Recreational use of dextromethorphan

For general information on this drug, including medical usage, see dextromethorphan.

Dextromethorphan or DXM, an active ingredient found in most cough suppressant cold medicines, is commonly used as a recreational drug. While having almost no psychoactive effects at medically-recommended doses, dextromethorphan has euphoric, hallucinogenic, and dissociative properties when administered in doses well above those which are considered therapeutic medically for cough suppression.

An online essay first published in 1995 by William E. White, entitled "The DXM FAQ", was possibly the first source of specific scientific details regarding dextromethorphan's potential for recreational use. This may have led to a number of "underground" websites in existence today, devoted to the topic of dextromethorphan as a recreational drug.

Due to its recreational use and theft concerns, many retailers in the US have moved dextromethorphan-containing products behind the counter so that one must ask a pharmacist to receive them or be 18 years (19 in NJ and AL) or older to purchase them. Some retailers also give out printed recommendations about the potential for abuse with the purchase of products containing dextromethorphan.

Classification

At high doses, dextromethorphan is classified as a dissociative anesthetic and hallucinogen, similar to the controlled substances ketamine and phencyclidine (PCP). Also like those drugs, dextromethorphan is an NMDA receptor antagonist. Dextromethorphan generally does not produce withdrawal symptoms characteristic of physically addictive substances, but there have been cases of psychological addiction.

Legality

Antitussive preparations containing dextromethorphan are legal to purchase from most pharmacies worldwide. Since dextromethorphan's use as a recreational drug usually involves only the ingestion of large quantities of an over-the-counter medication, no legal distinction currently exists between medical and recreational use, sale, or purchase, though some states, such as Illinois, now require signatures to purchase dextromethorphan medications and limit the purchase to two packages at a time.

The sale of dextromethorphan in its pure powder form may incur penalties in the United States, although no explicit law exists prohibiting its sale. There have been cases of individuals incurring time in prison and other penalties for selling pure dextromethorphan in this form, due to the incidental breaking of related drug laws — such as resale of a medication without proper warning labels.

Dextromethorphan was excluded from the Controlled Substances Act (CSA) of 1970 and was specifically excluded from the Single Convention on Narcotic Drugs. Dextromethorphan is still excluded from the CSA (as of 2008), however officials have warned that it could still be added if increased abuse warrants its scheduling.

Dextromethorphan is generally available over the counter in most countries, with three exceptions being Hong Kong, Sweden and Denmark.

Effects

Dextromethorphan, when consumed in low "recreational doses" (usually around or slightly more than 200 mg, or around 1.5 to 2.5 mg/kg), is described as having a euphoric effect. With middle doses (about 400 mg, or 2.5 to 7.5 mg/kg), intense euphoria (or dysphoria), vivid imagination, and closed-eye hallucinations may occur. With high doses (600 mg, or 7.5 mg/kg and over), profound alterations in consciousness have been noted, and users often report out-of-body experiences or temporary psychosis. Frequent and long-term usage at very high doses could possibly lead to toxic psychosis and other permanent psychological problems. Most users find such high doses to be extremely uncomfortable and are unwilling to repeat them. Flanging (speeding up or slowing down) of sensory input is also a characteristic effect of recreational use.

There may also be a marked difference between dextromethorphan hydrobromide, contained in most cough suppressant preparations, and dextromethorphan polistirex, contained in the brand name preparation Delsym. Polistirex is polymer that is bonded to the dextromethorphan that requires more time for the stomach to digest it as it requires that an ion exchange reaction take place prior to its dissolution into the blood. Because of this, dextromethorphan polistirex takes considerably longer to absorb, resulting in more gradual and longer lasting effects reminiscent of time release pills. As a cough suppressant, the polistirex version lasts up to 12 hours, so this duration may also hold true when used recreationally.

In 1981, a paper by Gosselin estimated the lethal dose to be between 50 and 500 mg/kg. Doses as high as 15-20 mg/kg are taken by some recreational users. It is suggested by a single case study that the antidote to dextromethorphan overdose is naloxone, administered intravenously.

In addition to producing PCP-like mental effects, high doses may cause a false-positive result for PCP and opiates in some drug tests.

Risks associated with use

Most risks result from abusing multi-symptom cold medications, rather than using a cough suppressant whose sole active ingredient is dextromethorphan. Recreational use of medications with multiple active ingredients can produce negative psychological and physiological effects and is highly unsafe. Multi-symptom cold medicines contain other active ingredients, such as acetaminophen, chlorphenamine, and phenylephrine, any of which can cause permanent bodily damage, or even death, if taken on the generally-accepted recreational dosing scale of dextromethorphan. Guaifenesin, an expectorant commonly accompanying dextromethorphan in cough preparations, while not generally fatal if taken on dextromethorphan's recreational dosing scale, it can cause unpleasant symptoms including vomiting, nausea, and headache. Sorbitol, an artificial sweetener found in many cough syrups containing dextromethorphan, can also have negative side effects including diarrhea and nausea when taken at recreational dosages of dextromethorphan.

Combining dextromethorphan with other substances can compound risks. CNS stimulants such as amphetamine and/or cocaine can cause a dangerous rise in blood pressure and heart rate. CNS depressants such as ethanol (drinking alcohol) will have a combined depressant effect, which can cause a decreased respiratory rate. Combining dextromethorphan with other CYP2D6 substrates can also cause both drugs to build to dangerous levels in the bloodstream.

Dextromethorphan has been shown to cause vacuolization, also known as Olney's lesions, in rats' brains. However, oral administration of dextromethorphan does not cause vacuolization in rats' brains. Furthermore, it should be noted that the occurrence of Olney's lesions in humans has not been proven or disproven, and critics claim that animal testing is not a reliable predictor of the effects of dextromethorphan or dissociative substances in general on humans.

The "DXM FAQ"

A document entitled "The DXM FAQ," by William E. White, classifies dextromethorphan's high-dose effects into four or five plateaus, each defined by a dosing range. The dosages are specified in ratios of milligrams (of the drug) per kilogram (of one's body mass). According to the FAQ, the plateaus occur as follows:

• First plateau: At a dosage of 1.5 to 2.5 mg/kg, effects include a sensation of alertness, stimulant effects such as restlessness, increased heartbeat, and increased body temperature, intensification of emotions, general euphoria, euphoria linked to music, alteration of sensations of gravity, loss of balance, and slight intoxication.

• Second plateau: At 2.5 to 7.5 mg/kg, effects include the same effects of the first plateau, with added choppy sensory input, entering a dreamlike state of consciousness, increasing detachment from outside world, a heavier "stoned" feeling than with first plateau, and/or closed-eye hallucinations.

• Third plateau: At 7.5 to 15.0 mg/kg, effects include flanging of visual effects, difficulty recognizing people or objects, chaotic blindness, dreamlike vision, inability to comprehend language, abstract hallucinations, delayed reaction time, decision making impairment, feelings of peace and quiet, near complete loss of motor coordination, short-term memory impairment, and/or feelings of rebirth.

• Fourth plateau: At 15.0 mg/kg or more, an individual may experience a perceived loss of contact and control with their own body, changes in visual perception, out-of-body experiences, perceptions of contact with "superior," supernatural, or other archetypal beings (ie. gods, aliens, vampires, etc.), other miscellaneous delusions, lack of movement or desire to move, rapid heart rate, complete blindness, increased hearing, and intensification of third plateau effects.

• Plateau Sigma: 2.5-7.5 mg/kg every three hours for 9–12 hours; There are some reports that suggest this fifth plateau occurs by prolonging dosage, rather than increasing it, ingesting small to moderate doses over time. White characterizes Plateau Sigma as bona-fide psychosis, a complete disconnection from reality, with prevalent, realistic, vivid open-eye visual and auditory hallucinations. For example, users have reported entirely realistic and vividly-recalled encounters with aliens and gods. Users have also reported a disconnection from emotion, such that inclinations and urges become auditory hallucinations of vocal commands to which the user is entirely obedient — as in, rather than simply feeling tired and sitting down, a user would hear a voice saying, "sit down now, you're tired," and feel inclined to obey. White says that of all the reports of Plateau Sigma experiences he received, over half were described as unpleasant, and users said they were unwilling to repeat the experience.

Pharmacology

Dextromethorphan's hallucinogenic and dissociative effects can be attributed largely to dextrorphan (DXO), a metabolite produced when dextromethorphan metabolizes within the body. Both dextrorphan and dextromethorphan are NMDA receptor antagonists, just like the dissociative hallucinogenic drugs ketamine and phencyclidine (PCP); however for that purpose, dextrorphan is more potent than dextromethorphan.

Just like all NMDA receptor antagonists, dextrorphan and dextromethorpan inhibit a neurotransmitter called glutamate from activating receptors in the brain. This can effectively slow or even shut down certain neural pathways, preventing areas of the brain from communicating with each other. This leaves the user feeling dissociated (disconnected) or potentially "out-of-body."

Dextromethorphan's euphoric effects have sometimes been attributed to the triggering of an increase in dopamine levels, since such an increase generally correlates to a pleasurable response to a drug, as is observed with recreational drugs. However the effect of dextrorphan and dextromethorphan on dopamine levels is a disputed subject. Studies show that some NMDA receptor antagonists, like ketamine and PCP, do raise dopamine levels. Other studies show that dizocilpine, another NMDA receptor antagonist, has no effect on dopamine levels. Some findings even suggest that dextromethorphan actually counters the dopamine increase caused by morphine. Due to these conflicting results, the actual effect of dextromethorphan on dopamine levels is yet to be determined.

See also

• Dissociative drug
  • Dextrorphan
  • Dextromethorphan
  • Ketamine
  • Nitrous oxide
  • Phencyclidine (PCP)
• Hallucinogen
• NMDA receptor antagonist
• Psychedelic
• Sigma agonist

External links

• Dextroverse
• Dextromethorphan FAQ at third-plateau.org
• Erowid
• Dextromethorphan User Forums at Fourth-plateau.org