Not what the doctor ordered

Where only first names appear, names have been changed to protect the identities of the sources.

The car pulled into an open space. The doors swung open and red vomit poured out, pooling on the asphalt.

"You're just not supposed to drink that much cough syrup," explains Adam, a senior, in retrospect. But then, he knew that already — that's what happens when he downs an eight-ounce bottle of Robitussin.

On that Saturday afternoon last fall, Adam purposely ingested 300 milligrams of Dextromethorphan (DXM), the non-narcotic cough suppressant active in over 140 over-the-counter cough medications. The recommended dosage is between 10 and 30 milligrams of DXM over several hours, according to the Drug Enforcement Agency (DEA). Adam had taken about 10 times that.

DXM, approved by the Food and Drug Administration (FDA) in 1954 as a safe anti-tussive, works by raising the coughing threshold in the brain, explains Elizabeth Assey, director of communications and media relations at Consumer Healthcare Products Association (CHPA), which launched a joint campaign with the Partnership for a Drug-Free America to raise awareness on cough medicine abuse. DXM is a cough suppressant that, when used in appropriate doses, can effectively and safely relieve coughs. But at excessive doses — between 250 and 1,500 milligrams — DXM acts like a hallucinogen, explains Charles Miller, chief of Congressional, Public and Interagency Relations at the National Drug Intelligence Center (NDIC).

And for as long as DXM has been legal, it has been abused. In fact, in 2004, 2.2 million teens — one in 11 — abused cough medications intentionally to get high, according to the Partnership for a Drug-Free America. This abuse is often called "robotripping," a reference to the popular brand of cough medicine Robitussin, and it is alarming health officials nationwide.

Recently, several state assemblies introduced bills to combat robotripping, and now, Maryland has joined in. On Feb. 2, SB-450, a bill aimed at curbing the abuse of cough medicine by putting all DXM products behind the counter and limiting the quantity available for purchase, was introduced to the Maryland General Assembly.

Which means Adam could soon be out of a high.

A needle in the arm

After emptying the contents of his stomach, almost completely ridding his mouth of the cherry flavor he so despises, Adam stumbled out of the car. Advised by a web site frequented by experimental drug users, Adam knew that if he drank enough Robitussin, his stomach lining would absorb the DXM before he inevitably threw up. This was Adam's fourth time, and he had already learned to deal with the downsides of DXM. As his friend, Phillipe, a senior, explains, "It's like heroin addicts. They probably don't enjoy sticking a needle in their arm, but the after-effects is why they do it."

As Adam and Phillipe began walking away from the mess they made, the after-effects kicked in quickly. Phillipe stopped, looked back at the car and, stunned, asked, "Oh my god, where are we?" He thought he had taken one step forward, but upon turning around, Phillipe discovered to his surprise and amusement that he had actually traveled 10 feet. Disoriented, the two boys slowly made their way across the parking lot to the ticket booth at the Renaissance Festival.

According to the Center for Substance Abuse Research at the University of Maryland (CESAR), DXM taken in high doses can cause powerful psychedelic effects ranging from altered perception of time, space and color to visual hallucination and complete disassociation from one's body. It can also result in, among other things, panic attacks, seizures, comas and, in rare cases, overdose and death.

But despite being aware of all possible dangers, that Saturday, Adam and Phillipe were only concerned with their high. Along with two other friends, both of whom were also high on DXM, they entered the Renaissance Festival, shielding their now-hypersensitive eyes from light. Despite the fact that he could barely look in the direction of the sun, Phillipe rationalizes that he only paid $5 for a four-hour high.

Lost in the maze

Cheap and easy to find, cough medicines can be purchased over-the-counter at most local drug stores and pharmacies, convenient for common consumers but also dangerous for potential DXM abusers. In attempts to deter recreational use, cough medicines with DXM have been created with unappealing flavors, packaged in larger bottles to make shoplifting more difficult and placed behind the counter at several pharmacies.

But in spite of these efforts, abuse persists, which Assey attributes to two factors: the misconception that abusing of over-the-counter and prescription medications is safer than abusing "street drugs" and the easy access teens have to these medicines through their parents' medicine cabinets or the Internet.

The latter has become increasingly significant with the advent of several web sites, much like the one Adam visited, that detail specific instructions on how to abuse DXM. The information — or misinformation — on these web sites, which often underestimates the dangers of DXM and sometimes even promotes its abuse, is then spread by word-of-mouth, explains Miller. Pure powder DXM — mostly intended for laboratory use in scientific research — is also available over the Internet, according to the NDIC.

Back at the Renaissance Festival, Adam and Phillipe were stuck. They had walked into a maze designed for young children, and they couldn't find their way out again. Phillipe propelled himself up over a nearby wall, jumping up and down repeatedly, admiring his feeling of weightlessness. "You thought you were never going to hit the ground," he remembers. While Phillipe bobbed up and down, Adam "cheated," peeking over the maze walls in a hopeless search for a way out.

But once they found their way in, it seemed there was no going back.

18 pills

Although Adam and Phillipe have both abused cough medicines several times, both insist that, according to their own Internet research, there is little to no chance of addiction. However, CESAR points out that repeated abuse of DXM over prolonged periods of time can result in symptoms that indicate physical dependence and tolerance. Cough medicine abusers also often experience withdrawal symptoms like insomnia, severe weight loss and heightened anxiety. The fact is that both boys keep coming back to it.

Phillipe first tried DXM because he thought it sounded like a good time. After experimenting with cough medicine, Phillipe says he wanted to robotrip every weekend. But he stopped himself from going that far, fearing — however incorrectly — that he "was going to have a hole in my stomach if I kept doing it." Even so, Phillipe says that he plans to continue casually abusing DXM in the future.

Unlike Phillipe, Adam's first reaction to robotripping was disgust. "I never even let my mom give it to me when I was sick, so chugging a whole bottle? Are you out of your mind?" he says, laughing. But revulsion quickly gave way to curiosity. Accompanied by a few friends, Adam drank half a bottle of cough syrup. Then, something went wrong. Feeling "giddy" and extremely ill, Adam ran into the bathroom, hugged the toilet and threw up violently. He knew vomiting was to be expected, but not so badly.

Apparently, Adam and his friends had purchased a brand of DXM cough medicine that also contains the drug Guaifenesin, which causes intense vomiting, according to Miller. Adam's mistake is not uncommon, says Assey, who explains that the dangerous side effects of DXM are only exaggerated when combined with other drugs.

But even that did not prevent Adam from trying again. The second time Adam did DXM, he swallowed 18 cough pills. He hallucinated red triangles spinning counterclockwise and, when looking in a mirror, imagined that his mouth had disappeared and he only had one eye. When Adam finally began to come down off of his high, his jaw shook uncontrollably, and every time he closed his eyes, he imagined the same hallucinations over and over again. Terrified by the withdrawal, Adam says that after every DXM trip, he vows never to abuse the drug again.

But again and again, that promise falls through — which is exactly how Adam wound up at the Renaissance Festival, the taste of cherry still lingering in his mouth.

Cornered

After miraculously stumbling upon an opening in the maze, Adam and one of the other boys retreated to a dark corner in one of the exhibit buildings. Adam crouched on the floor, entranced by an imaginary sun floating in front of him. He and his friend shouted out their hallucinations, startling people walking past them.

Suddenly, another friend who was also high on DXM popped in front of them, telling them that they were making a scene and insisting it was time to go. But Adam was less concerned with the cautionary advice than with the fact that his friend's ears were beginning to stretch. Adam sat transfixed as he watched his friend's face turn blue, his smile become gigantic and his lips disappear. But what was even more fascinating to Adam was that he thought his friend was a complete hallucination. "We thought he wasn't really there," he explains.

When Adam finally realized his friend was real, the four boys left the Renaissance Festival behind and hopped in the car, hoping to find a drug store to replenish their highs. The driver, who insisted he was hearing music when, in fact, there was none, charted a course to a nearby CVS. He drove into the parking lot, got out and began walking away from the car before his friends called him back. There was no CVS — he had completely imagined it.

3.6 grams

Surprisingly, even had there been a CVS and the boys swallowed another bottle of cough syrup each, they still would not have achieved the three- or four-bottle average of heavier DXM users, according to CESAR. The abuse of DXM in such large quantities is one of the main concerns of the bill currently in the Maryland General Assembly. It proposes to allow the purchase of only 3.6 grams of any DXM product in any 30-day period.

Decreasing the package size and restricting amounts available is a solution offered by many substance abuse organizations, says Karen Mahoney, an FDA spokesperson. She also cites making DXM a prescription drug, limiting its sale and adding an ingredient with unpleasant, but harmless, side effects as recommendations for abuse prevention.

If SB-450 passes, three of the four suggestions will be met, and DXM will forever be placed behind the counter in pharmacies across Maryland. According to Scott Gibson, a legislative aide to Maryland Senator J. Robert Hooper, who is SB-450's primary sponsor, the bill is intended to raise awareness about and restrict access to DXM by youth.

While SB-450 may have been proposed with good intentions, Adam thinks the passage of this bill would mean the punishment of many for the misdeeds of a few. "I think that's a shame because if somebody has a cough, they have to go through some trouble just because some stupid kid chugged [cough medicine]," he says.

But Phillipe commends the lawmakers for recognizing a problem and taking action, even if it means it will be more difficult for him to get a DXM high. "Good for them," he says. "They wised up. They got smart to the fact that kids will chug [cough medicine] and abuse it."

Cherry Coke

After the failed CVS adventure, the boys drove to Baltimore, their highs fading slowly. They stopped at a local restaurant and Adam ordered a cherry Coke. He slipped his straw into the tall glass and sipped, immediately gagging. His straw had hit a layer of unmixed cherry syrup, and when Adam sipped, all he tasted was the syrupy sweet cherry of Robitussin. In a fit of paranoia, Adam feared that he had permanently altered his taste buds and that from then on, everything he drank would taste like Robitussin. "It's funny now, but at the time, it was terrifying," he says.

So, to clear things up, Adam turned to the waitress and asked, "Is this Robitussin?"