A Food and Drug Administration advisory panel voted 15 to nine to continue to allow cough medicines containing dextromethorphan (DXM) to be sold over the counter despite recreational use that sends thousands of people to emergency rooms every year.
Approved by the FDA in 1958, DXM is found in more than 120 over-the-counter cough medicines like Robitussin, Coricidin, Dimetapp and generics. Taken at recommended doses, DXM can occasionally cause a mild high. But abusers consume it in doses 10 to 20 times higher for euphoriant and hallucinogenic effects, referred to as “robo-tripping” or “tussing.”
The DEA, which requested the FDA’s review, is concerned with increasing abuse, especially among adolescents. According to the Partnership for a Drug-Free America’s Attitude Tracking Study, one in ten teens admit to having abused OTC cough medicines, says Partnership CEO Steve Pasierb, M.Ed., who testified at the FDA hearing this past September.
Partnership research shows that two types of teens abuse DXM. One type is experimenting, only to discover DXM is a “lousy high.” The other type is drug-experienced and DXM adds variety.
“New users are going for a dreamy LSD high but end up being puking zombies,” Pasierb says. “Poly-abusers say it’s still on my list, but at the bottom.”
The Partnership and the Consumer Healthcare Products Association advocate legislation that would age-restrict sales of DXM products. Currently, sales are controlled on a store-by-store basis.
“It can’t be available to anyone under 18,” Pasierb says. “It’s easy do to with barcodes and computerized cash registers that lock the purchase until the buyer shows an ID.”
Eliot Gelwan, M.D. a psychiatrist at Emerson Hospital in Concord, Mass. wishes the vote had gone differently. He says DXM is abused by adults as well as adolescents, is much less benign than people, even medical professionals, think and should be available by prescription only.
DXM has a “narrow therapeutic window,” Gelwan says and doses accepted as safe and tolerable can easily escalate to problematic.
“When you hear of a struggle in an emergency room, the first thing you think is PCP. But at very high doses, DXM has similar neurochemical effects, causing berserk out-of-control behavior,” Gelwan says.
Toxic doses of DXM cough medicine also deliver toxic doses of co-ingredients like painkillers, decongestants and expectorants, which can cause the vomiting that keeps victims from overdosing. However, there have been fatalities, Gelwan says. The physical and psychological reactions of DXM withdrawal are similar to those of alcohol withdrawal, he adds.
Both Pasierb and Gelwan say more research is needed to quantify and qualify abuse of both over-the-counter and prescription cough medicine products.
“When clinicians take a substance use history, it’s not that common to ask about OTC medications and people don’t volunteer the information,” Gelwan says. “It has to be asked about.”
By Nan Shnitzler