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Dextromethorphan (DXM) is a common cough suppressant found in many household cold medicines, and it’s also sometimes abused for its mind-altering effects. As an over-the-counter (OTC) remedy, DXM has a long history of safe use for relieving coughs.
However, in large doses, this ordinary medicine can act as a powerful dissociative drug, leading to hallucinations and serious health risks. In the following sections, we explore DXM’s dual nature as a helpful medication and a substance of abuse, covering its uses, effects, dangers, and ways to promote safer use.
- DXM is a widely used over-the-counter cough suppressant that is safe at therapeutic doses but can cause dissociative hallucinations when abused in high amounts.
- Recreational DXM abuse (often called “robotripping”) can lead to serious side effects, including confusion, high blood pressure, seizures, and potentially life-threatening serotonin syndrome.
- Although DXM remains unscheduled in the U.S., many states restrict sales to minors; education, monitoring, and early intervention are key to prevention.
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What is dextromethorphan (DXM)?
DXM (dextromethorphan) is an over-the-counter cough suppressant found in many cold and cough medications. It was first approved in 1958 as a safer alternative to codeine for treating coughs. [1] At therapeutic doses, DXM has a wide safety margin and causes minimal side effects. It acts on the brain’s cough center to reduce the urge to cough, without producing the euphoric or pain-relieving effects of opioid drugs.
Therapeutic uses and safety profile
Beyond its everyday use for cough relief, DXM has other approved and potential medical applications. In neurology, DXM (combined with quinidine) is used to treat pseudobulbar affect, a condition involving inappropriate laughing or crying episodes. [1] Researchers are also exploring DXM’s neuroprotective properties for other conditions, like stroke, traumatic brain injury, and even depression, due to its similarity in action to ketamine. [1]
Notably, a recent combination of DXM with bupropion (an antidepressant used for depression, seasonal affective disorder, smoking cessation, and weight loss) was approved as an oral antidepressant (brand name Auvelity) in 2022. [2][3]
DXM is generally considered safe when it is used as directed. It is well tolerated and has a wide therapeutic window, which means that the difference between standard and dangerous doses is large. However, like any medication, it can cause mild side effects (such as drowsiness or dizziness) in some people who take it. Serious adverse effects are very rare at proper doses.
One necessary precaution is that DXM should never be taken by people on certain antidepressants (such as monoamine oxidase inhibitors or MAOIs and selective serotonin reuptake inhibitors or SSRIs) because of the risk of serotonin syndrome. [4]
Recreational use and abuse patterns
As mentioned, while it is considered safe in medicinal amounts, DXM can produce intoxicating effects at much higher doses, leading some people to misuse it as a recreational drug. Slang terms for DXM abuse include “robotripping” or “dexing,” referring to the hallucinogenic “trip” users experience. [5]
Recreational DXM abuse became more noticeable in the 1990s and 2000s. In 2006, just three DXM-containing products made up 66% of reported DXM misuse cases in the U.S. [1] Teens and young adults are the most frequent people who misuse the drug, as DXM medicines are cheap and easy to obtain. [7]
Analyses of internet drug forums have found that DXM has a positive reputation among users [8], which may further encourage experimentation. Many learn about “robotripping” online; some websites and videos even share dosing tips under the pretense of harm reduction. [9]
This easy accessibility and perception that “it’s just medicine” have contributed to ongoing DXM patterns of abuse.
What it feels like
People who use it often ingest hundreds of milligrams of DXM, which is far above the 10–30 mg per dose used for cough relief. The resulting high is described in “plateaus” of intoxication, with progressively stronger dissociative and hallucinogenic effects. There are typically four plateaus of DXM intoxication. [6] Within the first plateau (at doses on the lower end of the abuse range), users feel mild stimulation, euphoria, and altered perception.
The second plateau brings more intense euphoria, distorted visual perceptions or mild hallucinations, and impaired coordination. By the third plateau, the dose is high enough that users may experience profound dissociation, feeling detached from their body or surroundings, while also exhibiting confusion and psychosis. [6]
The fourth plateau (at extremely high doses) can cause complete disconnection from reality, a sense of entering “another universe,” and a loss of sensory contact with the environment. [6] Users at high doses often report out-of-body experiences and time distortion. At high doses, DXM affects the brain similarly to dissociative anesthetics, like ketamine or phencyclidine (PCP).
Risks and side effects of DXM abuse
Misusing dextromethorphan at high doses can lead to serious health risks. DXM is sometimes used in combination with other substances, intentionally or unknowingly, including cannabis, benzodiazepines, or opioids, like codeine. These combinations, such as in “sizzurp” or “Lean,” significantly amplify sedation, respiratory depression, and overdose risk.
Initial DXM misuse reactions, however, are contradictory and may include: confusion, inappropriate laughter, agitation, paranoia, euphoria, and hallucinations. [10]
In the short term, DXM intoxication commonly causes: [10]
- Confusion
- Dizziness
- Slurred speech
- Impaired coordination
Users may also become agitated or disoriented at higher doses. At very high doses, or when combined with other substances, DXM can cause dangerous physical reactions. These can include: [10]
- Rapid heartbeat (tachycardia)
- Dangerously high blood pressure (hypertension)
- Elevated body temperature (hyperthermia)
Seizures are also possible in severe cases of overdose. [10]
One life-threatening risk of DXM abuse is serotonin syndrome, which can occur if DXM is taken with other drugs that affect serotonin (such as certain antidepressants). DXM itself has mild serotonin reuptake-inhibiting properties. [1]
Legal status and regulatory considerations
DXM occupies a unique place in drug regulation because it is a widely used medicine with abuse potential. In the United States, dextromethorphan is not a controlled substance under the federal Controlled Substances Act. It is available over the counter in pharmacies.
However, due to rising abuse reports, the U.S. Food and Drug Administration (FDA) convened an advisory committee in 2010 to consider whether DXM should be made a controlled substance. [11] The committee ultimately recommended against scheduling DXM, noting its benefits and low risk when used correctly. Instead, many states enacted restrictions, such as prohibiting sales of DXM products to customers under 18. [9] These measures aim to curb teenage “robotripping” by limiting access.
Trend snapshot (2006 → 2024)
High-school DXM misuse has fallen steadily since its 6.9% peak in 2006. The latest data from Monitoring the Future shows only 2.8% of 12th graders admitted past-year misuse in 2024, less than half the mid-2000s level, even though 8th-grade prevalence remains higher at 4.4%. [12]
Internationally, regulations vary. Most countries allow DXM to be sold OTC, but some have tighter rules. For example, Russia classifies DXM as a controlled psychotropic substance, Indonesia banned single-ingredient DXM products, and China recently added DXM to its list of controlled psychotropic drugs.
These regulatory approaches reflect the challenge of balancing legitimate access to a helpful cough medication with the need to prevent misuse.
Recognizing DXM abuse and overdose
Because DXM is a legal medicine, signs of its abuse can be subtle and easily missed at first. Family members or clinicians should be alert to certain red flags.
Finding numerous empty cough syrup bottles or blister packs of cough medicine (especially large quantities or specific high-DXM brands) is an obvious warning sign.
Behavioral changes in a teenager or young adult may also hint at DXM misuse—for instance, sudden episodes of euphoria or lethargy, erratic mood swings, or hallucinations. During intoxication, people on a DXM high often have slurred speech, bloodshot eyes, impaired coordination, and a blank, dazed expression. They may exhibit unusual sensory behaviors, such as closing their eyes and “zoning out” or describing feeling detached from their body.
Overdose
Recognizing a DXM overdose is critical, as it requires urgent medical attention. Signs of DXM overdose include: [10]
- Extreme confusion
- Observable hallucinations
- Severe agitation
- Unresponsiveness
- Vomiting
- Irregular heart rate
- Seizures
Someone overdosing may have very high blood pressure and fever, or conversely, they may become unconscious. [1] A DXM overdose is a medical emergency, and anyone showing these symptoms after taking DXM (especially in combination with other substances) requires immediate emergency care.
Treatment and recovery options
In the case of an overdose, management is supportive medical care. Healthcare providers stabilize the patient’s airway and circulation and control agitation (often with benzodiazepine sedatives). If the overdose is caught early, activated charcoal can be given to absorb the drug. There is no specific antidote for DXM overdose, though some doctors have tried the opioid antidote naloxone in severe cases.
If serotonin syndrome occurs, it is often managed with sedation (benzodiazepines), cyproheptadine (a serotonin-blocking drug), and cooling measures. [1] Patients with life-threatening symptoms will be closely monitored in a hospital setting until the effects wear off.
For people struggling with chronic DXM misuse, long-term recovery focuses on counseling and support. There are no medications specific to DXM addiction, but behavioral therapies (like cognitive-behavioral therapy) and support groups help address the psychological dependence.
Co-occurring mental health disorders (such as depression or anxiety) should be treated by professionals as part of recovery. On the positive side, DXM does not create the severe physical dependence seen with some drugs, so many people can stop using it without medical detox. However, they may feel depression, fatigue, or cravings for a while after quitting.
Prevention and harm reduction strategies
One of the most effective ways to prevent DXM abuse is through public awareness. Parents, educators, and young adults should understand that just because DXM is available over-the-counter, it isn't risk-free when misused. Open conversations at home and in schools can dispel myths like "it's just cough syrup" and clarify the real health risks associated with "robotripping."
Policy and pharmacy practices
States enforcing age restrictions have seen success in reducing teenage DXM abuse. Requiring ID checks for purchases or placing DXM products behind the pharmacy counter encourages responsible use and limits impulsive experimentation. Advocacy for these simple but effective policy changes can decrease adolescent DXM misuse.
Practical tips for safer choices
While the safest choice is not to misuse DXM at all, practical advice can still protect individuals who experiment:
- Stick strictly to DXM-only products to avoid harmful additives.
- Never combine DXM with alcohol or other drugs, especially antidepressants.
- Avoid using DXM alone—always have a trusted friend present who knows how to seek help if necessary.
Recognizing and responding early
Family and caregivers should be alert to signs of misuse, like sudden changes in behavior, numerous empty cough medicine packages, or episodes of confusion and euphoria. Early recognition allows for intervention before misuse escalates into serious health issues or addiction.
Healthcare providers can also play a key role by discussing over-the-counter drug risks during routine visits, particularly with teenagers.
Promoting recovery without judgment
If someone you care about struggles with DXM misuse, approach them with understanding rather than judgment. Encourage open dialogue, seek professional support when needed, and reinforce the message that well-being is achievable.
Reducing the harms associated with DXM abuse involves compassion, education, sensible policy, and informed decision-making at personal and community levels.
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