Editing Recreational use of dextromethorphan

{{Short description|Cough suppressant drug susceptible to misuse}}
{{For|general information on this drug, including medical usage|dextromethorphan}}
{{Use dmy dates|date=March 2020}}
[[File:Dextromethorphan Tablet-15.jpg|thumb|Cough medicine containing dextromethorphan in tablet form (15mg)|175px]]
'''Dextromethorphan''', or '''DXM''', a common [[active ingredient]] found in many over-the-counter [[cough suppressant]] cold medicines, is used as a [[recreational drug use|recreational drug]] and [[entheogen]] for its [[dissociative]] effects.<ref name="cesar" /> Street names include '''Brownies''', '''Dextro''', '''Drix''', '''Gel''', '''Groove''', '''Lean''', '''Mega-perls''', '''Poor man's ecstasy''', '''Poor man's PCP, Red devils''', '''Robo''', '''Rojo''', '''Rome''', '''Skittles''', '''Sizzurp''', '''Triple Cs, Sky''' and '''Velvet'''.<ref>{{cite web |url=https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=1&contentid=2617 |title=Cough Medicine Abuse by Teens}}</ref>

It has almost no [[psychoactive]] effects at medically recommended doses. However, [[dextromethorphan]] has powerful dissociative and euphoric properties when administered in doses well above those considered therapeutic for cough suppression.<ref name="cesar">{{cite web |url=http://www.cesar.umd.edu/cesar/drugs/dxm.asp |title=Dextromethorphan (DXM) &#124; CESAR |website=Cesar.umd.edu |access-date=14 February 2014 |archive-date=6 January 2018 |archive-url=https://web.archive.org/web/20180106073947/http://www.cesar.umd.edu/cesar/drugs/dxm.asp |url-status=dead }}</ref> Recreational use of DXM is sometimes referred to in slang form as "robo-tripping" or "skittling", whose prefix derives from the [[Robitussin]] brand name, or "Triple Cs", which derives from the [[Coricidin]] brand whose tablets are printed with "CC+C" for "Chest Congestion and Cough". However, this brand presents additional danger when used at recreational doses due to the presence of [[chlorpheniramine]] (antihistamine).

In over-the-counter formulations, DXM is often combined with [[acetaminophen]] (paracetamol, APAP) to relieve pain;<ref>{{Cite news|url=https://www.drugs.com/mtm/acetaminophen-and-dextromethorphan.html|title=Acetaminophen and dextromethorphan medical facts from Drugs.com|work=Drugs.com|access-date=2017-04-18|language=en-US}}</ref> however, to achieve DXM's dissociative effects, the maximum daily therapeutic dose of 4000&nbsp;mg of APAP is often exceeded, potentially causing acute or chronic [[liver failure]], making abuse and subsequent tolerance of products which contain both DXM and APAP potentially fatal.<ref name=Cigina>{{cite web |title=DXM APAP |url=http://www.cigna.com/individualandfamilies/health-and-well-being/hw/medications/acetaminophen-and-dextromethorphan-d03378a1.html |archive-url=https://web.archive.org/web/20130106001214/http://www.cigna.com/individualandfamilies/health-and-well-being/hw/medications/acetaminophen-and-dextromethorphan-d03378a1.html |archive-date=6 January 2013 |publisher=Cigna Health Care |website=Cigna.com |access-date=4 January 2012}}</ref>

An online essay first published in 1995 entitled "The DXM FAQ" described dextromethorphan's potential for recreational use, and classified its effects into so-called plateaus.<ref>{{cite web |last1=White |first1=William E. |title=The Dextromethorphan FAQ |url=https://erowid.org/chemicals/dxm/faq/dxm_faq.shtml |website=Erowid |access-date=17 August 2018}}</ref> Each plateau is categorized depending on how much MG of DXM is ingested, each featuring varying or more intense effects. The defined number of plateaus vary depending on source, but the generally agreed-upon number is 4 or 5.<ref>{{cite web | url=https://www.justice.gov/archive/ndic/pubs11/11563/11563t.htm#:~:text=First%20Plateau%3A%20Mild%20inebriation.,An%20altered%20state%20of%20consciousness | title=Intelligence Bulletin: DXM (Dextromethorphan) }}</ref>

Owing to its recreational use,<ref>{{Cite web|url=https://www.drugabuse.gov/publications/drugfacts/over-counter-medicines|title=Over-the-Counter Medicines|last=Abuse|first=National Institute on Drug|website=www.drugabuse.gov|date=17 December 2017 |language=en|access-date=2019-12-03}}</ref> 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 [[New York (state)|New York]] and [[Alabama]], 21 in [[Mississippi]]) or older to purchase them.<ref>{{Cite web|url=https://www.chpa.org/dex.aspx|title=Dextromethorphan|website=www.chpa.org|access-date=2019-12-03}}</ref> 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 general anesthetic and hallucinogen, similar to the controlled substances [[ketamine]] and [[phencyclidine]] (PCP).<ref name=dea1>{{cite web |url=http://www.deadiversion.usdoj.gov/drugs_concern/dextro_m/dextro_m.htm |archive-url=https://web.archive.org/web/20101219103019/http://www.deadiversion.usdoj.gov/drugs_concern/dextro_m/dextro_m.htm |archive-date=19 December 2010 |title=DEXTROMETHORPHAN (Street Names: DXM, CCC, Triple C, Skittles, Robo, Poor Man's PCP |website=Deadiversion.usdoj.gov)}}</ref> Also like those drugs, dextromethorphan is an [[NMDA receptor antagonist]].<ref name="webtryp">{{cite press release |url=https://www.erowid.org/psychoactives/research_chems/research_chems_law3.pdf |archive-url=https://web.archive.org/web/20070606175644/https://erowid.org/psychoactives/research_chems/research_chems_law3.pdf |archive-date=2007-06-06 |url-status=live |title=FORMER MINOTMAN AND INTERNET CHEMICAL COMPANY SENTENCED FOR SELLING DESIGNER AND MISBRANDED DRUGS AND VIOLATING FEDERAL CUSTOMS LAWS |publisher=Erowid |date=30 June 2006 |access-date=14 February 2014}}</ref><ref name="Dxm_Hallucinogen">{{cite web |url=https://www.erowid.org/chemicals/dxm/dxm_effects.shtml |title=Erowid DXM Vault : Effects |publisher=Erowid |access-date=14 February 2014}}</ref> It generally does not produce withdrawal symptoms characteristic of [[physical dependence]]-inducing substances, but cases of both [[psychological dependence]] and physical dependence have been reported in the past, although physical dependence is usually only seen in cases of heavy abuse. Due to dextromethorphan's [[selective serotonin reuptake inhibitor]]-like action, the sudden cessation of recreational dosing in tolerant individuals can result in mental and physical [[withdrawal symptoms]] similar to the withdrawal from SSRIs. These withdrawal effects can manifest as psychological effects, including depression, irritability, cravings, and as physical effects, including lethargy, body aches, and a sensation of unpleasant tingling, not unlike a mild "electric shock".<ref>{{cite web |url=http://www.drugabusehelp.com/drugs/dxm/ |title=Drug Abuse Help: DXM Information |website=Drugabusehelp.com |access-date=14 February 2014 |archive-date=13 August 2020 |archive-url=https://web.archive.org/web/20200813091318/http://www.drugabusehelp.com/drugs/dxm/ |url-status=dead }}</ref><ref>{{cite web |url=http://www.info-drug-rehab.com/dxm.html |archive-url=https://web.archive.org/web/20130917011848/http://info-drug-rehab.com/dxm.html |archive-date=17 September 2013 |title=:: Cough Syrup and Dextromethorphan (DXM) Addiction and Abuse – Drug Rehab Information  |website=Info-drug-rehab.com}}</ref>

==Effects==
Dextromethorphan's effects have been divided into four plateaus.<ref>{{cite journal |last1=Stanciu |first1=Cornel N. |last2=Penders |first2=Thomas M. |last3=Rouse |first3=Eden M. |title=Recreational use of dextromethorphan, 'Robotripping'-A brief review |journal=The American Journal on Addictions |date=August 2016 |volume=25 |issue=5 |pages=374–377 |doi=10.1111/ajad.12389 |pmid=27288091 }}</ref>
#The first plateau (1.5 to 2.5&nbsp;mg per kg body weight) is described as having euphoria, auditory changes, mild stimulation, and change in perception of gravity.
#The second plateau (2.5 to 7.5&nbsp;mg/kg) causes intense [[euphoria]], vivid imagination, and [[closed-eye hallucination]]s.
#The third and fourth plateaus (7.5&nbsp;mg/kg and over) cause profound alterations in consciousness, and users often report out-of-body experiences or temporary [[psychosis]].<ref>{{cite journal |last1=Bornstein |first1=S |last2=Czermak |first2=M |last3=Postel |first3=J |title=Apropos of a case of voluntary medicinal intoxication with dextromethorphan hydrobromide |journal=Annales Médico-Psychologiques |volume=1 |issue=3 |year=1968 |pages=447–451 |pmid=5670018}}</ref><ref>{{cite journal |last1=Dodds |first1=A |last2=Revai |first2=E |title=Toxic psychosis due to dextromethorphan |journal=Med J Aust |year=1967 |volume=2 |issue=5 |page=231|doi=10.5694/j.1326-5377.1967.tb97739.x |s2cid=222056319 }}</ref> This results in a sort of [[flanging]] (speeding up and/or slowing down) of sensory input, which is another characteristic effect of recreational use.

Also, a marked difference is seen between dextromethorphan hydrobromide, contained in most cough suppressant preparations, and dextromethorphan polistirex, contained in the brand name preparation Delsym. Polistirex is a 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. This duration also holds true when used recreationally.

A 1981 estimate by Gosselin suggested that the lethal dose (LD50) of dextromethorphan in humans may range between 50 and 500 mg/kg. More specific experimental data indicate that the oral LD50 of dextromethorphan hydrobromide monohydrate in rats is approximately 116 mg/kg, according to the [https://www.sigmaaldrich.com/US/en/sds/sial/81091?userType=anonymous Safety Data Sheet] (SDS) provided by [https://www.sigmaaldrich.com/US/en/product/sial/81091#product-documentation Sigma-Aldrich]. The observed symptoms at this dosage include convulsions. Doses as high as 15–20&nbsp;mg/kg are taken by some recreational users. A single case study suggests that the antidote to dextromethorphan overdose is [[naloxone]], administered [[intravenously]].<ref>{{cite journal |last1=Schneider |first1=Sandra M. |last2=Michelson |first2=Edward A. |last3=Boucek |first3=Charles D. |last4=Ilkhanipour |first4=Kaveh |title=Dextromethorphan poisoning reversed by naloxone |journal=The American Journal of Emergency Medicine |date=May 1991 |volume=9 |issue=3 |pages=237–238 |doi=10.1016/0735-6757(91)90085-x |pmid=2018593 }}</ref>

In addition to producing PCP-like mental effects, high doses may cause a false-positive result for PCP and [[opiates]] in some drug tests.<ref name=dea1 /><ref>{{cite web |url=https://www.erowid.org/chemicals/dxm/dxm_testing.shtml |title=Erowid DXM Vault : Drug Tests |publisher=Erowid |access-date=14 February 2014}}</ref>

== Risks associated with use ==

Dextromethorphan has not been shown to cause [[vacuolization]] in animals, also known as [[Olney's lesions]], despite early speculation that it might, due to similarities with ketamine.<ref>{{cite web |url=https://www.erowid.org/chemicals/dxm/dxm_health2.shtml |title=The Bad News Isn't In |last=Anderson |first=Cliff |publisher=Erowid |access-date=14 February 2014}}</ref> In rats,<ref>{{cite journal |last1=Hashimoto |first1=K |last2=Tomitaka |first2=S |last3=Narita |first3=N |last4=Minabe |first4=Y |last5=Iyo |first5=M |last6=Fukui |first6=S |title=Induction of heat shock protein Hsp70 in rat retrosplenial cortex following administration of dextromethorphan |journal=Environmental Toxicology and Pharmacology |volume=1 |issue=4 |pages=235–239 |year=1996 |doi=10.1016/1382-6689(96)00016-6 |pmid=21781688|bibcode=1996EnvTP...1..235H }}</ref> oral administration of dextromethorphan did not cause vacuolization in laboratory tests.<ref>{{cite journal |last1=Carliss |first1=RD |last2=Radovsky |first2=A |last3=Chengelis |first3=CP |last4=O'neill |first4=TP |last5=Shuey |first5=DL |title=Oral administration of dextromethorphan does not produce neuronal vacuolation in the rat brain |journal=NeuroToxicology |volume=28 |issue=4 |pages=813–8 |year=2007 |pmid=17573115 |doi=10.1016/j.neuro.2007.03.009}}</ref> Oral administration of dextromethorphan repeatedly during adolescence, however, has been shown to impair learning in those rats during adulthood.<ref>{{cite journal |last1=Zhang |first1=TY |last2=Cho |first2=HJ |last3=Lee |first3=S |last4=Lee |first4=JH |last5=Choi |first5=SH |last6=Ryu |first6=V |last7=Yoo |first7=SB |last8=Lee |first8=JY |last9=Kim |first9=DG |last10=Jahng |first10=JW |display-authors=6 |title=Impairments in water maze learning of aged rats that received dextromethorphan repeatedly during adolescent period |journal=Psychopharmacology |volume=191 |issue=1 |pages=171–9 |year=2006 |doi=10.1007/s00213-006-0548-3 |pmid=17021924|s2cid=24001315 }}</ref> The occurrence of Olney's lesions in humans, however, has not been proven or disproven.

William E. White, author of the "DXM FAQ", has compiled informal research from correspondence with dextromethorphan users suggesting that heavy abuse may result in various deficits corresponding to the brain areas affected by Olney's lesions; these include loss of episodic memory, decline in ability to learn, abnormalities in some aspects of visual processing, and deficits of abstract language comprehension.<ref>{{cite web |url=http://www.dextroverse.org/txt/olney.txt |title=Erowid DXM Vault : This is your brain on dissociatives, the bad news is finally in |last=White |first=William E. |website=Dextroverse.com |access-date=14 February 2014 |format=TXT}}</ref> In 2004, however, White retracted the article in which he made these claims.<ref>{{cite web |url=https://www.erowid.org/chemicals/dxm/dxm_health3.shtml |title=Erowid DXM Vault : Response to "The Bad News Isn't In:" Please Pass The Crow, by William E. White |last=White |first=William E. |publisher=Erowid |access-date=14 February 2014}}</ref>

A formal survey of dextromethorphan users<ref>{{cite journal |last1=Ziaee |first1=V |last2=Akbari Hamed |first2=E |last3=Hoshmand |first3=A |last4=Amini |first4=H |last5=Kebriaeizadeh |first5=A |last6=Saman |first6=K |title=Side effects of dextromethorphan abuse, a case series |journal=Addictive Behaviors |date=September 2005 |volume=30 |issue=8 |pages=1607–13 |pmid=16122622 |doi=10.1016/j.addbeh.2005.02.005}}</ref> showed that more than half of users reported experience of these withdrawal symptoms individually for the first week after long-term/addictive dextromethorphan use: fatigue, apathy, flashbacks, and constipation. Over a quarter reported insomnia, nightmares, anhedonia, impaired memory, attention deficit, and decreased libido. Rarer side effects included panic attacks, impaired learning, tremor, jaundice, urticaria (hives), and myalgia. Medical DXM use has not been shown to cause the above issues.<ref name="cesar" />

=== Other ingredients ===

Misuse of multisymptom cold medications, rather than use of a cough suppressant whose sole active ingredient is dextromethorphan, carries significant risk of fatality or serious illness. Multisymptom cold medicines contain other active ingredients, such as [[paracetamol]] (acetaminophen), which can cause permanent bodily damage such as kidney failure or death if taken in quantities exceeding the recommended dose. [[Chlorphenamine]] and [[phenylephrine]] may also contribute to the harm. [[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.<ref name="kirages">{{cite journal |last1=Kirages |first1=T |last2=Sulé |first2=H |last3=Mycyk |first3=M |title=Severe manifestations of coricidin intoxication |journal=Am J Emerg Med |volume=21 |issue=6 |pages=473–5 |year=2003 |pmid=14574654 |doi=10.1016/S0735-6757(03)00168-2}}</ref><ref>{{cite journal |last1=Kintz |first1=P |last2=Mangin |first2=P |title=Toxicological Findings in a Death Involving Dextromethorphan and Terfenadine |journal=The American Journal of Forensic Medicine and Pathology |date=December 1992 |volume=13 |issue=4 |pages=351–352 |doi=10.1097/00000433-199212000-00018 |pmid=1288270 |s2cid=28648140 }}</ref><ref>{{cite web |url=https://www.erowid.org/chemicals/dxm/dxm_info2.shtml |title=Erowid DXM Vault : Guide to DXM in Non-Prescription Drugs |publisher=Erowid |access-date=14 February 2014}}</ref> [[Guaifenesin]], an expectorant commonly accompanying dextromethorphan in cough preparations, can cause unpleasant symptoms including [[vomiting]], nausea, [[kidney stones]],<ref>{{cite journal |pmid=10608519 | doi=10.1089/end.1999.13.665 | volume=13 | issue=9 | title=Guaifenesin- and ephedrine-induced stones | year=1999 | journal=J. Endourol. | pages=665–7 | last1 = Assimos | first1 = DG | last2 = Langenstroer | first2 = P | last3 = Leinbach | first3 = RF | last4 = Mandel | first4 = NS | last5 = Stern | first5 = JM | last6 = Holmes | first6 = RP}}</ref> and [[headache]].

=== Interactions ===

Combining dextromethorphan with other substances can compound risks. Central nervous system (CNS) [[stimulants]] such as [[amphetamine]] and/or [[cocaine]] can cause a dangerous rise in blood pressure and heart rate. [[CNS depressant]]s such as [[alcohol (drug)|alcohol]] will have a combined depressant effect, which can cause a decreased [[Breathing|respiratory]] rate. Combining dextromethorphan with other [[CYP2D6 inhibitor|CYP2D6 substrates]] can cause both drugs to build to dangerous levels in the bloodstream.<ref name="nhtsa">{{cite web |url=http://www.nhtsa.gov/PEOPLE/injury/research/job185drugs/dextromethorphan.htm |title=Drugs and Human Performance FACT SHEETS – Dextromethorphan |publisher=National Highway Traffic Safety Administration |website=Nhsta.gov |access-date=14 February 2014 |archive-date=16 October 2023 |archive-url=https://web.archive.org/web/20231016102557/https://www.nhtsa.gov/people/injury/research/job185drugs/dextromethorphan.htm |url-status=dead }}</ref><ref>{{cite web |url=https://www.erowid.org/chemicals/dxm/faq/dxm_side_effects.shtml |title=Erowid DXM Vault : DXM FAQ – Side Effects |publisher=Erowid |access-date=14 February 2014}}</ref> Combining dextromethorphan with other [[Serotonin|serotonergic]] drugs could possibly cause [[serotonin syndrome]], an excess of serotonergic activity in the CNS and [[peripheral nervous system]].

== Pharmacology ==
Dextromethorphan is primarily a [[sigma receptor]] agonist and an [[Serotonin–norepinephrine reuptake inhibitor|SNRI]], and dextromethorphan's effects as a dissociative hallucinogen may be attributed partially to [[dextrorphan]] (DXO), a [[metabolite]] produced when dextromethorphan is metabolized by the body. Both dextrorphan and dextromethorphan are [[NMDA receptor antagonist]]s,<ref>{{cite journal |last1=Helmy |first1=Sanaa A. K. |last2=Bali |first2=Ayham |title=The Effect of the Preemptive Use of the NMDA Receptor Antagonist Dextromethorphan on Postoperative Analgesic Requirements |journal=Anesthesia and Analgesia |date=March 2001 |volume=92 |issue=3 |pages=739–744 |id={{INIST|914417}} |doi=10.1213/00000539-200103000-00035 |pmid=11226111 |s2cid=28669085 |doi-access=free }}</ref> alike other dissociative hallucinogens such as ketamine and PCP. Although dextrorphan is more potent than its "parent molecule" dextromethorphan, it likely works in combination with dextromethorphan to produce hallucinogenic effects due to only a small percentage of dextromethorphan being metabolized into dextrorphan.<ref>{{cite journal |last1=Pechnick |first1=Robert N. |last2=Poland |first2=Russell E. |title=Comparison of the Effects of Dextromethorphan, Dextrorphan, and Levorphanol on the Hypothalamo-Pituitary-Adrenal Axis |journal=Journal of Pharmacology and Experimental Therapeutics |date=May 2004 |volume=309 |issue=2 |pages=515–522 |doi=10.1124/jpet.103.060038 |pmid=14742749 |s2cid=274504 }}</ref>

As NMDA receptor antagonists, dextrorphan and dextromethorphan inhibit the excitatory amino acid and [[neurotransmitter]] [[glutamate]] 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 or disconnected, experienced as [[brain fog]] or [[derealization]].<ref name="Muir KW and Lees KR">{{cite journal |last1=Muir |first1=KW |last2=Lees |first2=KR |title=Clinical experience with excitatory amino acid antagonist drugs |journal=Stroke |volume=26 |issue=3 |pages=503–513 |date=1995 |url=http://stroke.ahajournals.org/cgi/content/full/26/3/503 |doi=10.1161/01.STR.26.3.503 |doi-access=free|pmid=7886734|url-access=subscription }}</ref><ref name="Kristensen">{{cite journal |last1=Kristensen |first1=JD |last2=Svensson |first2=B |last3=Gordh Jr. |first3=T |title=The NMDA-receptor antagonist CPP abolishes neurogenic 'wind-up pain' after intrathecal administration in humans |journal=Pain |volume=51 |issue=2 |pages=249–253 |year=1992 |doi=10.1016/0304-3959(92)90266-E |pmid=1484720|s2cid=37828325 }}</ref>

== Legality ==
Antitussive preparations containing dextromethorphan are legal to purchase from pharmacies in most countries, with some exceptions being UAE, France, and Sweden.<ref>{{cite web |url=https://www.erowid.org/chemicals/dxm/dxm_law.shtml |title=Erowid DXM Vault : Legal Status |publisher=Erowid |access-date=14 February 2014}}</ref>{{citation needed|date=August 2009}} In [[Russia]], dextromethorphan (commonly sold under the brand names Tussin+ and Glycodin) is a Schedule III controlled substance and is placed in the same list as [[benzodiazepines]] and the majority of [[barbiturates]].<ref>{{cite web |url=http://base.garant.ru/12112176 |title=Decision of the Government of the Russian Federation No. 681 of June 30, 1998 on the Approval of the List of Narcotic Drugs, Psychotropic Substances and Their Precursors That Shall Be Subject to Control in the Russian Federation (with Amendments and Additions) |website=Base.garant.ru |language=ru |access-date=14 February 2014}}</ref>

=== China ===
In December 2021, the [[National Medical Products Administration]] reclassified all oral single-component dextromethorphan to prescription drugs due to potential abuse. The authorities also mandated manufacturers to remove statements like "no addiction or tolerance with long-term use" from their instructions.<ref>{{cite news |date=2021-12-16 |title= |script-title=zh: 国家药监局关于氢溴酸右美沙芬口服单方制剂转换为处方药的公告（2021年第151号） |trans-title=The National Medical Products Administration's Announcement on the Reclassification of Dextromethorphan Hydrobromide Oral Formulations to Prescription Drugs (Announcement No. 151 of 2021) |publisher=国家药品监督管理局 |url=https://www.nmpa.gov.cn/directory/web/nmpa/xxgk/ggtg/qtggtg/20211227162159192.html |accessdate=2022-02-15 |archive-url=https://web.archive.org/web/20220215013414/https://www.nmpa.gov.cn/directory/web/nmpa/xxgk/ggtg/qtggtg/20211227162159192.html |archive-date=2022-02-15}}</ref> Despite the online sales ban, the drug can still be found on some niche e-commerce platforms in China and [[Twitter]].<ref>{{Cite web |author=Wei |first=Qian |date=16 February 2023 |editor=Zhou |editor-first=Lei |title= |script-title=zh: 深陷困境的年轻人，嗑“镇咳药”成瘾 |trans-title=Young people mired in difficulties addicted to cough suppressants |url=https://www.lifeweek.com.cn/h5/article/detail.do?artId=191298 |archive-url=https://web.archive.org/web/20230419150741/https://www.lifeweek.com.cn/h5/article/detail.do?artId=191298 |archive-date=2023-04-19 |access-date=2023-04-15 |website=三联生活周刊 |publisher=三联数字刊 |language=zh-CN}}</ref>

In April 2024, the National Medical Products Administration announced that dextromethorphan, compound diphenoxylate tablets, [[nalfurafine]], and [[lorcaserin]] are included in the second-class psychotropic drug catalog. The announcement took effect in July.<ref>{{Cite web |title= |script-title=zh:右美沙芬等被列入第二类精神药品目录_绿政公署_澎湃新闻-The Paper |url=https://www.thepaper.cn/newsDetail_forward_27283236 |access-date=2024-05-07 |website=[[The Paper (newspaper)|The Paper]]}}</ref><ref>{{Cite web |title= |script-title=zh:国家药监局 公安部 国家卫生健康委关于调整精神药品目录的公告（2024年第54号） |trans-title=Announcement by the National Medical Products Administration, Ministry of Public Security, and National Health Commission on the Adjustment of the Catalog of Psychotropic Drugs (No. 54 of 2024) |url=https://www.nmpa.gov.cn/xxgk/ggtg/ypggtg/ypqtggtg/20240507084000186.html}}</ref> In August, Xi'an police arrested a suspect and seized 23 boxes of dextromethorphan; in October, the [[Hepu County]] People's Court sentenced one defendant to 7 months in prison,<ref>{{Cite web |title=【禁毒科普】别碰！有人贩卖"右美沙芬"牟利，被判刑！ |url=https://m.thepaper.cn/newsDetail_forward_29294197 |website=[[The Paper (newspaper)|The Paper]]}}</ref> while the [[Yanchi County]] People's Court sentenced a pharmacy owner to 6 months, both for drug trafficking involving dextromethorphan.<ref>{{Cite web |title=基层动态丨盐池县人民法院公开审理一起贩卖毒品案 |url=https://m.thepaper.cn/newsDetail_forward_29241903 |website=[[The Paper (newspaper)|The Paper]]}}</ref><ref>{{Cite web |title=售卖右美沙芬给吸毒人员，药店店主明知故犯获刑 |url=https://m.thepaper.cn/newsDetail_forward_29265872 |publisher=中国禁毒}}</ref>

===Indonesia===
After previously being available over the counter, the [[National Agency of Drug and Food Control of Republic of Indonesia]] (BPOM-RI) now prohibits single-component dextromethorphan drug sales with or without prescription. Indonesia is the only country in the world that makes single-component dextromethorphan illegal even by prescription<ref>{{cite web | url=http://nasional.news.viva.co.id/news/read/506418-bpom-tetap-batalkan-izin-edar-obat-dekstrometorfan | title=BPOM Tetap Batalkan Izin Edar Obat Dekstrometorfan | date=22 May 2014 }}</ref> and violators may be prosecuted by law. [[National Anti-Narcotics Agency (Indonesia)|Indonesian National Narcotic Bureau]] has even threatened to revoke pharmacies' and drug stores' licenses if they still stock dextromethorphan, and will notify the police for criminal prosecution.<ref>{{cite web | url=http://daerah.sindonews.com/read/878465/21/bnn-ancam-tutup-apotek-penjual-dextromethorphan-1404129585 | title=BNN Ancam Tutup Apotek Penjual Dextromethorphan }}</ref> As a result of this regulation, 130 drugs have been withdrawn from the market, but drugs containing multicomponent dextromethorphan can be sold over the counter.<ref>{{Cite web |url=http://www.pom.go.id/files/edaran_dektrome_2013.pdf |title=Archived copy |access-date=25 April 2015 |archive-date=10 August 2017 |archive-url=https://web.archive.org/web/20170810021225/http://www.pom.go.id/files/edaran_dektrome_2013.pdf |url-status=dead }}{{full citation needed|date=April 2015}}</ref> In its official press release, the bureau also stated that dextromethorphan is often used as a substitute for marijuana, amphetamine, and heroin by drug abusers, and its use as an antitussive is less beneficial nowadays.<ref>{{Cite web |url=http://www.pom.go.id/new/index.php/view/pers/231/Penjelasan-Terkait-Produk-Obat-Batuk-yang-Beredar--dan--Mengandung-Bahan-Dekstrometorfan-Tunggal-.html |title=Badan Pengawas Obat dan Makanan |access-date=25 April 2015 |archive-date=3 February 2017 |archive-url=https://web.archive.org/web/20170203184008/http://www.pom.go.id/new/index.php/view/pers/231/Penjelasan-Terkait-Produk-Obat-Batuk-yang-Beredar--dan--Mengandung-Bahan-Dekstrometorfan-Tunggal-.html |url-status=dead }}{{full citation needed|date=April 2015}}</ref>

The Director of Narcotics, Psychotropics, and Addictive Substances Control (NAPZA) BPOM-RI, Dr. Danardi Sosrosumihardjo, SpKJ, explains that dextromethorphan, morphine, and heroin are derived from the same tree, and states the effect of dextromethorphan to be equivalent to 1/100 of morphine and injected heroin.<ref>{{cite web | url=http://health.liputan6.com/read/2058886/ini-alasan-130-obat-batuk-ditarik-dari-pasaran | title=Ini Alasan 130 Obat Batuk Ditarik dari Pasaran | date=5 June 2014 }}</ref>
By contrast, the Deputy of Therapeutic Product and NAPZA Supervision BPOM-RI, Dra. Antonia Retno Tyas Utami, Apt. MEpid., states that dextromethorphan, being chemically similar to morphine, has a much more dangerous and direct effect to the central nervous system, thus causing mental breakdown in the user. She also claimed, without citing any prior scientific study or review, that unlike morphine users, dextromethorphan users cannot be rehabilitated.<ref>{{cite web | url=http://health.liputan6.com/read/708598/dibanding-morfin-obat-batuk-berdekstro-lebih-mematikan | title=Dibanding Morfin, Obat Batuk Berdekstro Lebih Mematikan! | date=2 October 2013 }}</ref> This claim is contradicted by numerous scientific studies which show that [[naloxone]] alone offers effective treatment and promising therapy results in treating dextromethorphan addiction and poisoning.<ref name=pmid2018593>{{cite journal |doi=10.1016/0735-6757(91)90085-X |pmid=2018593 |title=Dextromethorphan poisoning reversed by naloxone |journal=The American Journal of Emergency Medicine |volume=9 |issue=3 |pages=237–8 |year=1991 |last1=Schneider |first1=Sandra M. |last2=Michelson |first2=Edward A. |last3=Boucek |first3=Charles D. |last4=Ilkhanipour |first4=Kaveh }}</ref><ref>{{cite journal |pmid=840529 |url=http://pediatrics.aappublications.org/content/59/1/117.short |year=1977 |last1=Shaul |first1=W. L. |title=Dextromethorphan toxicity: Reversal by naloxone |journal=Pediatrics |volume=59 |issue=1 |pages=117–8 |last2=Wandell |first2=M |last3=Robertson |first3=W. O. |doi=10.1542/peds.59.1.117 |s2cid=29592313 |url-access=subscription }}</ref><ref name=pmid8895234>{{cite journal |doi=10.1016/0304-3959(96)81972-5 |pmid=8895234 |title=Continuous co-administration of dextromethorphan or MK-801 with morphine: Attenuation of morphine dependence and naloxone-reversible attenuation of morphine tolerance |journal=Pain |volume=67 |issue=1 |pages=79–88 |year=1996 |last1=Manning |first1=Barton H. |last2=Mao |first2=Jianren |last3=Frenk |first3=Hanan |last4=Price |first4=Donald D. |last5=Mayer |first5=David J. |s2cid=5999093 }}</ref> Dra. Antonia Retno Tyas Utami also claimed high rates of dextromethorphan abuse - including fatalities - in Indonesia, and even more questionable, suggested that [[codeine]], despite being a more physically addictive μ-opioid class antitussive, be made available as an alternative to dextromethorphan.<ref>{{cite web | url=http://health.kompas.com/read/2013/10/01/1618072/BPOM.akan.Tarik.Pil.Dekstro | title=BPOM akan Tarik Pil Dekstro | date=October 2013 }}</ref>

=== United States ===
{{main|Dextromethorphan regulation by U.S. jurisdiction}}
No legal distinction currently exists in the United States between medical and recreational use, sale, or purchase. Some states and store chains have implemented restrictions, such as requiring signatures for DXM sale, limiting quantities allowable for purchase, and requiring that purchasers be over the age of majority in their state. The sale of dextromethorphan in its pure powder form may incur penalties, although no explicit law exists prohibiting its sale or possession, other than in Illinois. Cases of individuals being sentenced to time in prison and other penalties for selling pure dextromethorphan in this form have been reported, because of the incidental violation of more general laws for the sale of legitimate drugs – such as resale of a medication without proper warning labels.<ref name="webtryp" />

Dextromethorphan was excluded from the [[Controlled Substances Act]] (CSA) of 1970 and was specifically excluded from the [[Single Convention on Narcotic Drugs]]. As of 2010, it was still excluded from [[U.S. Schedules of Controlled Substances]]; however, officials have warned that it could still be added if increased abuse warrants its scheduling.<ref name=dea1 /> The motivation behind its exclusion from the CSA was that under the CSA, all [[Chirality (chemistry)|optical isomers]] of listed Schedule II opiates are automatically [[List of Schedule II drugs (US)|Schedule II substances]]. Since dextromethorphan is an optical isomer of the Schedule II opiate [[levomethorphan]] (but does not act like an opiate), an exemption was necessary to keep it an uncontrolled substance. The [[Federal Analog Act]] does not apply to dextromethorphan because a new drug application has been filed for it.{{citation needed|date=December 2023}}

== See also ==
* [[Dissociative drug]]
** [[Nitrous oxide]]
** [[Ketamine]]
*** [[K-hole]]
** [[Phencyclidine]]
* [[NMDA receptor antagonist]]
* [[Psychedelic drug]]
* [[Purple drank]]
* [[Benadryl challenge]]
* [[Sigma agonist]]

== References ==
{{Reflist}}

== External links ==
* [http://www.dextroverse.org/ Dextroverse]
* [//www.erowid.org/chemicals/dxm/dxm_article1.shtml The Electric Cough-Syrup Acid Test by Jim Hogshire from Harper's]
* [//www.erowid.org/chemicals/dxm/dxm.shtml Erowid Dextromethorphan Vault]

{{Hallucinogens}}

[[Category:Stimulants]]
[[Category:Substance-related disorders]]