Issue 32, 2006

Emergency Department Visits Involving Dextromethorphan

Dextromethorphan (DXM) is a cough suppressant approved by the Food and Drug Administration (FDA) that is found in many over-the-counter (OTC) cough and cold remedies.¹ It is generally safe when taken at recommended doses. When taken in large amounts, though, DXM can produce hallucinations and a "high" similar to psychotropic drugs, such as phencyclidine (PCP). Dangerous side effects may include blurred vision, loss of physical coordination, abdominal pain, and rapid heartbeat. Side effects may be worsened if the ingested product also contains other pharmaceutical ingredients, such as acetaminophen, pseudoephedrine, antihistamines, or expectorants, which are commonly found in cough and cold medicines.²

In recent years DXM has become available, primarily over the Internet, in bulk powdered form, and concern has grown over the nonmedical use of DXM by teenagers. In May 2005, the FDA issued a warning about the dangers of DXM abuse involving over-the-counter products and DXM obtained from illicit sources.³

The Drug Abuse Warning Network (DAWN) collects data from a national sample of short-term, general, non-Federal hospitals⁴ and publishes estimates of emergency department (ED) visits involving illicit drugs as well as nonmedical use of pharmaceuticals. This issue of The DAWN Report examines the characteristics of ED visits that involve DXM and products containing DXM. Included are findings on the age of ED patients who used DXM and the reason for their visit to the ED. Also provided are the rates of DXM-related ED visits per 100,000 population for different age groups and the frequency with which DXM products are found in combination with alcohol. The ED visits considered here exclude the small number of patients who go to the ED to obtain admission to the hospital's detoxification or substance abuse treatment unit.

During 2004, there were about 106 million ED visits to short-term, general, non-Federal hospitals in the United States.⁵ Of those, DAWN estimates that just under 2 million were drug related, with just under a half million involving nonmedical use of pharmaceuticals. About 12,500, or approximately 0.7 percent, of all drug-related ED visits in 2004 involved DXM or products containing DXM.

Nonmedical use of DXM products accounted for 5,581 (44%) of the estimated 12,584 DXM-related ED visits in 2004, and about half (48%) of these nonmedical visits involved patients aged 12 to 20 (Table 1).⁶ The rate of ED visits resulting from nonmedical use of DXM products was 7.1 visits per 100,000 population for those aged 12 to 20, while the rate for other age groups was 2.6 or less (Figure 1).

Medical use of DXM included ED visits attributed to adverse reactions that occured when DXM products were used as prescribed or according to directions (for OTC products). About 30 percent of all DXM-related ED visits in 2004 were a result of adverse reactions and involved patients across all age categories. The rates of these ED visits ranged from 0.8 to 2.2 visits per 100,000 across the various age categories (Table 1).

Figure 1. Rates of ED visits for nonmedical and medical use of DXM, by age
Source: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).

Suicide attempts involving DXM products accounted for 14 percent of DXM-related ED visits. ED visit rates for suicide attempts involving DXM products ranged from 1.4 to 1.7 for those aged 12 to 34. These visits are extremely rare among younger (aged 0 to 11) and older (aged 35 or older) patients.

The smallest category of DXM-related ED visits involved accidental ingestions, and more than 9 out of 10 of these visits involved patients under the age of 12. That is the equivalent of 2.8 visits per 100,000 population for those under the age of 12.

Alcohol was involved in about 13 percent of ED visits resulting from nonmedical use of DXM products for those aged 12 to 17, and 36 percent of such visits for those aged 18 to 20 (Figure 2). Patients aged 35 to 54 had the highest involvement of alcohol (53%). For the youngest (aged 0 to 11) and oldest (aged 55 or older) patients, alcohol involvement was lower (0% and 4%, respectively).

Figure 2. ED visits involving nonmedical use of DXM and alcohol, by age
Source: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).

Alcohol is also an ingredient in some cough medications. Some common products (e.g., NyQuil^®) contain a mixture of DXM and up to 10 percent alcohol. In these cases, alcohol may play a role in the ED visit without being specifically documented in the ED medical record. Therefore, these findings may understate the involvement of alcohol and its contribution to the side effects leading to ED visits.

1. U.S. National Library of Medicine, National Institutes of Health. (2003, April 1). Dextromethorphan. Retrieved September 26, 2006, from http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a682492.html
2. National Institute on Drug Abuse. (2001, March). Hallucinogens and dissociative drugs. (NIH Publication No. 01-4209). Retrieved September 29, 2006, from http://www.drugabuse.gov/ResearchReports/Hallucinogens/halluc4.html
3. Food and Drug Administration. (2005, May 20). FDA warns against abuse of dextromethorphan (DXM) (Talk Paper T05-23). Rockville, MD: National Press Office. Retrieved September 29, 2006, from http://www.fda.gov/bbs/topics/ANSWERS/2005/ANS01360.html
4. Specialty hospitals, including children's hospitals, are excluded from the DAWN sample.
5. AHA Annual Survey Database, Fiscal Year 2003. Health Forum LLC, Copyright 2003, One North Franklin Street, Chicago, IL 60606.
6. Nonmedical use describes visits to the ED that cannot be attributed to accidental ingestion, suicide attempt, or medical use. Thus, nonmedical use of DXM includes taking more than a prescribed or recommended dose, as well as other forms of drug misuse or abuse.