BULLETIN INTELLIGENCE

U. S. D E P A R T M E N T O F J U S T I C E

Background

DXM is a synthetically produced substance that 

is chemically related to codeine, though it is not an 

opiate. DXM is an ingredient in more than 140 overthe-counter cough and cold remedies and since the 

1950s has gradually replaced codeine as the most 

widely used cough suppressant in the United States. 

It is available in capsule, liquid, liquid gelatin capsule, lozenge, and tablet forms. It also is available in 

powdered form on the Internet—typically for sale to 

laboratories conducting research on DXM. 

When ingested at recommended dosage levels, 

DXM generally is a safe and highly effective cough 

suppressant; however, when ingested in larger 

amounts, DXM produces negative physiological 

effects. Reports of DXM abuse have resulted in 

monitoring by the Drug Enforcement Administration 

(DEA), and DXM could be added to the Controlled 

Substances Act if warranted. In 2003 legislation was 

introduced in Texas and North Dakota to prohibit the 

sale of DXM to minors. The proposed legislation did 

not pass in either state. A similar bill introduced in 

California this year was also defeated.

Slang terms for DXM include DM, robo, rojo, 

and velvet. Slang terms for DXM intoxication 

include robo tripping, skittling, and dexing. 

Abuse 

Most DXM abusers ingest the drug orally, 

although some snort the pure powdered form of the 

drug. Abusers ingest various amounts of DXM 

depending on their body weight and the effect or 

plateau that they are attempting to achieve (see text 

box on page 2). Some abusers ingest 250 to 1,500 

milligrams in a single dosage, far more than the recommended therapeutic dose of 10 to 20 milligrams 

every 4 hours or 30 milligrams every 6 to 8 hours.

Over-the-counter products that contain DXM 

often contain other ingredients such as acetaminophen, chlorpheniramine, and guaifenesin. Large 

dosages of acetaminophen can cause liver damage; large dosages of chlorpheniramine can cause 

increased heart rate, lack of coordination, seizures, 

and coma; and large dosages of guaifenesin can 

cause vomiting. Some first-time users may not 

abuse DXM repeatedly if they experience negative 

DXM (Dextromethorphan)

Product No. 2004-L0424-029 OCTOBER 2004

The abuse of DXM (dextromethorphan)—a common ingredient contained in over-the-counter cough and 

cold medicines—is an increasing concern for law enforcement officers in the United States. Adolescents 

are the primary abusers of the drug, most likely because it is inexpensive and relatively easy to obtain. 

Additionally, because DXM is a common ingredient in many cough and cold medicines, many adolescents 

do not perceive any risk in abusing the drug. Compounding the problem is that few parents know about the 

potential for abuse of the drug. 
DXM (Dextromethorphan)

2

side effects—such as vomiting—commonly associated with the other ingredients contained in 

over-the-counter DXM medications. Nonetheless, 

some DXM abusers “robo shake,” a practice 

whereby they drink a large amount of cough syrup 

containing DXM and then force themselves to 

vomit so as to absorb enough DXM through the 

stomach lining to achieve the desired effect while 

expelling the other ingredients. Some more experienced abusers use a chemical procedure to extract 

the DXM from the other ingredients contained in 

cough syrups to avoid such side effects. (This procedure cannot be used on DXM products sold in 

nonliquid form.) 

Recommended dosages of DXM generally are 

safe but can cause nausea, gastrointestinal disturbances, slight drowsiness, and dizziness. Acute 

dosages (between 250 and 1,500 milligrams) can 

cause blurred vision, body itching, rash, sweating, 

fever, hypertension, shallow respiration, diarrhea, 

toxic psychosis, coma, and an increase in heart rate, 

blood pressure, and body temperature. Some abusers become violent after ingesting the drug. Little is 

known about the long-term effects of DXM abuse; 

however, anecdotal reporting and limited clinical 

research suggest that extensive and prolonged 

abuse may cause learning and memory impairment. 

While studies indicate that DXM is not addictive, 

some former DXM abusers report experiencing 

cravings for the drug.

Deaths caused by DXM overdoses are rare as 

most abusers ingest DXM products that contain 

other ingredients that cause vomiting, which expels 

the DXM from their bodies. 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. 

DXM abuse levels are difficult to determine. 

Commonly used drug toxicology screens and field 

NDIC

Figure 1. Cough medications with DXM may contain 

other active ingredients.

DXM Plateaus

Abusers describe the DXM experience as 

occurring on four different plateaus. Abusers 

ingest increasing amounts of DXM (based on 

their weight) to reach each succeeding plateau. 

Abusers report the following effects occurring in 

each plateau: 

First Plateau: Mild inebriation.

Second Plateau: An effect similar to alcohol 

intoxication and, occasionally, mild hallucinations. 

The abuser’s speech can become slurred, and 

short-term memory may be temporarily impaired.

Third Plateau: An altered state of consciousness. 

The abuser’s senses, particularly vision, can 

become impaired. 

Fourth Plateau: Mind and body dissociation or an 

“out-of-body” experience. The abuser can lose 

some or all contact with his or her senses. The 

effects at this plateau are comparable to the effects 

caused by ketamine or PCP (phencyclidine).
National Drug Intelligence Center

 3

tests do not accurately detect the presence of DXM. 

Therefore, more thorough laboratory testing must 

be performed. DEA recommends the gas chromatography/mass spectrometer (GC/MS) test, as other 

laboratory tests may produce false positives. 

National surveys conducted to estimate rates of 

drug abuse do not include questions regarding 

DXM. However, the American Association of Poison Control Centers reports that the total number of 

calls to centers nationwide involving DXM abuse 

or misuse have increased since 2000 (see Table 1). 

Calls involving abuse or misuse of DXM by teenagers increased approximately 100 percent from 

2000 (1,623) through 2003 (3,271). Calls involving 

abuse by other age groups increased 21 percent 

from 2000 through 2002, before decreasing slightly 

in 2003. 

Availability

DXM abusers can obtain the drug at almost any 

pharmacy or supermarket. Most seek out products 

that have a high concentration of the drug. One of the 

most frequently abused products containing DXM is 

Coricidin® HBP Cough & Cold, which contains 30 

milligrams of DXM per tablet. Abusers often refer to 

Coricidin® HBP Cough & Cold as triple C because 

of the three Cs imprinted on the red tablets. Other 

slang terms include skittles, dex, candy, and red devils. Another frequently abused product containing 

DXM is Robitussin® DM, a syrup that contains 2 

milligrams of DXM per milliliter.

Concerns about shoplifting and abuse of products containing DXM have resulted in some stores 

instituting new policies and procedures regarding 

access and sales of such products. Specifically, 

some stores place such products where consumers 

must ask for them, and some have limited the number of packages that can be sold to each customer.

DXM frequently is available at raves and other 

venues where youths congregate. At such events, 

DXM occasionally is sold as another drug or in 

combination with other drugs. For example, DXM 

sometimes is sold in tablet form by drug dealers 

who claim that the tablet contains MDMA (3,4-

methylenedioxymethamphetamine, also known as 

ecstasy). When DXM is used in combination with 

MDMA, the combination can increase the risk of 

life-threatening hyperthermia. Drug dealers also 

have distributed DXM to abusers who thought they 

were purchasing heroin or ketamine. 

Table 1. Calls Involving Abuse or Misuse of 

DXM to Poison Control Centers

Year Teenagers All Other

Age Groups

2000 1,623 900

2001 2,276 1,107

2002 2,881 1,139

2003 3,271 1,111

Source: American Association of Poison Control Centers.

NDIC

Figure 2. Coricidin® HBP Cough & Cold tablets.
DXM (Dextromethorphan)

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Pure powdered DXM—typically intended for 

sale to laboratories conducting research on the 

drug—is available from some Internet web sites. 

DXM purchased from such sites contains no other 

ingredients, which substantially increases the risk 

of overdose. Two powdered DXM-related deaths 

occurred in Illinois—one in September 2003 and 

the other in February 2004. One incident was ruled 

a suicide; the other was an accidental overdose.

Outlook

DXM abuse among adolescents most likely 

will increase as the drug is relatively easy to obtain 

and inexpensive. Moreover, adolescents perceive 

the risk in abusing the drug as low. Stemming 

DXM abuse will require increased public awareness of the drug’s potential for abuse, increased 

awareness of the inherent risks associated with 

abusing DXM, and increased diligence of parents, 

educators, health care providers, law enforcement 

personnel, and retailers who market products containing DXM. 

Sources

American Association of Poison Control Centers

American Journal of Health-System Pharmacy

Associated Press

Columbia University

DrugAbuse.com

Drug Enforcement Administration

Maryland Poison Control Center

Office of National Drug Control Policy

©Porrata Consulting

Figure 3. Cough syrup with DXM.