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Tanaka T, Sato H, Kimura S, Kasai K, Umehara T. An Autopsy Case of Dextromethorphan Poisoning. J UOEH 2024; 46:221-226. [PMID: 38839290 DOI: 10.7888/juoeh.46.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
A woman in her 30s who was being treated for a mental illness with several psychotropic drugs was admitted to the hospital after being found in a state of unconsciousness and respiratory arrest at home. She was pronounced dead 12 hours after she was discovered. Her autopsy revealed symmetrical hemorrhagic necrosis in the putamen on both sides of her cerebrum. Although many drugs were detected in her blood, all of those other than dextromethorphan (DXM) were within or below the therapeutic range. Her blood DXM was 1.73 μg/ml at admission and 1.61 μg/ml at autopsy, which were within the toxic range or coma-to-death range. The cause of death was diagnosed as DXM poisoning. DXM can cause hallucinations and euphoria if taken in excess, but since it is available as an over-the-counter drug at general pharmacies, an increasing number of young people are overdosing on it, mistakenly believing it to be a safe drug with few side effects. We believe that further social measures against DXM are necessary in Japan, such as disseminating correct knowledge in society and regulating over-the-counter sales.
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Affiliation(s)
- Toshiko Tanaka
- Department of Forensic Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Hiroaki Sato
- Department of Forensic Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Satoshi Kimura
- Department of Clinical Pathology, Kitakyushu City Yahata Hospital, Japan
| | - Kentaro Kasai
- Department of Forensic Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Toshihiro Umehara
- Department of Forensic Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
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McClure EW, Daniels RN. Classics in Chemical Neuroscience: Dextromethorphan (DXM). ACS Chem Neurosci 2023. [PMID: 37290117 DOI: 10.1021/acschemneuro.3c00088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
Dextromethorphan (DXM) was introduced in 1958 as the first non-opioid cough suppressant and is indicated for multiple psychiatric disorders. It has been the most used over-the-counter cough suppressant since its emergence. However, individuals quickly noticed an intoxicating and psychedelic effect if they ingested large doses. DXM's antagonism at N-methyl-d-aspartate receptors (NMDAr) is thought to underly its efficacy in treating acute cough, but supratherapeutic doses mimic the activity of dissociative hallucinogens, such as phencyclidine and ketamine. In this Review we will discuss DXM's synthesis, manufacturing information, drug metabolism, pharmacology, adverse effects, recreational use, abuse potential, and its history and importance in therapy to present DXM as a true classic in chemical neuroscience.
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Affiliation(s)
- Elliot W McClure
- Department of Pharmaceutical Sciences, Lipscomb University College of Pharmacy, Nashville, Tennessee 37204, United States
| | - R Nathan Daniels
- Department of Pharmaceutical Sciences, Union University College of Pharmacy, Jackson, Tennessee 38305, United States
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Shimozawa S, Usuda D, Sasaki T, Tsuge S, Sakurai R, Kawai K, Matsubara S, Tanaka R, Suzuki M, Hotchi Y, Tokunaga S, Osugi I, Katou R, Ito S, Asako S, Mishima K, Kondo A, Mizuno K, Takami H, Komatsu T, Oba J, Nomura T, Sugita M. High doses of dextromethorphan induced shock and convulsions in a 19-year-old female: A case report. World J Clin Cases 2023; 11:3870-3876. [PMID: 37383112 PMCID: PMC10294160 DOI: 10.12998/wjcc.v11.i16.3870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/14/2023] [Accepted: 05/04/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Dextromethorphan is a prevalent antitussive agent that can be easily obtained as an over-the-counter medication. There has been a growing number of reported cases of toxicity in recent years. Generally, there are numerous instances of mild symptoms, with only a limited number of reports of severe cases necessitating intensive care. We presented the case of a female who ingested 111 tablets of dextromethorphan, leading to shock and convulsions and requiring intensive care that ultimately saved her life.
CASE SUMMARY A 19-year-old female was admitted to our hospital via ambulance, having overdosed on 111 tablets of dextromethorphan (15 mg) obtained through an online importer in a suicide attempt. The patient had a history of drug abuse and multiple self-inflicted injuries. At the time of admission, she exhibited symptoms of shock and altered consciousness. However, upon arrival at the hospital, the patient experienced recurrent generalized clonic convulsions and status epilepticus, necessitating tracheal intubation. The convulsions were determined to have been caused by decreased cerebral perfusion pressure secondary to shock, and noradrenaline was administered as a vasopressor. Gastric lavage and activated charcoal were also administered after intubation. Through systemic management in the intensive care unit, the patient’s condition stabilized, and the need for vasopressors ceased. The patient regained consciousness and was extubated. The patient was subsequently transferred to a psychiatric facility, as suicidal ideation persisted.
CONCLUSION We report the first case of shock caused by an overdose of dextromethorphan.
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Affiliation(s)
- Shintaro Shimozawa
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Daisuke Usuda
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Toru Sasaki
- Clinical Training Center, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Shiho Tsuge
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Riki Sakurai
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Kenji Kawai
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Shun Matsubara
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Risa Tanaka
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Makoto Suzuki
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Yuta Hotchi
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Shungo Tokunaga
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Ippei Osugi
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Risa Katou
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Sakurako Ito
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Suguru Asako
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Kentaro Mishima
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Akihiko Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Keiko Mizuno
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Hiroki Takami
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Takayuki Komatsu
- Department of Sports Medicine, Faculty of Medicine, Juntendo University, Bunkyo-city 113-8421, Tokyo, Japan
| | - Jiro Oba
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Tomohisa Nomura
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
| | - Manabu Sugita
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-city 177-8521, Tokyo, Japan
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Ji JJ, Zhao J, Xiang P, Yan H, Shen M. Chiral analysis of dextromethorphan and levomethorphan in human hair by liquid chromatography-tandem mass spectrometry. Forensic Toxicol 2022; 40:312-321. [PMID: 36454412 DOI: 10.1007/s11419-022-00620-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/07/2022] [Indexed: 01/26/2023]
Abstract
PURPOSE Methorphan exists in two enantiomeric forms including dextromethorphan and levomethorphan. Dextromethorphan is an over-the-counter antitussive drug, whereas levomethorphan is strictly controlled as a narcotic drug. Chiral analysis of methorphan could, therefore, assist clinicians and forensic experts in differentiating between illicit and therapeutic use and in tracing the source of the drug. METHODS A method for enantiomeric separation and quantification of levomethorphan and dextromethorphan in human hair was developed and validated using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Hair was extracted in hydrochloric acid/methanol (1:20, v/v). The supernatant were separated using a Supelco Astec Chirobiotic™ V2 column (250 × 2.1 mm, i.d., 5 μm particle size) and analyzed on a triple quadrupole linear ion trap mass spectrometer in multiple reaction monitoring mode. RESULTS The limits of detection for dextromethorphan and levomethorphan were 2 and 1 pg/mg, respectively; the lower limit of quantification was 2 pg/mg for both drugs. Good linearity (r > 0.995) was observed for both analytes over the linear range. Precision values were below 10% for both analytes; accuracy values ranged from 87.5 to 101%. The extraction recoveries were 78.3-98.4%, and matrix effects were 70.5-88.6%. This method was applied to human hair samples from 120 people suspected of methorphan use to further distinguish the drug chirality. Dextromethorphan was detected in all 120 samples at a concentration range of 2.7-19,100 pg/mg, whereas levomethorphan was not detected in any sample. CONCLUSIONS A sensitive quantitative method was established for the enantiomeric separation of dextromethorphan and levomethorphan in hair. This is the first study to achieve chiral analysis of methorphan in human hair.
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Affiliation(s)
- Jiao-Jiao Ji
- Department of Forensic Medicine, Shanghai Medical College, Fudan University, Shanghai, 200032, China.,Department of Forensic Toxicology, Shanghai Key Laboratory of Forensic Medicine, Academy of Forensic Science, Shanghai, 200063, China
| | - Junbo Zhao
- Department of Forensic Toxicology, Shanghai Key Laboratory of Forensic Medicine, Academy of Forensic Science, Shanghai, 200063, China
| | - Ping Xiang
- Department of Forensic Toxicology, Shanghai Key Laboratory of Forensic Medicine, Academy of Forensic Science, Shanghai, 200063, China
| | - Hui Yan
- Department of Forensic Toxicology, Shanghai Key Laboratory of Forensic Medicine, Academy of Forensic Science, Shanghai, 200063, China
| | - Min Shen
- Department of Forensic Toxicology, Shanghai Key Laboratory of Forensic Medicine, Academy of Forensic Science, Shanghai, 200063, China.
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Schifano F, Chiappini S, Miuli A, Mosca A, Santovito MC, Corkery JM, Guirguis A, Pettorruso M, Di Giannantonio M, Martinotti G. Focus on Over-the-Counter Drugs' Misuse: A Systematic Review on Antihistamines, Cough Medicines, and Decongestants. Front Psychiatry 2021; 12:657397. [PMID: 34025478 PMCID: PMC8138162 DOI: 10.3389/fpsyt.2021.657397] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/15/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Over the past 20 years or so, the drug misuse scenario has seen the emergence of both prescription-only and over-the-counter (OTC) medications being reported as ingested for recreational purposes. OTC drugs such as antihistamines, cough/cold medications, and decongestants are reportedly the most popular in being diverted and misused. Objective: While the current related knowledge is limited, the aim here was to examine the published clinical data on OTC misuse, focusing on antihistamines (e.g., diphenhydramine, promethazine, chlorpheniramine, and dimenhydrinate), dextromethorphan (DXM)- and codeine-based cough medicines, and the nasal decongestant pseudoephedrine. Methods: A systematic literature review was carried out with the help of Scopus, Web of Science databases, and the related gray literature. For data gathering purposes, both the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and PROSPERO guidelines were followed (PROSPERO identification code CRD42020209261). Results: After completion of the selection, eligibility, and screening phases, some 92 articles were here taken into consideration; case reports, surveys, and retrospective case series analyses were included. Findings were organized according to the specific OTC recorded. Most articles focused here on DXM (n = 54) and diphenhydramine (n = 12). When specified, dosages, route(s) of administration, toxicity symptoms (including both physical and psychiatric ones), and outcomes were here reported. Conclusion: Results from the systematic review showed that the OTC misusing issues are both widespread worldwide and popular; vulnerable categories include adolescents and young adults, although real prevalence figures remain unknown, due to a lack of appropriate monitoring systems. Considering the potential, and at times serious, adverse effects associated with OTC misusing issues, healthcare professionals should be vigilant, and ad hoc preventative actions should be designed and implemented.
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Affiliation(s)
- Fabrizio Schifano
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Stefania Chiappini
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom.,Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Andrea Miuli
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Alessio Mosca
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Maria Chiara Santovito
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - John M Corkery
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Amira Guirguis
- Swansea University Medical School, Institute of Life Sciences 2, Swansea University, Swansea, United Kingdom
| | - Mauro Pettorruso
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Massimo Di Giannantonio
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Giovanni Martinotti
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
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Balbani APS. Cough: neurophysiology, methods of research, pharmacological therapy and phonoaudiology. Int Arch Otorhinolaryngol 2015; 16:259-68. [PMID: 25991944 PMCID: PMC4435438 DOI: 10.7162/s1809-97772012000200016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2011] [Accepted: 06/25/2011] [Indexed: 12/13/2022] Open
Abstract
Introduction: The cough is the more common respiratory symptom in children and adults. Objective: To present a revision on the neurophysiology and the methods for study of the consequence of the cough, as well as the pharmacotherapy and phonoaudiology therapy of the cough, based on the works published between 2005 and 2010 and indexed in the bases Medline, Lilacs and Library Cochrane under them to keywords “cough” or “anti-cough”. Synthesis of the data: The consequence of the cough involves activation of receiving multiples becomes vacant in the aerial ways and of neural projections of the nucleus of the solitary treatment for other structures of the central nervous system. Experimental techniques allow studying the consequence of the cough to the cellular and molecular level to develop new anti-cough agents. It does not have evidences of that anti-cough exempt of medical lapsing they have superior effectiveness to the one of placebo for the relief of the cough. The phonoaudiology therapy can benefit patients with refractory chronic cough to the pharmacological treatment, over all when paradoxical movement of the vocal folds coexists. Final Comments: The boarding to multidiscipline has basic paper in the etiological diagnosis and treatment of the cough. The otolaryngologist must inform the patients on the risks of the anti-cough of free sales in order to prevent adverse poisonings and effect, especially in children.
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Chiang YC, Ye LC, Hsu KY, Liao CW, Hung TW, Lo WJ, Ho IK, Tao PL. Beneficial effects of co-treatment with dextromethorphan on prenatally methadone-exposed offspring. J Biomed Sci 2015; 22:19. [PMID: 25890152 PMCID: PMC4376496 DOI: 10.1186/s12929-015-0126-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 03/05/2015] [Indexed: 11/10/2022] Open
Abstract
Background Heroin use among young women of reproductive age has drawn much attention around the world. Although methadone is widely used in maintenance therapy for heroin/morphine addiction, the long-term effects of prenatal exposure to methadone and preventative therapy remain unclear. For revealing this question, female pregnant Sprague–Dawley rats were sub-grouped to receive (1) vehicle, (2) methadone 5 mg/kg at embryonic day 3 (E3) and then 7 mg/kg from E4 to E20, (3) dextromethorphan (DM) 3 mg/kg, and (4) methadone + DM (the rats received methadone followed by DM treatment), subcutaneously, twice a day from E3 to E20. The body weight, natural withdrawal, pain sensitivity, ED50, conditioned place preference and water maze were conducted at different postnatal stages (P1 to P79) of offspring. The quantitative real-time RT-PCR and electrophysiology were also used to measure the gene expression of opioid receptors in the spinal cord and changes of LTP/LTD in the hippocampus, separately. Results Prenatal exposure to methadone or DM did not affect survival rate, body weight, water maze and LTP or LTD of offspring. However, prenatal methadone significantly increased the withdrawal symptoms, pain sensitivity, addiction liability and decreased the mRNA expression of pain related opioid receptors. Co-administration of DM with methadone in the maternal rats effectively prevented these abnormalities of offspring induced by methadone. Conclusions Our study clearly showed that co-administration of dextromethorphan with methadone in the maternal rats prevented the adverse effects induced by prenatal methadone exposure. It implies that dextromethorphan may have a potential to be used in combination with methadone for maintenance treatment in pregnant heroin-addicted women to prevent the adverse effects induced by methadone on offspring. Electronic supplementary material The online version of this article (doi:10.1186/s12929-015-0126-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yao-Chang Chiang
- Center for Drug Abuse and Addiction, China Medical University Hospital, Taichung, Taiwan. .,Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan.
| | - Li-Ci Ye
- Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan.
| | - Kuei-Ying Hsu
- Center for Neuropsychiatric Research, National Health Research Institutes, Zhunan, Miaoli County, Taiwan.
| | - Chien-Wei Liao
- Center for Neuropsychiatric Research, National Health Research Institutes, Zhunan, Miaoli County, Taiwan.
| | - Tsai-Wei Hung
- Center for Neuropsychiatric Research, National Health Research Institutes, Zhunan, Miaoli County, Taiwan.
| | - Wan-Jou Lo
- Center for Neuropsychiatric Research, National Health Research Institutes, Zhunan, Miaoli County, Taiwan.
| | - Ing-Kang Ho
- Center for Drug Abuse and Addiction, China Medical University Hospital, Taichung, Taiwan. .,Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan.
| | - Pao-Luh Tao
- Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan. .,Center for Neuropsychiatric Research, National Health Research Institutes, Zhunan, Miaoli County, Taiwan.
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