INCLINE VILLAGE, NEV. – A 14-year-old intoxicated and confused girl is brought into the emergency department by her parents. She has nystagmus and is extremely ataxic. One of her friends reports that she may have taken some “skittles.”
What are “skittles”? How about “red hots”? “Triple C”?
All are street names for Coricidin, the dextromethorphan-containing cough and cold medication that has become one of the more frequent reasons for calls to poison control centers over the past few years, Steven R. Offerman, M.D., said at an annual emergency medicine meeting sponsored by the University of California, Davis.
“It is just rampant now,” said Dr. Offerman in the toxicology division of the department of emergency medicine at the University of California, Davis. “We're seeing this in poison control all the time.”
Between 2000 and 2003, the number of calls to poison control centers nationwide involving abuse or misuse of dextromethorphan by teenagers has roughly doubled, to 3,271 calls in 2003, according to the American Association of Poison Control Centers. Although there are several products that contain dextromethorphan, almost 90% of the calls involve Coricidin.
The reason that product is so popular has to do with the fact that it comes in gelatin tablets, Dr. Offerman said.
Dextromethorphan was first approved in 1958 and was introduced as a replacement for codeine in cough medications. The first product, Romilar, came in tablet form. Its abuse potential was quickly discovered, and in the 1970s Romilar tablets were taken out of the over-the-counter market. New products put dextromethorphan into cough syrups intentionally designed with a bad taste to discourage abuse.
In the 1990s, however, several products reintroduced it in tablet form, he said.
The high that teens get from dextromethorphan is described as an LSD-like, hallucinogenic high. Dextromethorphan is a prodrug converted to the d-isomer of levorphanol, a semisynthetic morphine derivative, which noncompetitively antagonizes N-methyl-D-aspartate (NMDA) receptors, and possibly also affects serotonin receptors.
Teens who are in the know talk about using specific dosages to reach different “plateaus”: the first, a mild stimulant effect (100–200 mg); the second, intoxication with mild hallucinations (200–400 mg); the third and most sought after, an “out of the body” experience (300–600 mg, or 14–16 Coricidin HBP Cough/Cold tablets, each of which contains 30 mg dextromethorphan hydrobromide).
At doses above 600 mg, individuals become fully dissociated, the fourth plateau.
Web sites contain recipes for making dextromethorphan cough syrups more palatable and provide instructions on how to extract it from Sucrets lozenges, Dr. Offerman said.
Treatment of an overdose requires supportive care, but it is also a good idea to consider decontamination with activated charcoal, Dr. Offerman advised. Many of the products also contain an antihistamine, which delays gastric emptying.
Dr. Offerman said he recommends giving charcoal all the way up to 6 hours after ingestion.
Emergency department physicians also need to be aware that many of the dextromethorphan-containing products may also contain large amounts of other active ingredients, particularly acetaminophen.
Drug toxicology screens do not specifically test for dextromethorphan, but the drug can cross-react with the test for phencyclidine (PCP).
Some reports have suggested that naloxone is effective in reversing dextromethorphan. But there have also been reports that naloxone does not work, Dr. Offerman said.