DXM (Dextromethorphan)— also known as robo—is a cough suppressant and expectorant ingredient in some over-the-counter (OTC) cold and cough medications that are often abused by adolescents and young adults. The most common sources of abused DXM are “extra-strength” cough syrup, which typically contains around 15 milligrams of DXM per teaspoon, and pills and gel capsules, which typically contain 15 milligrams of DXM per pill. OTC medications that contain DXM often also contain antihistamines and decongestants.

What is it?

Cough suppressor found in many over-the-counter medications, such as cough syrup, tablets, capsules, or powder. Popular over-the-counter brands: Robitussin, Coricidin HBP

Street Names

CCC, DXM, Poor Man’s PCP, Robo, Skittles, Triple C

How is it used?

DXM is taken by drinking cough syrup or swallowing tablets, capsules, or powder. Extensive “how to" abuse information on various web sites. Preferred by teenagers and younger for its easy accessibility. Tablets are easy to conceal and students will take them in school.

How does it affect the body?

• Increase in perceptual awareness, altered time perception
• Hallucinations, confusion
• Addictive
• Loss of coordination, slurred speech, sweating, lethargy
• High doses of DXM with alcohol or other drugs, including antidepressants, can cause death.

Classic Hallucinogens*

LSD (d-lysergic acid diethylamide)—also known as acid, blotter, doses, hits, microdots, sugar cubes, trips, tabs, or window panes—is one of the most potent mood- and perception-altering hallucinogenic drugs. It is a clear or white, odorless, water-soluble material synthesized from lysergic acid, a compound derived from a rye fungus. LSD is initially produced in crystalline form, which can then be used to produce tablets known as “microdots” or thin squares of gelatin called “window panes.” It can also be diluted with water or alcohol and sold in liquid form. The most common form, however, is LSD-soaked paper punched into small individual squares, known as “blotters.”

Psilocybin(4-phosphoryloxy-N,N-dimethyltryptamine)—also known as magic mushrooms, shrooms, boomers, or little smoke—is extracted from certain types of mushrooms found in tropical and subtropical regions of South America, Mexico, and the United States. In the past, psilocybin was ingested during religious ceremonies by indigenous cultures from Mexico and Central America. Psilocybin can either be dried or fresh and eaten raw, mixed with food, or brewed into a tea, and produces similar effects to LSD.

Peyote (Mescaline)—also known as buttons, cactus, and mesc—is a small, spineless cactus with mescaline as its main ingredient. It has been used by natives in northern Mexico and the southwestern United States as a part of religious ceremonies. The top, or “crown,” of the peyote cactus has disc-shaped buttons that are cut out, dried, and usually chewed or soaked in water to produce an intoxicating liquid. Because the extract is so bitter, some users prepare a tea by boiling the plant for several hours. Mescaline can also be produced through chemical synthesis.

DMT (Dimethyltryptamine)—also known as Dimitri—is a powerful hallucinogenic chemical found naturally occurring in some Amazonian plant species (see “Ayahuasca”) and also synthesized in the laboratory. Synthetic DMT usually takes the form of a white crystalline powder and is typically vaporized or smoked in a pipe.

Ayahuasca—also known as hoasca, aya, and yagé—is a hallucinogenic brew made from one of several Amazonian plants containing DMT (the primary psychoactive ingredient) along with a vine containing a natural alkaloid that prevents the normal breakdown of DMT in the digestive tract. Ayahuasca tea has traditionally been used for healing and religious purposes in indigenous South American cultures, mainly in the Amazon region.

Dissociative Drugs

PCP (Phencyclidine)—also known as ozone, rocket fuel, love boat, hog, embalming fluid, or superweed—was originally developed in the 1950s as a general anesthetic for surgery. While it can be found in a variety of forms, including tablets or capsules, it is usually sold as a liquid or powder. PCP can be snorted, smoked, injected, or swallowed. It is sometimes smoked after being sprinkled on marijuana, tobacco, or parsley.

Ketamine—also known as K, Special K, or cat Valium—is a dissociative currently used as an anesthetic for humans as well as animals. Much of the ketamine sold on the street has been diverted from veterinary offices. Although it is manufactured as an injectable liquid, ketamine is generally evaporated to form a powder that is snorted or compressed into pills for illicit use. Because ketamine is odorless and tasteless and has amnesia-inducing properties, it is sometimes added to drinks to facilitate sexual assault.

DXM (Dextromethorphan)—also known as robo—is a cough suppressant and expectorant ingredient in some over-the-counter (OTC) cold and cough medications that are often abused by adolescents and young adults. The most common sources of abused DXM are “extra-strength” cough syrup, which typically contains around 15 milligrams of DXM per teaspoon, and pills and gel capsules, which typically contain 15 milligrams of DXM per pill. OTC medications that contain DXM often also contain antihistamines and decongestants.

Salvia divinorum—also known as diviner’s sage, Maria Pastora, Sally-D, or magic mint—is a psychoactive plant common to southern Mexico and Central and South America. Salvia is typically ingested by chewing fresh leaves or by drinking their extracted juices. The dried leaves of salvia can also be smoked or vaporized and inhaled.

*In this report, the term “hallucinogen” will refer to the classic hallucinogenic drugs LSD and Psilocybin.

Some over-the-counter (OTC) and prescription cough and cold medicines contain active ingredients that are psychoactive (mind-altering) at higher-than-recommended dosages and are frequently abused for this purpose. These products may also contain other drugs, such as expectorants and antihistamines, which are dangerous at high doses and compound the dangers of abuse.

Two commonly abused cough and cold medicines are:

• Dextromethorphan (DXM), a cough suppressant and expectorant found in many OTC cold medicines. It may produce euphoria and dissociative effects or even hallucinations when taken in quantities greater than the recommended therapeutic dose.

• Promethazine-codeine cough syrup, a medication that contains codeine, an opioid that acts as a cough suppressant and can also produce relaxation and euphoria when consumed at a higher-than-prescribed dose. It also contains promethazine HCl, an antihistamine that additionally acts as a sedative. Although only available by prescription, promethazine-codeine cough syrup is sometimes diverted for abuse.

How Are Cough and Cold Medicines Abused?

Cough and cold medicines are usually consumed orally in tablet, capsule, or syrup form. They may be mixed with soda for flavor and are often abused in combination with other drugs, such as alcohol or marijuana.

Because they are easily purchased in drugstores without a prescription, cough syrups, pills, and gel capsules containing DXM—particularly “extra strength” forms—are frequently abused by young people (who refer to the practice as “robotripping” or “skittling”). To avoid nausea produced by high doses of the expectorant guaifenesin commonly found in DXM containing syrups, young people may instead abuse Coricidin® HBP Cough & Cold capsules (street name C-C-C or triple-C), which contain DXM but lack guaifenesin.

Drinking promethazine-codeine cough syrup mixed with soda (a combination called syrup, sizzurp, purple drank, barre, or lean) was referenced frequently in some popular music beginning in the late 1990s and has become increasingly popular among youth in several areas of the country. A variation of “purple drank” is promethazine-codeine cough syrup mixed with alcohol. Users may also flavor the mixture with the addition of hard candies.

How Does Abusing Cough and Cold Medicines Affect the Brain?

When taken as intended, cough and cold medicines safely treat symptoms of lower and upper respiratory congestion and discomfort caused by colds and flu. But when taken in higher quantities or when such symptoms aren’t present, they may affect the brain in ways very similar to illegal drugs.

When taken in high doses, DXM acts on the same cell receptors as dissociative hallucinogenic drugs like PCP or ketamine. Users describe effects ranging from mild stimulation to alcohol- or marijuana-like intoxication, and at high doses, sensations of physical distortion and hallucinations.

Codeine attaches to the same cell receptors targeted by illegal opioids like heroin. Consuming more than the daily recommended therapeutic dose of promethazine-codeine cough syrup can produce euphoria similar to that produced by other opioid drugs; people addicted to codeine may consume several times the recommended, safe amount. Also, both codeine and promethazine HCl act as depressants of the central nervous system, producing sedating or calming effects.

When abused, both codeine and DXM directly or indirectly cause a pleasurable increase in the amount of dopamine in the brain’s reward pathway. Repeatedly seeking to experience that feeling can lead to addiction—a chronic relapsing brain disease characterized by inability to stop using a drug despite damaging consequences to a person’s life and health.

What Are the Other Health Effects of Abusing Cough and Cold Medicines?

Abusing DXM can cause impaired motor function, numbness, nausea or vomiting, increased heart rate and blood pressure, and at high doses, extreme agitation, increased body temperature, and a buildup of excess acid in body fluids. High doses of acetaminophen, a pain reliever commonly found with DXM, can cause liver damage. On rare occasions, hypoxic brain damage—caused by severe respiratory depression and a lack of oxygen to the brain—has occurred as a result of the combination of DXM with decongestants often found in the medication.

When abused, promethazine-codeine cough syrup presents a high risk of fatal overdose due to its effect of depressing the central nervous system, which can slow or stop the heart and lungs. Mixing with alcohol greatly increases this risk. Promethazine-codeine cough syrup has been linked to the overdose deaths of a few prominent musicians.

What are hallucinogens?

Hallucinogens are a diverse group of drugs that alter a person’s awareness of their surroundings as well as their own thoughts and feelings. They are commonly split into two categories: classic hallucinogens (such as LSD) and dissociative drugs (such as PCP). Both types of hallucinogens can cause hallucinations, or sensations and images that seem real though they are not. Additionally, dissociative drugs can cause users to feel out of control or disconnected from their body and environment.

Some hallucinogens are extracted from plants or mushrooms, and some are synthetic (human-made). Historically, people have used hallucinogens for religious or healing rituals. More recently, people report using these drugs for social or recreational purposes, including to have fun, deal with stress, have spiritual experiences, or just to feel different.

Common classic hallucinogens include the following:

• LSD (D-lysergic acid diethylamide) is one of the most powerful mind-altering chemicals. It is a clear or white odorless material made from lysergic acid, which is found in a fungus that grows on rye and other grains. LSD has many other street names, including acid, blotter acid, dots, and mellow yellow.
• Psilocybin (4-phosphoryloxy-N,N-dimethyltryptamine) comes from certain types of mushrooms found in tropical and subtropical regions of South America, Mexico, and the United States. Some common names for psilocybin include little smoke, magic mushrooms, and shrooms.
• Peyote (mescaline) is a small, spineless cactus with mescaline as its main ingredient. Peyote can also be synthetic. Common names for peyote are buttons, cactus, and mesc.
• DMT (N,N-dimethyltryptamine) is a powerful chemical found naturally in some Amazonian plants. Ayahuasca is a tea made from such plants, and when taken in this form it is also known as hoasca, aya, and yagé. People can also make DMT in a lab. Synthetic DMT usually takes the form of a white crystalline powder that is smoked. A popular name for synthetic DMT is Dimitri.
• 251-NBOMe is a synthetic hallucinogen with similarities both to LSD and MDMA (see DrugFacts: MDMA) but that is much more potent. Developed for use in brain research, when sold on the street it is sometimes called N Bomb or 251.

Common examples of dissociative drugs include the following:

• PCP (Phencyclidine) was developed in the 1950s as a general anesthetic for surgery, but it is no longer used for this purpose due to serious side effects. PCP can be found in a variety of forms, including tablets or capsules; however, liquid and white crystal powder are the most common. PCP has various slang names, such as Angel Dust, Hog, Love Boat, and Peace Pill.
• Ketamine is used as a surgery anesthetic for humans and animals. Much of the ketamine sold on the streets comes from veterinary offices. It mostly sells as a powder or as pills, but it also available as an injectable liquid. Ketamine is snorted or sometimes added to drinks as a date-rape drug. Slang names for ketamine include Special K and Cat Valium.
• Dextromethorphan (DXM) is a cough suppressant and mucus-clearing ingredient in some over-the-counter cold and cough medicines (syrups, tablets, and gel capsules). Robo is a common slang name for DXM.
• Salvia (Salvia divinorum) is a plant common to southern Mexico and Central and South America. Salvia is typically ingested by chewing fresh leaves or by drinking their extracted juices. The dried leaves of salvia can also be smoked or vaporized and inhaled. Popular names for salvia are Diviner's Sage, Maria Pastora, Sally-D, and Magic Mint.

How do people use hallucinogens?

People use hallucinogens in a wide variety of ways, as shown in the following chart:

How do hallucinogens affect the brain?

Research suggests that classic hallucinogens work at least partially by temporarily disrupting communication between brain chemical systems throughout the brain and spinal cord. Some hallucinogens interfere with the action of the brain chemical serotonin, which regulates:

• mood
• sensory perception
• sleep
• hunger
• body temperature
• sexual behavior
• intestinal muscle control

Dissociative hallucinogenic drugs interfere with the action of the brain chemical glutamate, which regulates:

• pain perception
• responses to the environment
• emotion
• learning and memory

What are some other effects of hallucinogens?

Classic Hallucinogens
Short-Term Effects

Classic hallucinogens can cause users to see images, hear sounds, and feel sensations that seem real but do not exist. The effects generally begin within 20 to 90 minutes and can last as long as 12 hours in some cases (LSD) or as short as 15 minutes in others (synthetic DMT). Hallucinogen users refer to the experiences brought on by these drugs as "trips." If the experience is unpleasant, users sometimes call it a "bad trip."

Along with hallucinations, other short-term general effects include:

• increased heart rate
• nausea
• intensified feelings and sensory experiences (such as seeing brighter colors)
• changes in sense of time (for example, the feeling that time is passing by slowly)

Specific short-term effects of some hallucinogens include:

• increased blood pressure, breathing rate, or body temperature
• loss of appetite
• dry mouth
• sleep problems
• spiritual experiences
• feelings of relaxation
• uncoordinated movements
• excessive sweating
• panic
• paranoia—extreme and unreasonable distrust of others
• psychosis—disordered thinking detached from reality
• bizarre behaviors

Long-Term Effects

Two long-term effects have been associated with use of classic hallucinogens, although these effects are rare.

• Persistent Psychosis—a series of continuing mental problems, including:
  • visual disturbances
  • disorganized thinking
  • paranoia
  • mood changes
• Hallucinogen Persisting Perception Disorder (HPDD)—recurrences of certain drug experiences, such as hallucinations or other visual disturbances. These flashbacks often happen without warning and may occur within a few days or more than a year after drug use. These symptoms are sometimes mistaken for other disorders, such as stroke or a brain tumor.

Both conditions are seen more often in people who have a history of mental illness, but they can happen to anyone, even after using hallucinogens one time. For HPDD, some antidepressant and antipsychotic medications can be used to improve mood and treat psychosis. Behavioral therapies can be used to help people cope with fear or confusion associated with visual disturbances.

Dissociative Drugs
Short-Term Effects

Dissociative drug effects can appear within a few minutes and can last several hours in some cases; some users report experiencing drug effects for days.

Effects on a Developing Fetus

While the effects of most hallucinogens on the developing fetus are unknown, researchers do know that mescaline in peyote may affect the fetus of a pregnant woman using the drug.

Effects depend on how much is used. In low and moderate doses, dissociative drugs can cause:

• numbness
• disorientation and loss of coordination
• hallucinations
• increase in blood pressure, heart rate, and body temperature

In high doses, dissociative drugs can cause the following effects:

• memory loss
• panic and anxiety
• seizures
• psychotic symptoms
• amnesia
• inability to move
• mood swings
• trouble breathing

Long-Term Effects of Dissociative Drugs

More research is needed on the long-term effects of dissociative drugs. Researchers do know repeated use of PCP can result in addiction. Other long-term effects may continue for a year or more after use stops, including:

• speech problems
• memory loss
• weight loss
• anxiety
• depression and suicidal thoughts

Can a person overdose on hallucinogens?

It depends on the drug. An overdose occurs when a person uses enough of a drug to produce serious adverse effects, life-threatening symptoms, or death. Most classic hallucinogens may produce extremely unpleasant experiences at high doses, although the effects are not necessarily life-threatening. However, serious medical emergencies and several fatalities have been reported from 251-NBOMe.

Overdose is more likely with some dissociative drugs. High doses of PCP can cause seizures, coma, and death. Additionally, taking PCP with depressants such as alcohol or benzodiazepines can also lead to coma. Benzodiazepines, such as alprazolam (Xanax), are prescribed to relieve anxiety or promote sleep.

However, users of both classic hallucinogens and dissociative drugs also risk serious harm because of the profound alteration of perception and mood these drugs can cause.

• Users might do things they would never do in real life, like jump out of a window or off a roof, for instance, or they may experience profound suicidal feelings and act on them.
• With all drugs there is also a risk of accidental poisoning from contaminants or other substances mixed with the drug.
• Users of psilocybin also run the risk of accidentally consuming poisonous mushrooms that look like psilocybin. Taking poisonous mushrooms can result in severe illness or possible death.

Are hallucinogens addictive?

In some cases, yes. Evidence suggests that certain hallucinogens can be addictive, and that people can develop a tolerance to them.

For example, LSD is not considered an addictive drug because it doesn't cause uncontrollable drug-seeking behavior. However, LSD does produce tolerance, so some users who take the drug repeatedly must take higher doses to achieve the same effect. This is an extremely dangerous practice, given the unpredictability of the drug. In addition, LSD produces tolerance to other hallucinogens, including psilocybin.

The misuse and addiction potential of DMT is currently unknown. Unlike other hallucinogens, DMT does not appear to lead to tolerance. There is also little evidence that taking it in the form of ayahuasca tea can lead to addiction.

On the other hand, PCP is a hallucinogen that can be addictive. People who stop repeated use of PCP experience drug cravings, headaches, and sweating as common withdrawal symptoms.

More research is needed on the tolerance or addiction potential of a variety of hallucinogens.

Tolerance vs. Dependence vs. Addiction

Long-term use of prescription opioids, even as prescribed by a doctor, can cause some people to develop a tolerance, which means that they need higher and/or more frequent doses of the drug to get the desired effects.

Drug dependence occurs with repeated use, causing the neurons to adapt so they only function normally in the presence of the drug. The absence of the drug causes several physiological reactions, ranging from mild in the case of caffeine, to potentially life-threatening, such as with heroin. Some chronic pain patients are dependent on opioids and require medical support to stop taking the drug.

Drug addiction is a chronic disease characterized by compulsive, or uncontrollable, drug seeking and use despite harmful consequences and long-lasting changes in the brain. The changes can result in harmful behaviors by those who misuse drugs, whether prescription or illicit drugs.

How is a hallucinogen addiction treated?

There are no FDA-approved medications to treat addiction to hallucinogens. While behavioral treatments can be helpful for patients with a variety of addictions, scientists need more research to find out if behavioral therapies are effective for addiction to hallucinogens.

Could hallucinogens be medicines?

Potentially. Some hallucinogens have been studied for possible therapeutic benefits in treating mental disorders such as depression.

Ketamine was approved many years ago as an anesthetic for painful medical procedures. In March 2019, the medicine esketamine (called “Spravato” by the manufacturer) was approved by the Food and Drug Administration as a treatment for severe depression in patients that do not respond to other treatments. Esketamine is closely related to the drug ketamine which is used illicitly and so there are concerns about the potential for abuse of this newly approved medication. In response, esketamine will be limited to administration in medical facilities.

Unlike a prescription that can be taken home and might be diverted into recreational use, esketamine will be administered in a medical office as a nasal spray. Patients must wait at least 2 hours under medical supervision to ensure proper management of potential side effects. It is a rapid acting medication, so improvements may be seen immediately or within the first few weeks of treatment (unlike most other antidepressants which can take weeks to begin to show an effect). Traditional antidepressants target the neurotransmitters serotonin, norepinephrine or dopamine. Esketamine affects the receptor for a different brain chemical called glutamate and so it represents a new approach to treating depression.

Evidence has also mounted in recent years that psilocybin may be effective in treating depression, and this is currently being studied in clinical trials. Psilocybin is not approved by the Food and Drug Administration (FDA), but in 2018, the FDA granted “Breakthrough Therapy” designation to one pharmaceutical company to facilitate clinical trials for its psilocybin-assisted therapy for treatment-resistant depression; the trials will determine the most optimal dose of the drug. It has also been studied as a possible treatment for depression and anxiety suffered by people with terminal illnesses.

Points to Remember

• Hallucinogens are a diverse group of drugs that alter perception, thoughts, and feelings. They cause hallucinations, or sensations and images that seem real, but they are not.
• Hallucinogens are split into two categories: classic hallucinogens and dissociative drugs.
• People use hallucinogens in a wide variety of ways, including smoking, snorting, and absorbing through the lining in the mouth.
• The effects of classic hallucinogens can begin with 20 to 90 minutes of taking them and include increased heart rate, nausea, intensified feelings and sensory experiences, and changes in sense of time.
• The effects of dissociative drugs can begin within minutes and can last several hours and include numbness, disorientation and loss of coordination, hallucinations, and increased blood pressure, heart rate, and body temperature.
• Persistent psychosis and flashbacks are two long-term effects associated with some hallucinogens.
• Evidence suggests a few hallucinogens can be addictive, and some of them can produce tolerance.
• There are no FDA-approved medications to treat addiction to hallucinogens. Scientists need more research to find out if behavioral therapies are effective for addiction to hallucinogens.
• Some hallucinogens are being studied as possible therapies for depression. Esketamine was recently approved by the FDA as a treatment for severe depression in patients that do not respond to other treatments.