We are writing this article to raise awareness among parents and counselors about a legal and readily available drug that is widely used by adolescents to achieve high levels: dextromethorphan (DXM). DXM is a component of certain drugs that are supposed to help us get better. Therefore, adolescents often abuse this drug without being aware of the possible consequences and dangers. Given the personal insight and experience we've had with the harmful effects of DXM, we share this story in the hope of reaching a larger population and developing more effective prevention strategies related to teenage drug use.
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When co-author Sharon Davis's son was 17, he began to abuse over-the-counter cough suppressants (OTC). He had used marijuana and K2 (synthetic marijuana) for a few years, but it was coricidin – a cold drug marketed for people with high blood pressure – that really damaged him.
Sharon's son became a different person. He had always been a moody kid, but his mood turned into anger, mania, and psychosis. Over a period of four months, his father and mother took him to the emergency room four times. It wasn't until he attempted suicide that they really got him the help he needed and found out the full extent of his addiction.
He became acquainted with coricidin through some friends. Soon he was using 30 tablets at a time. Coricidin use led to cocaine use. Cocaine use led to methamphetamine use. Two years later he is working on recovery, but his spirit and sanity will never be the same.
According to the Drug-Free Children Partnership, 50% of American teenagers have abused a drug and overdose is the fourth leading cause of teenage death. Parents, counselors, and other adults are aware of the problem of drug use among teenagers, and the country's opioid epidemic has brought the issue of drug abuse to the fore. This attention is long overdue. However, this focus also misleads us by overlooking other critical concerns.
For example, our society largely neglects to talk about the large-scale problem of abuse of OTC medicine by adolescents and its potential as a gateway to other drugs. In fact, OTC cough and cold medicine is one of the most popular drugs that teens use to get high. According to the Monitoring the Future survey, funded by the National Institute on Drug Abuse, more adolescents were ranked high on OTC medicine than prescription opioids in 2019.
Why OTC?
OTC cough medication is easy to get for teenagers. In some places, teenagers can buy these drugs from their local stores. In addition, most stores have these drugs on shelves where they are easy to steal. Teenagers can also get them from their peers and even parents. Not necessarily finding these types of medication "dangerous", many parents will keep them in an unlocked medication cabinet and unwittingly give their teenagers easy access to them. 
The psychoactive drug in OTC cough and cold medicine is DXM, which falls into a class of drugs known as dissociative hallucinogens. Other drugs in this category include PCP, ketamine, and nitrous oxide. The Food and Drug Administration (FDA) approved DXM as a cough suppressant in 1958. It is still legal to buy and use DXM in the United States. DXM is a safe drug when used as directed, but when used at 10 times or more the recommended dose acts as a strong dissociative, distorting reality. Currently, 85% -90% of OTC cough medications contain this powerful antitussive (cough suppressant). DXM is a synthetic opioid drug, but it activates different opioid receptors in the brain than prescription opioids.
Teenagers usually abuse DXM to sense the euphoric, dreamlike experiences and hallucinations it causes. When individuals use DXM to get high, they experience various degrees of drunkenness known as plateaus.
There are four plateaus associated with DXM. The first plateau includes mild poisoning and stimulating effects. The second plateau shows increased intoxication and mild hallucinations. On the third plateau, the user enters a state of altered consciousness with impaired senses and psychosis. The fourth plateau involves a sense of derealization (in which the world appears unreal) and depersonalization (e.g. detachment from the self).
Users describe the higher plateaus as similar to other realms or alternate universes. In general, users feel like they are being transported to another dimension outside of the body. They lose their sense of self and time. It is common for users to post videos or blogs about their experiences, including how they felt and what they saw on high. The slang term robo-tripping is how many teenagers relate to DXM. Slang terms for the drug itself include Triple-Cs, Robo, Kegel, Red Hots, and Dex.
Why is DXM problematic?
DXM is a dangerous drug when used outside therapeutic doses, but little has been done to curb its abuse among teenagers. For decades we have known the consequences of misusing this drug, including seizures, hyperthermia, tachycardia, psychosis, mania, and even death.
The opioid epidemic in this country is a national crisis. It is well worth public attention and government funding to address. At the same time, the abuse of DXM among teenagers is appalling, yet rarely highlighted. This drug is more popular than opioids among young people, and it's legal, inexpensive, and easy to get.
It is imperative that prevention efforts and policies address this problem. For example, laws similar to those from 2005 requiring pharmacies to bring the popular methamphetamine drug pseudoephedrine off the counter could make DXM less readily available. In some states, buyers of OTC cough and cold medication that contain DXM are required to provide ID showing they are 18 years of age or older. We believe this should become mandatory across the country and that sellers of these drugs should be held accountable.
In addition, mass education campaigns for parents, teachers, law enforcement agencies and counselors need to remind adults of the dangers of these drugs, while prevention programs for children and adolescents should focus more on the dangers of OTC drugs. National campaigns and policy changes are needed, but these alone are unlikely to be enough to bring about real change. True prevention efforts require work on multiple levels – from policy makers in Washington to counselors and parents in local communities. Each of us has a role to play and each of us can make a difference.
Where do young people hear about DXM?
In today's time of productive use of the Internet and social media, young people have more access to the world than ever before. Peer pressure to use drugs has been a major concern for the past several decades. Vulnerable teens were believed to be influenced by their peers in the neighborhood and at school. This peer pressure was face to face.
Today's teenagers are still exposed to personal peer pressure, but they are now exposed to that pressure virtually as well. Peer influence can come not only from local teenagers at school but also from millions of teenagers around the world online. Many teenagers access the internet and learn about substance abuse, including how to come into contact with OTC cough and cold medication.
A quick search of popular sites like YouTube can lead teens to videos that either warn of the dangers of DXM or encourage users to experience the high of it. Unfortunately, many websites provide dosage recommendations and “trigger” suggestions for a better high-getting experience.
For example, Reddit, one of the most popular social media sites in the world, has an estimated 430 million active users. Reddit is made up of threads that allow users to post on specific topics and topics. These topics are like cybercommunities made up of members who have similar interests. One of these threads, called r / DXM, has more than 31,500 users. This thread allows users to describe their DXM highs and side effects. It also provides advice on minimizing certain side effects such as nausea.
Other websites and cybercommunities such as Dextroverse.org and the Vaults of Erowid offer teenagers the opportunity to report their maximum DXM levels and get advice from other users on how to use the drug. The DexCalc.com website allows users to enter their weights and receive a recommended dose for the “high plateau” they want to reach. Although many of these sites claim that their purpose is "harm reduction", teenagers usually use these sites to get suggestions and advice on the "safest" ones with pleasure. All of these websites are accessible to young people and can be used free of charge.
Prevention efforts
Fifteen years ago, the FDA issued warning labels about OTC cough and cold medication to alert parents to the dangers of drug abuse by adolescents. The Stop Medicine Abuse campaign was launched nationwide in 2004, but that campaign was clearly unsuccessful. More needs to be done to discourage adolescents from abusing OTC drugs.
As advisors, we have to take the front line of true prevention efforts. This means we need to know more about DXM (and other OTC drugs), the reasons teens use it, the ways teens get it, and the most effective methods of preventing its abuse.
Parental involvement is a good first step. Parents need to know what to look for and how to talk to their teenagers about OTC drugs. Counselors need to get the message across to parents in order to be realistic and honest when educating teens about DXM. Anxiety tactics don't work for many teenagers. In fact, they can make teenagers more curious to see the results for themselves. A better approach to prevention might be for parents, family members and other adults to improve the quality of their connection and communication with adolescents.
Research shows that establishing consistent messages against substance abuse and setting clear boundaries early on can be one of the best prevention efforts for teenage drug use. Simple steps like hiding medication and taking inventory can also be effective. Most parents want to trust their teenagers, but having drugs with DXM that teenagers can access is not advisable, and many parents are unaware of the dangers of DXM drugs. OTC cough and cold medication should be stored just as safely as opioid prescriptions.
Parents also need to know which websites their teenagers access online. A parallel line of defense is to check your browsing history and establish clear rules about which teenagers can access online. Drug use is one of the leading causes of death among teenagers (it causes more than 5,000 deaths each year, according to the National Institute on Drug Abuse). Parents don't want their teens looking for guns or deadly poisons online, and no parent should have their teens looking for how to get up on DXM. Parents may not be comfortable with this advice. Eventually, it might feel like sniffing, and teenagers are likely to resist too. Even so, what teenagers access online can be one of the biggest indicators of drug use.
Establishing rules for computer / Internet use (e.g., allowing a teenager to use the Internet for two hours a day after completing their homework), installing a firewall and placing bans or Passwords for downloads can be security measures that contribute to prevention or if necessary, intervention. The earlier parents set budget rules for the Internet, the better. Proactively planning and making rules before kids reach their teens can prove to be much easier than trying to set new rules once teens are in their late teens.
It is often uncomfortable for teenagers to talk to teenagers about drug use. Many parents don't know where to start. Some parents fear that talking about drugs will increase their children's curiosity about the use. Other parents simply find the subject embarrassing or uncomfortable. As counselors, we need to help parents develop communication skills with their children and adolescents, especially from middle childhood. Counselors can provide parents with resources to learn about substance abuse information, and we can intervene if a teen has already started using it. It's almost a certainty that teenagers will talk to other teenagers about the level of OTC cough and cold medication. As counselors, we need to encourage parents to talk to their children about their choice not to go high.
If Sharon Davis as a counselor and parent had recognized the signs of DXM abuse in her son, he might have gotten help sooner. We want parents and counselors to hear that DXM is one of the most popular drugs for teenagers. While it's legal and easy to get, it's not safe if misused. Sharon couldn't stop her son from being harmed, but we hope her story will help parents of children and youth across the country protect their own sons and daughters.
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Emily Weaver is a PhD student in the Clinical Mental Health Advisory Program at Arkansas State University. She plans to graduate this spring, become a licensed professional counselor, and pursue a career in addiction counseling. Contact her at [email protected].
Sharon J. Davis is a Professor at Arkansas State University and a Certified Rehabilitation Advisor. Contact them at [email protected].
David Saarnio is Professor of Psychology at Arkansas State University, specializing in Developmental Psychology.
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