• FDA / DailyMed - Dextromethorphan OTC Drug Facts Label (Dextromethorphan Hydrobromide)
• FDA / DailyMed - Dextromethorphan Hydrobromide and Quinidine Sulfate Label (serotonin syndrome warning)
• NIDA - Treatment Approaches for Drug Addiction DrugFacts
• SAMHSA FindTreatment.gov Treatment Services Locator
• SAMHSA National Helpline
• 988 Suicide & Crisis Lifeline

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