The National Institute on Drug Abuse puts it in one sentence: the symptoms of withdrawal from DXM have not been well studied [1].
That is the honest answer to the question most people arrive here with, and it is why this page carries no timeline, no worst day and no month-by-month course. A page that invented those would sound more helpful and be worth less than nothing, because somebody would measure a real week against a made-up chart.
What is established is a great deal, and most of it matters more than a timeline would. What dextromethorphan is, what it does at high doses, that misuse can lead to addiction, the liver risk hiding in combination products, what an overdose does to breathing, and which treatments exist.
This page covers all of that and ends with what to ask on a first call. Our page on dextromethorphan and its effects covers the drug itself, and our drug addiction hub covers the wider picture.
What the Evidence Says About DXM Withdrawal
NIDA’s sentence is the position, and it is worth understanding why it is the position.
DXM is not an opioid in the way that word is usually meant. NIDA states that DXM is an opioid without effects on pain reduction and does not act on the opioid receptors [1]. So the opioid withdrawal course, which is published per drug and rests on receptor pharmacology, does not transfer here. Neither does the stimulant one.
That leaves a gap, and the gap is real rather than a failure to look. NIDA’s own page on over-the-counter medicines says the symptoms of withdrawal from DXM and loperamide have not been well studied [1]. That is a federal agency describing the state of the science.
What to do with that, practically, is not complicated. Describe what you are actually feeling to somebody who can assess it, rather than matching it against a chart. Our general page on withdrawal symptoms covers the substances where the picture is better mapped.
What DXM Is and Where It Comes From
It is a cough medicine, and that is most of why this is hard to spot.
The Drug Enforcement Administration describes dextromethorphan as a cough suppressant found in more than 120 over-the-counter cold medications, either alone or combined with other drugs such as analgesics, antihistamines, decongestants or expectorants [2]. The DEA lists it among drugs of concern rather than as a scheduled controlled substance [2].
MedlinePlus describes what it is for. Dextromethorphan is in a class of medications called antitussives, and it works by decreasing activity in the part of the brain that causes coughing [3].
NIDA names where misused supplies come from: the most common sources are extra-strength cough syrup, tablets and gel capsules [1]. The DEA also publishes the street names, which is worth knowing if you are the person who found the bottles. Its list includes CCC, Dex, Robo, Skittles and Triple C [2].
What DXM Does at High Doses
The effects are not the ones people expect from a cough medicine.
NIDA states that when taken in large doses, DXM causes a depressant effect and sometimes a hallucinogenic effect, similar to PCP and ketamine [1]. Short-term effects of misuse can range from mild stimulation to alcohol- or marijuana-like intoxication, and at high doses a person may have hallucinations or feelings of physical distortion, extreme panic, paranoia, anxiety and aggression [1].
NIDA’s list of other health effects runs: hyperexcitability, poor motor control, lack of energy, stomach pain, vision changes, slurred speech, increased blood pressure and sweating [1]. The DEA’s list overlaps and adds a sign a clinician looks for directly: over-excitability, lethargy, loss of coordination, slurred speech, sweating, hypertension, nausea, vomiting, and involuntary spasmodic movement of the eyeballs [2].
This page gives no amounts. A figure on a consumer page is an instruction however it is dressed, and the amount is not the thing that matters here anyway.
Can Misusing DXM Become an Addiction?
NIDA’s answer is yes, without hedging that part.
Repeatedly seeking that feeling can lead to addiction, which NIDA describes as a chronic relapsing brain condition characterized by the inability to stop using a drug despite damaging consequences to a person’s life and health [1]. It states directly that misuse of DXM can lead to addiction [1].
NIDA also gives the test that is actually useful. An addiction develops when continued use of the drug causes issues, such as health problems and failure to meet responsibilities at work, school, or home [1].
That is the checklist worth reading against your own last few months. It is more informative than a withdrawal chart would have been, because it describes the thing that decides whether treatment is needed.
The Acetaminophen Problem Nobody Warns About
This is the harm that is often already done by the time somebody decides to stop.
NIDA states that misuse of DXM products containing acetaminophen can cause liver damage [1]. Many cold medications combine the two, and the DEA’s description of DXM products names analgesics such as acetaminophen among the common combinations [2].
MedlinePlus adds the warning that catches people out. Combination products may contain the same active ingredients, and taking two of them at the same time could cause an overdose [3]. It also says dextromethorphan should only be used according to the label or package directions, and that taking it in large amounts can cause serious side effects or death [3].
Two practical consequences follow. If acetaminophen-containing products have been part of this, say so at the assessment, because liver function is checkable. And this page publishes no ceiling figure of its own for either ingredient, because the number that matters is on the package and in the hands of a clinician.
Overdose: What Happens and What to Do
The danger is breathing, and the instruction is short.
NIDA states that a person can overdose on cold medicines containing DXM [1]. When people overdose on DXM their breathing often slows or stops, which can decrease the amount of oxygen reaching the brain, a condition called hypoxia, and hypoxia can have short- and long-term effects on the mind and the nervous system including coma, permanent brain damage and death [1].
NIDA’s instruction: a person who has overdosed needs immediate medical attention, so call 911, and if the person has stopped breathing or breathing is weak, begin CPR [1]. NIDA also states that DXM overdoses can also be treated with naloxone [1]. That sentence is attributed to NIDA deliberately, because the same page says DXM does not act on the opioid receptors [1]; both statements are NIDA’s, and a reader is better served by having both than by having us choose between them.
If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental-health crisis call or text 988.
The DEA’s framing is less alarming and its hedges are part of the claim. DXM overdose can be treated in an emergency room setting and generally does not result in severe medical consequences or death [2]. Most DXM-related deaths are caused by ingesting the drug in combination with other drugs, and DXM-related deaths also occur from impairment of the senses, which can lead to accidents [2].
If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental-health crisis call or text 988.
Why an Assessment Beats a Self-Managed Stop
The argument here is not that withdrawal is dangerous. It is that nobody knows what this withdrawal looks like, and the harms are somewhere else.
An assessment covers liver function where acetaminophen products were involved, mental health, and what an ordinary week looks like. It also covers everything else being used, and that matters: NIDA notes these medicines are often misused in combination with other drugs, such as alcohol and marijuana [1]. Both of the DEA’s routes to a fatal outcome run through combinations and accidents rather than through DXM alone [2].
Panic, paranoia and anxiety are on NIDA’s high-dose list [1], and for some people those did not start with the cough syrup. Where a mental health condition sits underneath, dual diagnosis treatment is the name for care that treats both at once.
The output of that hour is a recommended level of care and a first plan. Our pages on the levels of care and on how long rehab takes explain what that means week to week.
Treatment for DXM Misuse: What Exists
There is no medication for this, and NIDA says so plainly: there are no medications approved specifically to treat DXM addiction [1].
What there is, is behavioral treatment, and NIDA names two approaches. Cognitive-behavioral therapy helps modify a person’s drug-use expectations and behaviors and manage triggers and stress [1]. Contingency management provides vouchers or small cash rewards for positive behaviors such as staying drug-free [1]. NIDA’s verb is “may be helpful”, and that hedge stays [1]. Our pages on therapy approaches used in treatment and on cognitive behavioral therapy explain what those sessions involve.
Where an acute phase needs supervision, that is one level of care rather than the whole of treatment. SAMHSA’s detoxification protocol states that detoxification is not substance abuse treatment and rehabilitation [4], and its chapter on settings describes the range, from an ambulatory service in a physician’s office to twenty-four-hour care in an acute care inpatient setting [5].
Medical detox sits at one end of that range. Some people step into residential rehab, others into an outpatient program. Our guide to getting into rehab covers the order the calls happen in, our treatment centers lists our campuses by state, and if cost is the obstacle, see what rehab costs and whether insurance covers it.
Frequently Asked Questions
Does DXM cause withdrawal? NIDA states that the symptoms of withdrawal from DXM have not been well studied. That is not the same as saying nothing happens, and it is not the same as saying something does. It means the research to describe it has not been done. NIDA does state that misuse of DXM can lead to addiction, so what somebody feels on stopping is worth describing to a clinician rather than matching against a chart.
How long does DXM withdrawal last? There is no published answer, and this page will not invent one. NIDA reports that the symptoms of withdrawal from DXM have not been well studied. Borrowing the opioid course would be wrong on its own terms, because NIDA states DXM does not act on the opioid receptors. An assessment is the way to get a picture of your own situation rather than a generic one.
Can misusing DXM become an addiction? Yes. NIDA states that misuse of DXM can lead to addiction, and describes addiction as a chronic relapsing brain condition characterized by the inability to stop using a drug despite damaging consequences. Its practical test is whether continued use is causing issues such as health problems and failure to meet responsibilities at work, school, or home.
Is a DXM overdose dangerous? It can be. NIDA states that when people overdose on DXM their breathing often slows or stops, decreasing oxygen to the brain, and that this hypoxia can cause coma, permanent brain damage and death. The DEA says most DXM-related deaths involve the drug taken with other drugs. If someone is unresponsive or has trouble breathing, call 911, and begin CPR if breathing has stopped or is weak. For a mental-health crisis, call or text 988.
What treatment is there for DXM misuse? NIDA states there are no medications approved specifically to treat DXM addiction, and that behavioral therapies such as cognitive-behavioral therapy and contingency management may be helpful. An assessment comes first, then a level of care. SAMHSA notes that detoxification is not substance abuse treatment and rehabilitation, so ask what follows it and who runs the therapy hours.
Sources
- National Institute on Drug Abuse. (2017). Over-the-Counter Medicines DrugFacts. National Institutes of Health. https://nida.nih.gov/publications/drugfacts/over-counter-medicines
- Drug Enforcement Administration. DXM. Drug Fact Sheet, Drugs of Concern. U.S. Department of Justice. https://www.dea.gov/factsheets/dxm
- MedlinePlus. Dextromethorphan. National Library of Medicine. https://medlineplus.gov/druginfo/meds/a682492.html
- Center for Substance Abuse Treatment. (2006). Detoxification and Substance Abuse Treatment, Chapter 1: Overview, Essential Concepts, and Definitions in Detoxification. Treatment Improvement Protocol (TIP) Series No. 45. Substance Abuse and Mental Health Services Administration, via NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK64119/
- Center for Substance Abuse Treatment. (2006). Detoxification and Substance Abuse Treatment, Chapter 2: Settings, Levels of Care, and Patient Placement. Treatment Improvement Protocol (TIP) Series No. 45. Substance Abuse and Mental Health Services Administration, via NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK64109/
This page is for general information and is not medical advice. Only a licensed clinician who knows your history can tell you what is right for you. If you or someone you know is in immediate danger, call 911. For free, confidential support 24/7, call or text 988.
Author
Chief Medical Officer,
The Recovery Village
