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A few weeks ago we reported on a new study demonstrating that a drug called Nuedexta (containing dextromethorphan and quinidine) might ease some devastating complications of Alzheimer’s disease. A parent took us to task for not discussing the dangers of dextromethorphan.
Q. I am concerned about an article you wrote that mentioned the use of dextromethorphan for calming the agitation of Alzheimer’s disease. You said it is available in cough syrup.
My son read ten years ago about using cough syrup with “dex” to calm down. He tried it and has become a full-blown dextromethorphan addict. What started out as a small amount turned into bottles at a time.
He is now clinically diagnosed as mentally ill. Before cough syrup, he was functioning in a managerial position.
Your article did not warn readers about the dangers of misusing dextromethorphan. Cough syrup addiction destroyed my son’s life. Using this drug in any way other than its intended purpose should be strictly avoided.
A. Dextromethorphan is perceived as the safest and most effective cough medicine in America. It is sold over the counter as the “DM” or “DXM” in dozens of popular OTC cold and cough medicine. You will find dextromethorphan in Coricidin HBP, Dimetapp DM, Robitussin DM, Mucinex DM, Nyquil Cold & Flu, and dozens of other products.
The History of Dextromethorphan:
The cough medicine that most people used in the early 20th century often contained codeine. It was sold in low doses over the counter in most states and was partially effective at calming a cough. But some people abused codeine-containing cold remedies even though the dose was relatively low
Because the military and other government organizations feared codeine abuse and addiction, there was a search for a substitute cough medicine that would not pose an abuse potential. Dextromethorphan was approved by the FDA in 1958 and eventually became the go-to ingredient in most OTC cough remedies.
How Effective are DM Cough Medicines?
Given the widespread use of DM-containing cough remedies for so many decades it is shocking to discover that there are few well-controlled trials demonstrating effectiveness. An article in American Family Physician (Feb. 15, 2007) summarized the medical knowledge:
“Dextromethorphan may be beneficial in adults with cough, but its effectiveness has not been demonstrated in children and adolescents.”
Please note the use of the words “may be beneficial in adults with cough.” The authors were careful not to say is beneficial.
Another article in American Family Physician (July 15, 2012) notes under the heading:
Therapies Not Effective for the Common Cold in Children
“Dextromethorphan: Not superior to placebo in nocturnal cough or sleep quality in the child or parents”
Under the heading “Effective Interventions” the authors note that:
“Studies of dextromethorphan and guaifenesin [an expectorant] for cough are almost evenly split, with some demonstrating benefit and others not.”
The independent Cochrane Collaboration (Cochrane Database of Systematic Reviews, Oct. 18, 2004) analyzed all the available data from well-controlled clinical trials and concluded:
“There is no good evidence for or against the effectiveness of OTC medicines in acute cough.”
None of these assessments offers a ringing endorsement of dextromethorphan as a cough suppressant. One overview suggests that dextromethorphan has limited effectiveness at best, reducing coughs caused by colds by less than 20% (Chest, Jan., 2006)
The People’s Pharmacy Bottom Line on DM Effectiveness:
From our vantage point dextromethorphan appears to be barely better than placebo. Large, well-controlled trials spanning several days or weeks need to be done to establish whether this common ingredient reliably eases a cough for most people.
Dextromethorphan Dangers:
When the FDA approved dextromethorphan in 1958, the agency assumed it had solved the problems of codeine abuse. DM was thought to be a safe and nonaddictive cough suppressant.
Little did the FDA realize that “dex” or DXM posed unique problems. By 1975 there were clear signals that people were abusing this drug. It is considered a “dissociative anesthetic,” creating a sense of separation between mind and body.
At high doses the drug can cause altered perceptions, disorientation, dizziness, euphoria, increased energy, lethargy, hallucinations, alterations in the perception of time, hyperactivity, panic, nausea, vomiting, paranoia, insomnia, sweating, rapid heart rate, muscle spasms and blackouts.
Even in so-called normal doses, dextromethorphan may cause adverse reactions for some people.
Dextromethorphan Side Effects:
- Digestive upset, nausea, vomiting, constipation, diarrhea
- Skin reactions, rash, itching
- Drowsiness, fatigue, sedation
- Mental disorientation, confusion, anxiety
Your son’s tragic experience with “dex” is clear evidence that some lives have been ruined by this drug. Thank you for reminding us that there are some serious risks associated with dextromethorphan and that it should only be used in the recommended dose and for the intended purpose.
What About Dextromethorphan and Quinidine for Dementia?
The article that you were concerned about involved a prescription medicine called Nuedexta that was approved by the FDA in 2010 for treating a neurological condition called pseudobulbar affect (PBA). People with PBA experience uncontrollable inappropriate laughing or crying. It is a devastating brain disease.
Alzheimer’s disease is even more devastating for patients and their families. One of the more common complications of this dementia is agitation. It can manifest as verbal or physical abuse and is terribly distressing for caregivers. When the anxiety and agitation become too much to handle, patients with Alzheimer’s disease dementia often end up in a nursing home.
When staff members can no longer deal with the agitation they have been known to dose patients with Alzheimer’s disease with powerful antipsychotic medications. Drugs like aripiprazole (Abilify), haloperidol (Haldol), olanzepine (Zyprexa), risperidone (Risperdal) or quetiapine (Seroquel) were far too frequently dispensed to confused nursing home residents. Eventually the FDA became so concerned that it issued a black box warning (its strongest alert) that:
“Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death.”
Anything that can calm someone suffering from Alzheimer’s disease without causing them undue risks would be very welcome. That’s why there has been such interest in a recent study of patients suffering from Alzheimer’s disease agitation. The investigators found that Nuedexta could be helpful in reducing agitation and aggression (JAMA, Sept. 22/29, 2015). The FDA has not yet approved it for this use.
The ingredients in Nuedexta are quinidine, an old heart rhythm regulator, and dextromethorphan. The dose of dextromethorphan in Nuedexta is 20 mg, one third the dose recommended in an OTC product like Robitussin 12 Hour Cough Relief.
The Future of Dextromethorphan for Alzheimer’s Disease:
Given that the dose of DM in the prescription drug Nuedexta is substantially lower than that found in cough medications, we suspect that the risks of abuse that you described with your son are also much lower. If Nuedexta is approved by the FDA for treating the agitation and aggression of Alzheimer’s disease dementia, it will require careful oversight by a physician.
As the authors of an accompanying editorial in JAMA point out:
“Effective treatment options for agitation in patients with Alzheimer disease are limited, so clinical innovation in this area is a high priority.”
What’s your experience with dextromethorphan? Do you find it to be an effective cough suppressant? Are you concerned about abuse of this drug? Do you think it might offer benefits for people with Alzheimer’s disease dementia? Share your thoughts below and please vote on this article at the top of the page.
Adam
I think that the current state of affairs in America concerning the pharmaceutical system is a travesty. The amount of ignorance and misinformation regarding drugs like dextromethorphan is appalling. This is the fault of the FDA, the DEA, and a generally uninformed, uninterested body of governing officials. There is an epidemic of OTC substance abuse that is being brushed under the rug, so to speak, and nobody seems to be willing to ask the question about the elephant in the room here, which is; where is the money trail ending? Why should there be a problem like this in a country so supposedly advanced in technology, diverse in culture, and pioneering in research?
This is the kind of problem that plagues nations of the third world, like the glue sniffing epidemic in the Philippines. This observation, in and of itself, identifies a two-fold problem, the first of which is that we have a problem every bit as sad and distressing as the glue-sniffing crisis in the Philippines, and secondly, nobody in America is willing to admit we have a problem that is every bit as sad and distressing as the glue sniffing crisis in far-eastern countries. What is that crisis? Hurt people needing relief and being enabled by a blind-eye, approach to government that tends to punish its people for their pain, but does little to actually alleviate it. That is, why do I have this problem? Same man, different voice now. We are broken.
Louise
Florida
My mom has end-stage Alzheimer’s disease and there are times she “sundowns” and turns almost like a monster–uncontrollable and undirectable in the middle of the night. I never use any kind of sedatives, but a standard dose of over-the-counter cough syrup with dextromethorphan always calms her down *without* sedating her. Sedation is the last thing I want which increases risk of falling. Dextromethorphan is all that is needed. She will be asleep in a half hour.
kitty
NY
It seems to me that the last thing Alzheimer’s patients and caregivers care about is addiction. As a caretaker for someone with Alzheimer’s, I find the letter about dangers of the medication and many of the comments ridiculous. A managerial position? Hello, by the time Alzheimer’s patients develop problems that according to the article may be helped by the drug, they cannot turn on the tv set or use the microwave, much less work in any kind of position. Driving? Who on earth would allow Alzheimer’s patients to drive? At any rate, my father probably wouldn’t know how to start a car. He cannot turn the key either, doesn’t remember how. In terms of addiction – I doubt Alzheimer’s patient even understand they need the medication. Many of them either forget to take pills or take too many. I took over dispensing my father’s medications after he decided he needed to finish the bottle – and this was before he was diagnosed with mild to moderate Alzheimer’s.
The author of the letter and some of the people who write comments needs to learn something about Alzheimer’s. Mental issues… LOL. The other day I found the brush we use to clean the toilet in my father’s bed. He used it to scratch some itch. Oh, and Steve, above, Alzheimer patients are already far beyond MCI.
Kevin
Florida
I was addicted to DXM for over 10 years, starting when I was about 15 or 16. I used to buy many bottles or pills at a time. I used at work, at school, at home. There was pretty much never a time when I was not high on the drug. I was diagnosed with depression when I was around the same age. Now, I also have anxiety and panic disorder well after stopping the drug. I took many trips to the emergency room and felt what I believe were a lot of near-death experiences. I thought I was going to die many times because of overdose/serotonin syndrome/etc. I have had my stomach pumped, tubes shoved up my nose, pulled out IVs/catheters, had to be strapped to hospital beds, and more. All because I was going crazy on this drug.
Oddly enough, none of these things kept me from abusing the drug. Eventually, I had sourced a supplier of pure DXM powder. I purchased 100 grams and had it shipped to my door along with a milligram scale and 200 empty pill capsules. I figured if I am going to abuse this drug, I might as well skip all the inactive ingredients, sugars, and fillers in the syrup. I was taking over a gram a day, every day, for the last few years of my abuse.
The thing that actually got me off the drug was my current girlfriend. I don’t know what it was, but something just clicked in my brain when I met her, and I decided I would never do the drug again. I threw away all of my supplies except for the scale, and I haven’t used since. This was over 2 years ago. Since then, I still have to take medication for depression and anxiety, but I still feel depressed and anxious on almost a daily basis. I also now have IBS-D, so I have to take medication to calm my intestinal tract as well.
So far, even with the help of my doctors and prescription medication, I am not able to keep my anxiety, nausea, and depression away 100% of the time, but things have gotten progressively better. I don’t know why I’m writing this post. I just think I want to inform people that this stuff really is a dangerous drug when abused like I have. If anyone reading this is thinking about using it as an escape from reality, please be careful. It is very powerful and ruined what should have been one of the most happy and fun decade of my life.
I have many other things to look forward to now, but getting high on cough syrup definitely isn’t one of them.
Allison
South Carolina
Just a word of caution, I suffer from what is known as an MAO deficiency. In other words, my body reacts to drugs and foods as though I were actually taking an MAO Inhibitor drug (which I never have). Anything containing DM could prove devastating, if not fatal, to me. I think your readers should be warned about the possible interaction.
joy
Back when my children were small I was told to give them robitussin DM and it was a big help.
Now when I get a bronchitis I find that Mucinex is a huge help to me.
I am very careful to use the smallest dose needed and for the shortest time.
This year when my husband was dying with Parkinson’s and had a parkinson’s -related dementia, his hospice Dr. gave him a very small dose of Seroquel each night. It gave us peaceful relaxed times together. I was able to keep him home with me as his full time caregiver and enjoyed it in spite of getting exhausted.
We must always be careful with ALL meds. we take.
Jane
SC
I occasionally take Robitussin DM. I take the prescribed dosage, have no coughing, and it helps me sleep. However, over twenty years ago, I had bronchitis with a very bad cough. At the same time I was being honored at a reception and overdosed on cough syrup trying to control my cough. I ended up in the ER and in the hospital for a week. I do not remember which cough syrup I took or if it contained DM. Thank you for this information. I will certainly keep it in mind when using cough syrup.
Barbara
South Carolina
I have been taking Neudexta daily for a few years now but had no idea it was for anything mentioned in this article. I have MS, and one of my symptoms was uncontrollable laughter (always at the worst times), so my neurologist put me on Neudexta and it has helped tremendously. This is all very interesting.
Julie
Houston TX
Robitussin DM triggered migraines in me so I had to find another solution. The most effective cough suppressant turned out to be Vicks Vaporub rubbed on the bottoms of my feet. It stops a persistent cough within 60-90 seconds and allows me to sleep peacefully all night when I have a cold or flu. I think it’s superior to Robitussin.
Terry Graedon
We have written about this remedy a number of times. Here are a few links:
https://www.peoplespharmacy.com/2015/12/14/53251/
https://www.peoplespharmacy.com/2013/06/03/vicks-on-feet-for-cough/
https://www.peoplespharmacy.com/2014/09/22/vicks-quelled-racking-nighttime-cough/
https://www.peoplespharmacy.com/2013/12/02/vicks-on-the-soles-of-your-feet-is-better-than-diamonds-on-the-soles-of-your-shoes/
Steve
MA
I’m pretty certain I stopped using DM for coughs as I got older due to the anticholinergic effect on my BPH, has been quite a while since I’ve used it. People also taking other meds with anticholinergic effects, almost everything, might want to know that the effects of all are additive and have been linked to MCI, mild cognitive impairment in age 65 and over folks, as you increase your anticholinergic effects.
John
Harrison, OH
Your comments on anticholinergics posing an under-recognized danger as we age, especially the cognitive ones. As a psychologist who consulted with nursing facilities, it was easy to look like a wizard when some little old guy with no history of psychosis or dementia suddenly went nutty as a fruitcake, and my first question would be when he was started on Flomax, one notorious offender in this category. But DM is NOT one of this class, as it is NOT an anticholinergic. It affects some endorphin receptors, affects serotonin reuptake, and in high doses is an NMDA antagonist, but it has no effect on acetylcholine. Sometimes this issue is confused because cough syrups that contain DM often also contain antihistamines like diphenhydramine or chlorpheniramine that do also act as anticholinergics.
Kathy
Colorado
In 2009, at age 42, I had a ruptured cerebral aneurysm, which should have killed me or left me disabled. That modern medicine enabled me to survive with few deficits is only half of the miracle for me: the other half of the miracle is Nuedexta. Although I had amazingly few physical and mental deficits after the rupture, I was no longer able to handle emotions, especially negative emotions, as a result of damage near my brain stem, which was devastating to my life as a wife and mother. My neurologist didn’t know what to do for me — until he thought to try Nuedexta. Luck and interventional “coiling” surgery by a talented neuroradiologist saved my life, but Nuedexta enabled me to continue living.
Al J
Dallas, TX
Thanks for warning us about the dangers of DM cough syrups. My doctor prescribed Robitussin DM years ago because I can’t take cough syrup with codeine. I am glad that I do not exceed the directions on the amount to take.
Susan
Baltimore
I’m concerned about the quinidine effect in Nuedexta and haven’t seen much comment about it. Can it have deleterious effects on older people with dementia?
Terry Graedon
Though quinidine can have serious side effects, there isn’t enough research yet on Nuedexta to know what the hazards are.
J. David Auner
Springfield, MO, USA
“Robitussin Robbie” is an unusual kind of addict but is a real problem. This combination drug with DM and quinidine is a complicated drug because of the toxicity of quinidine and all the drug interactions, especially with OTC cimetidine/Tagamet. Abuse of this combination drug is likely to lead to near- death experiences or death from the cardiac effects of quinidine.
Buck
Charlotte NC
I use guaifenesin with dextromethorphan practically every night at bedtime to avoid waking myself up coughing. I have year-round allergies and constant drainage, so this is a big help getting a good night’s sleep. I do not take it during the daytime unless I am sick because it does seem to increase drowsiness.
We recommend this combination to friends and family who complain they cannot stop coughing due to a cough or cold illness of some kind.
CM
Denver, CO
My husband and I take a Dex cough syrup as needed and have for years. It has effectively stopped the cough. We only use it at night and only occasionally. But you offer good advice and we will be more aware.
Timbra
If we would just stop criminalizing drugs addiction and legalize all drugs, people wouldn’t be abusing things even more dangerously just to get relief.
Andrew
Greensboro, NC
I have personally used guanifenesin-dextromethorphan cough syrups and prescribed it for patients when I was practicing pediatrics and have usually had good results from it. For “tickly” coughs, the only other treatment that works as well is codeine, which is a much more potentially addictive compound. As is the case with codeine, DM works better if given with acetaminophin, ibuprofen, or aspirin, but this may increase the drowsiness as well as the cough itself. I realize this is anecdotal, but used with a bit of caution regarding amount and duration of treatment, I feel that DM has a definite place in treating some–but not all–dry, hacking coughs.