DXM

By Donna Leinwand, USA TODAY
Emergency rooms and schools across the nation are reporting that waves of youths are overdosing on non-prescription cough and cold medicines that are widely available in drugstores and supermarkets.

The dozens of overdoses in the past two years — including at least five deaths in which the abuse of over-the-counter medicines was a factor — reflect how medicines such as Robitussin and Coricidin are becoming more popular as recreational drugs for kids as young as 12, police and doctors say.

The incidents represent a dangerous turn from past decades, when some youths would guzzle cough syrup to try to get a buzz from alcohol and codeine, authorities say. Most cough and cold medicines no longer contain alcohol, and those with codeine, an addictive opiate, are available only by prescription. But more than 120 over-the-counter medicines include dextromethorphan, or DXM, a cough suppressant that when taken in heavy doses can produce hallucinations and a loss of motor control, much as PCP does.

Kids don't have to drink entire bottles of goopy cough syrup to go "Robotripping" or "Dexing." Pills such as Coricidin HBP Cough & Cold tablets — known as "Triple C's" — offer far more potent doses of DXM with less hassle. Youths can buy the medicines easily, then go to Web sites to learn how much someone of their weight should take to get high.

Whether in cough syrup or pills, DXM costs just a few dollars, is "easy to get ... and there's a lot of information about how to get high on it on the Internet," says Charles Nozicka, medical director of pediatric emergency medicine at St. Alexius Medical Center in Hoffman Estates, Ill., west of Chicago. He says that he began seeing DXM overdoses among teens three or four years ago, and that lately he has seen as many as four cases a week.

Authorities say DXM overdoses typically occur in clusters, as word of the drug spreads in a community's middle schools and high schools. This fall, parents and school officials in Naples, Fla., who had known little about DXM were shocked when several kids in their early teens suddenly passed out in class after overdosing on the drug.

At Pine Ridge Middle School in Naples in September, a 13-year-old girl brought about 80 Coricidin pills to campus one day and gave some to six friends, authorities there say. Each of the friends took at least five pills — the recommended dosage for adults is no more than one pill every six hours — and soon the school was in chaos. Two students lost consciousness in their first-period classes; they and one other overdosed youth were treated at a local hospital.

The girl who distributed the pills thought it would be "fun to feel messed up and act ... drunk," says Cpl. Joseph Scott of the sheriff's office in Collier County, which is in southwestern Florida on the Gulf Coast.

Another round of overdoses occurred on Nov. 6 at Immokalee High School, which also is in Collier County. A 15-year-old girl and two of her friends took five Coricidin pills each before school. By 10:45 a.m., the girl "couldn't remember her own name," Scott says. When paramedics could not stabilize her heartbeat, they called for a helicopter to take her to a hospital. Authorities learned later that she had obtained the pills from a boy who had taken them from his home. The girl's friends did not have to be hospitalized.

Scott says that many parents in Collier County were shaken by the idea that youths could buy large amounts of such a potentially dangerous drug at a local store, and then consume the drug, without breaking any laws. "It's something people aren't really informed about yet. The parents we've dealt with so far are pretty much in shock," Scott says. "It seems right now it's mostly the younger kids" who are taking DXM.

Scott says his office is compiling information packets about DXM that will be distributed to local pharmacies and schools.

Restricting access

Elsewhere, growing concerns about DXM have led some drugstores to restrict access to cough and cold medicines.

After two teenage girls and two 20-year-old men in Merrill, Wis., overdosed on medicines containing DXM this year, some drugstores in the city of about 10,000 people 160 miles north of Madison began to stow such remedies behind their counters. At the Aurora Pharmacy, customers now must request Coricidin tablets, and they aren't allowed to buy several boxes at once. Pharmacist Jim Becker says he wants the drug "where we can keep an eye on it."

Drug manufacturers say they sympathize with concerns about drug abuse, but they have resisted efforts to restrict consumers' access to Coricidin, Robitussin and other remedies containing DXM.

"The vast majority of people take them responsibly," says Fran Sullivan, spokesman for Wyeth Consumer Healthcare in Madison, N.J., which makes Robitussin products. "As a medicine, it works hands-down, so we want people to be able to use it if they need it."

Aware that teens might be tempted to abuse its newest DXM product, anti-cough gel-tabs, Wyeth made its packaging large enough so that it is difficult to stash in a backpack or pocket, Sullivan says. The company advertises on TV shows geared to adults, he says.

"We've noticed that the abuse comes and goes in waves," he says. "It gets really popular in a small area for a short period of time and then it dies out. Teens end up in the emergency room, it makes the local newspaper, and the area goes on alert."

Schering-Plough, which makes Coricidin, is working with the Partnership for a Drug-Free America to create an educational Web site on DXM, company spokeswoman Mary-Fran Faraji says. Company representatives also are meeting with pharmacists, parents, schools and retailers to discuss ways to prevent drug abuse.

But Faraji says Schering-Plough doesn't plan to eliminate DXM from its non-prescription cough and cold medicines. She notes that most of the potential alternatives to DXM as a cough suppressant are opiates that carry more potential for abuse. "Reformulating our product is not going to make the abuse issue go away," Faraji says. "Our product is safe and effective when used as directed."

DXM approved decades ago

DXM, a synthetic drug that chemically is similar to morphine, was approved by the Food and Drug Administration as a cough suppressant in 1954. Drug manufacturers began putting it in cough syrups in the 1970s as a replacement for codeine.

DXM is sold legally without a prescription because it does not make users high when taken in small doses. The recommended dose, about one-sixth to one-third of an ounce of an extra-strength cough syrup, contains 15 to 30 milligrams of DXM, according to the National Institute on Drug Abuse. At doses of 4 or more ounces of cough syrup, DXM produces effects similar to those of PCP or the anesthetic ketamine, the institute says. DXM can produce hallucinations, depressed breathing, elevated blood pressure and an irregular heartbeat. Overdoses can cause seizures, comas and death.

It can be particularly dangerous when taken with other drugs.

Lee Cantrell, interim director of the California Poison Control System's San Diego division, says that Robitussin and some other cough and cold remedies containing DXM have additional ingredients that can be fatal to abusers if taken in huge doses. For example, antihistamines, which often are combined with DXM in cough and cold remedies, can be toxic and cause respiratory distress, Cantrell says. He says cough medicine abuse emerged as a problem in California about three years ago.

During what officials called a "mini-outbreak" of DXM overdoses in New Jersey two months ago, a 15-year-old boy had to be treated for acetaminophen poisoning after he drank two bottles of Robitussin and took some Coricidin. Acetaminophen is a pain reliever/fever reducer that, over time, can cause liver damage if taken in large doses.

The federal government does not keep statistics on DXM abuse, but drug specialists say anecdotal evidence suggests that its use does not approach that of methamphetamine or the club drug Ecstasy. DXM abusers, drug specialists say, typically are young teens who are seeking a cheap alternative to drugs that are more expensive and more difficult to get.

Still, "what we see in the emergency department is probably the tip of the iceberg," Nozicka says of DXM abuse in his community near Chicago. "There's probably a lot more going on, but most (overdose cases) don't end up in the emergency room."

Some drug counselors and doctors say young adults have begun using DXM with alcohol, Ecstasy and other drugs.

DXM "looks innocuous enough, but if you take enough of it, it can cause serious problems," says Ed Bottei, medical director of the Iowa Statewide Poison Control Center in Sioux City. A 22-year-old college student in Ames, Iowa, died of a DXM overdose in October 2002. "Even though it's an over-the-counter medicine, it can still hurt you," Bottei says.

Authorities who have been more focused on illegal drugs often have been surprised by sudden outbreaks of DXM overdoses.

After a series of overdoses in the Detroit area in August, the U.S. Drug Enforcement Administration issued an alert that warned parents, schools and local communities about an "escalation" in DXM abuse.

The alert cited a "disturbing increase" of overdoses in the Grosse Point area, near Detroit.

DEA special agent David Jacobson, spokesman for the agency's Detroit office, says that federal drug enforcement analysts usually can forecast regional trends in drug use, based on geographic patterns. But "Robotripping" came out of nowhere, he says.

"Law enforcement hadn't heard about it, but all the kids had," Jacobson says. As he and others in the community asked around, they found that DXM abuse "was not only out there, but it was out there more than we thought."

Internet fuels trend

Like others who monitor DXM abuse, Jacobson says the Internet has fueled the trend.

"Now (DXM cases) pop up everywhere," he says. "If one kid is doing it anywhere, kids here will know about it."

At Michigan State University in East Lansing, the student health center is planning to include a question about DXM abuse on its next student health survey in the spring, says Dennis Martell, the university's interim coordinator for health education.

"We want to be proactive in identifying the problem before it becomes the rage," he says.

Meanwhile, as word of DXM spreads among teens and young adults, pharmacies are reporting more thefts of cough and cold medicines, as well as suspicious purchases.

Victor Vercammen, a pharmacist who works in a drugstore north of Chicago, says he recently watched two young men try to buy six packages of Coricidin. As the clerk rang up the purchase, Vercammen confronted the pair.

"I could tell as the conversation went on that they planned to misuse it, so I asked if they realized that it could cause a seizure, that it could be fatal," says Vercammen, a spokesman for the Illinois Pharmacists Association. "My hope was that educating them at least gets them to think about it. The popular conception is that because it's over-the-counter, it's safer."