Dextromethorphan in Cough Syrup: The Poor Man’s Psychosis

Dextromethorphan (3-methoxy-N-methylmorphinan), also known as "DXM" and "the poor man's PCP," is a synthetically produced drug that is available in more than 140 over-the-counter cough and cold preparations. Dextromethorphan (DXM) has overtaken codeine as the most widely used cough suppressant due to its availability, efficacy, and safety profile at directed doses. However, DXM is subject to abuse. When consumed at inappropriately high doses (over 1500 mg/day), DXM can induce a state of psychosis characterized by Phencyclidine (PCP)-like psychological symptoms, including delusions, hallucinations, and paranoia. We report a noteworthy case of severe dextromethorphan use disorder with dextromethorphan-induced psychotic disorder in a 40-year-old Caucasian female, whose symptoms remitted only following treatment with a combination of an antipsychotic and mood stabilizer. While some states have begun to limit the quantity of DXM sold or restrict sales to individuals over 18-years of age, there is currently no federal ban or restriction on DXM. Abuse of DXM, a readily available and typically inexpensive agent that is not detected on a standard urine drug screen, may be an under-recognized cause of substance-induced psychosis. It is imperative that clinicians are aware of the potential psychiatric sequelae of recreational DXM use.