PEDIATRICS Vol. 118 No. 5 November 2006, pp. 2267-2269 (doi:10.1542/10.1542/peds.2006-2050)
LETTER TO THE EDITOR |
The Prevalence of Dextromethorphan Abuse Among High School Students
Russel Falck, MALinna Li, MS
Robert Carlson, PhD
Jichuan Wang, PhD
Department of Community Health,
Center for Interventions, Treatment and Addictions Research,
Wright State University,
Boonshoft School of Medicine,
Dayton, OH 45435
To the Editor.—
Dextromethorphan is the d-isomer of the codeine analog, levorphanol, and the active ingredient in >100 over-the-counter cough and cold preparations. Reports of dextromethorphan abuse date back to the 1960s.1,2 There is some evidence suggesting that when used inappropriately at very high doses (eg, 1500 mg/day), dextromethorphan can result in a dependence-like syndrome.2 Psychological symptoms of dextromethorphan intoxication can include euphoria, an altered sense of time, paranoia, and disorientation as well as tactile, visual, and auditory hallucinations. Physical symptoms include but are not limited to hyperexcitability, ataxia, and nystagmus.3 These symptoms bear a remarkable similarity to those seen with phencyclidine (PCP), a powerful dissociative anesthetic that has also been abused since the 1960s.4 Research on the pharmacology of dextromethorphan shows that it is metabolized by the liver enzyme CYP2D6 to dextrorphan, a metabolite with an affinity for N-methyl-D-aspartate receptors, which explains the PCP-like effects that can result from consuming higher-than-recommended doses of the drug.5,6 Earlier research suggested that dextromethorphan abuse was sporadic and declining7; however, recent case reports about its misuse have again raised concern about the purposeful ingestion of dextromethorphan for its consciousness-altering properties, particularly among young people.8–10 In addition to calling attention to the dangers of dextromethorphan abuse, some observers have highlighted the role of the Internet in facilitating the abuse of the drug.11 Still, the scope of dextromethorphan abuse among adolescents is unknown. To address this issue, we report the results of a recently conducted survey of high school students in a midsized Midwestern community that assessed the prevalence of dextromethorphan abuse.
The Dayton Area Drug Survey (DADS) is a biennial, cross-sectional study that provides estimates of teen drug use for schools and the community. In early 2006, 7th- to 12th-grade students in 15 school districts in the Dayton, Ohio, area participated in the DADS. Students responded anonymously and voluntarily in classroom settings to DADS questions on computer-scannable answer forms. Data were collected in accordance with a protocol approved by the Wright State University institutional review board. More information on the DADS methodology is available elsewhere.12 In addition to the DADS standard multiple-choice items on commonly abused drugs, for the first time supplemental questions focusing on dextromethorphan were included in the survey and asked of 11th- and 12th-grade students only. Specifically, these students were asked: "On how many occasions (if any) have you used dextromethorphan, sometimes called DM, Triple C, Tuss, Robo, to get high or intoxicated in your lifetime?" with never, 1 to 2, 3 to 5, 6 to 9, 10 to 19, and 
20 as response options. A similar question was asked to assess use in the 12-month time period before the survey. More than 4000 students responded to these 2 questions. The majority of responders were white (85%) and suburban (95%), and they were almost evenly split between boys (49%) and girls (51%).
Among 12th-grade students (n = 2437), 4.9% reported lifetime use of dextromethorphan, whereas 3.7% reported abuse in the past 12 months. Among 11th-grade students (n = 1739), 3.4% reported lifetime use, and 2.4% reported use in the past 12 months. Among 12th-graders who reported use, 55% had used it 3 times; among 11th-graders, 33.9% had used it 3 times. We used 
2 tests to identify potential differences between those students who reported having used dextromethorphan at least once in their lifetimes for nonmedical purposes with those students who had not. Results show that significantly more boys than girls used the drug (P = .002), but there were no significant differences in use between white and nonwhite (P = .93) adolescents. Virtually no dextromethorphan abuse was reported by black or Asian-American girls. In the 30 days before the survey, proportionately more dextromethorphan abusers smoked a half-pack of cigarettes or more per day (P = .0001), got drunk on alcohol more than twice (P = .0001), and smoked marijuana more than twice (P = .0001) than did nonusers. In addition, proportionately more dextromethorphan abusers reported lifetime experience with drugs such as LSD or psilocybin (P = .0001) and 3,4-methylenedioxymethamphetamine (MDMA)/ecstasy (P = .0001) than did nonusers. For example, among 12th-grade dextromethorphan users, 69.2% reported the lifetime use of LSD or psilocybin, compared with 6.7% of non–dextromethorphan users.
To help avoid the potential of stimulating interest in dextromethorphan as a recreational drug, we chose not to use the brand names of products known to be commonly abused, such as Robitussin or Coricidin, in the survey questions. For similar reasons, we also chose not to survey students in earlier grade levels about the drug. Consequently, abuse of the drug among teenagers may be more widespread than our data show. Regardless, the lifetime prevalence of dextromethorphan abuse among high school seniors in the Dayton area exceeds that associated with anabolic steroids (2.2%), MDMA (4.0%), heroin (4.1%), crack cocaine (4.4%), and Ritalin (4.8%) and rivals methamphetamine (5.5%).
To the best of our knowledge, this is the first large-scale epidemiologic study of the nonmedical use of dextromethorphan among youth. Our results suggest that significant numbers of adolescents are abusing dextromethorphan. Given the plethora of dangers associated with consuming the drug for recreational purposes and in excess of its recommended dosage levels, and difficulty detecting it in urinalysis,11,13 it may be prudent to again consider restricting the availability of the drug. An informational campaign about dextromethorphan abuse targeting parents of teenagers might also be appropriate. Pediatricians and emergency department physicians should be aware of the fact that the recreational use of dextromethorphan among teenagers is more common than case reports on its abuse might suggest.
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
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