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The abuser's speech can become slurred, and short-term memory may be temporarily impaired. Third Plateau: An altered state of consciousness. The abuser's senses, particularly vision, can become impaired. Fourth Plateau: Mind and body dissociation or an "out-of-body" experience. The abuser can lose some or all contact with his or her senses.

The effects at this plateau are comparable to the effects caused by ketamine or PCP phencyclidine. Over-the-counter products that contain DXM often contain other ingredients such as acetaminophen, chlorpheniramine, and guaifenesin.

Large dosages of acetaminophen can cause liver damage; large dosages of chlorpheniramine can cause increased heart rate, lack of coordination, seizures, and coma; and large dosages of guaifenesin can cause vomiting. Some first-time users may not abuse DXM repeatedly if they experience negative side effects--such as vomiting--commonly associated with the other ingredients contained in over-the-counter DXM medications.

Nonetheless, some DXM abusers "robo shake," a practice whereby they drink a large amount of cough syrup containing DXM and then force themselves to vomit so as to absorb enough DXM through the stomach lining to achieve the desired effect while expelling the other ingredients. Some more experienced abusers use a chemical procedure to extract the DXM from the other ingredients contained in cough syrups to avoid such side effects.

This procedure cannot be used on DXM products sold in nonliquid form. Figure 1. Photo of cough medicine bottle with the active ingredients label showing Acetaminophen, Dextromethorphan, and Pseudoephedrine.

Recommended dosages of DXM generally are safe but can cause nausea, gastrointestinal disturbances, slight drowsiness, and dizziness. Acute dosages between and 1, milligrams can cause blurred vision, body itching, rash, sweating, fever, hypertension, shallow respiration, diarrhea, toxic psychosis, coma, and an increase in heart rate, blood pressure, and body temperature. Some abusers become violent after ingesting the drug.

Little is known about the long-term effects of DXM abuse; however, anecdotal reporting and limited clinical research suggest that extensive and prolonged abuse may cause learning and memory impairment. Most DXM-related deaths are caused by ingesting the drug in combination with other drugs. DXM-related deaths also occur from impairment of the senses, which can lead to accidents. In , a year-old boy in Colorado who abused DXM died when he was hit by two cars as he attempted to cross a highway.

State law enforcement investigators suspect that the drug affected the boy's depth perception and caused him to misjudge the distance and speed of the oncoming vehicles.

DXM abuse levels are difficult to determine. Commonly used drug toxicology screens and field tests do not accurately detect the presence of DXM. Therefore, more thorough laboratory testing must be performed. National surveys conducted to estimate rates of drug abuse do not include questions regarding DXM.

However, the American Association of Poison Control Centers reports that the total number of calls to centers nationwide involving DXM abuse or misuse have increased since see Table 1. Calls involving abuse or misuse of DXM by teenagers increased approximately percent from 1, through 3, Calls involving abuse by other age groups increased 21 percent from through , before decreasing slightly in In , Poison Control Centers received calls involving abuse or misuse of DXM from 1, teenagers and people from all other age groups.

In , Poison Control Centers received calls involving abuse or misuse of DXM from 2, teenagers and 1, people from all other age groups. In , Poison Control Centers received calls involving abuse or misuse of DXM from 3, teenagers and 1, people from all other age groups. DXM abusers can obtain the drug at almost any pharmacy or supermarket. Most seek out products that have a high concentration of the drug. Other slang terms include skittles, dex, candy, and red devils. Concerns about shoplifting and abuse of products containing DXM have resulted in some stores instituting new policies and procedures regarding access and sales of such products.

Specifically, some stores place such products where consumers must ask for them, and some have limited the number of packages that can be sold to each customer.

DXM frequently is available at raves and other venues where youths congregate.