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Dextromethorphan: Another "Ecstasy"?
The letter by Cranston and Yoast1 in the April issue of the ARCHIVES, which discusses the abuse potential of dextromethorphan (DMX), is timely because it is a readily available substance that was recently distributed in Texas at "rave" parties as the newest ecstasy.2 Rave parties are all-night dances that were originally popularized by European adolescents at which loud "techno" music is played and at which euphoriant drugs called ecstasy are usually available. Ecstasy refers to methamphetamine drugs, but can also be composed of gamma hydroxybutyrate and ma huang/ephedra. Because DMX is legal and is widely available on the Internet in quantities large enough to be abused,2 we'd like to address a few points that need clarification. First, the authors stated that "dextromethorphan is a nonopioid drug." Actually, DMX is an opioid; it is the D-isomer of levorphanol, a semisynthetic morphine derivative.3-4 Dextromethorphan undergoes metabolic O-demethylation to its active metabolite dextrorphan, which has similar activities to phencyclidine.5 Second, in addition to the triad that they describe, which includes ataxia, nystagmus, and altered mental status, seizures also may occur at 20 to 30 mg/kg.4 Euphoria and hallucinations occur in doses from 300 to 1800 mg/kg (20 or more times the dose in a teaspoonful). Dextromethorphan has an onset of action within 15 to 30 minutes, and peaks in 2.5 hours, with duration of action between 3 to 6 hours.4-5 Lastly, DMX can interact with monoamine oxidase inhibitors, causing severe hyperthermia, and may cause serotonin syndrome.6 Dextromethorphan inhibits the metabolism of norepinephrine and serotonin and blocks the reuptake of serotonin. Physicians need to be aware of the abuse potential of DMX, as well as the availability of drug information on the Internet. Adolescents can download instructions on making illicit substances, as well as purchase the ingredients necessary to create these dangerous products. Finally, physicians need to remember that DMX is found as a component of a large number of nonprescription cough and cold remedies, usually in combination with decongestants, antihistamines, and acetaminophen. These other compounds have toxic properties that are independent of dextromethorphan and may require specific treatment.
Robin B. McFee, DO, MPH;
Howard C. Mofenson, MD, FAAP, ABMT;
Thomas R. Caraccio, PharmD, ABAT
Mineola, NY
1. Cranston JW, Yoast R. Abuse of dextromethorphan. Arch Fam Med. 1999;8:99-100.
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2. InteliHealth, Pharmaceuticals. Drug being distributed as ecstasy turns out to be over the counter. Available at: http://ipn.intelihealth.com./ipn/ihtIPN. Accessed November 16, 1999.
3. Silvasti M, Karttunen P, Tukiainen H, et al. Pharmacokinetics of dextromethorphan and dextrorphan: a single dose comparison of three preparations in human volunteers. Int J Clin Pharmacol Ther Toxicol. 1987;25:493-497.
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4. Albertson TE. Dextromethorphan. In: Olson K, ed. Poisoning and Drug Overdose. 3rd ed. Stamford, Conn: Appleton & Lange; 1999:155-156.
5. Pender ES, Parks BR. Toxicity with dextromethorphan-containing products: a literature review and report of 2 cases. Pediatr Emerg Care. 1991;7:163-167.
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6. Sovner R, Wolfe J. Interaction between dextramethorphan and monoamine oxidase inhibitor therapy with isocarboxazid. N Engl J Med. 1988;319:1671.
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Arch Fam Med. 2000;9:123.
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