For decades, teenagers have found it easy to get high without buying drugs illegally: Chug cough syrup or down a fistful of cold tablets, cope with the vomiting or other possible side effects, and await the hallucinations.
But in recent months, an apparent surge in abuse of dextromethorphan, or DXM, the key ingredient in some cough suppressants and cold remedies, has sparked an unprecedented response among drug manufacturers, pharmacists and awareness groups.
Last year, poison control centers took 3,271 calls related to the drug, twice the number of 2001, according to the American Association of Poison Control Centers. Cold medicine abuse was blamed for a handful of deaths in the past two years, several experts said.
While no precise statistics are available, a January report from the White House's Office of National Drug Control Policy said adolescents are "increasingly abusing" DXM, singling out Portland, Ore.; Detroit; Houston; Tampa-St. Petersburg, Fla.; and Denver as hot spots.
"It's something that's been around for a long time, but it seems to be coming back since at least 2000 among young adults," said Andrea Barthwell, the office's deputy director for demand reduction.
When the Phoenix Academy recently surveyed youths in its Austin, Texas, drug rehabilitation program, it found that half of the 40 teens had misused cold medicines, with an average starting age of 11½ years.
"We've seen kids abuse over-the-counter stuff before, but I do think there are more products out there now, and they're much more accessible," said Laurie DeLong, the center's program director.
Drug makers and sellers say they want to change that.
Since January, Walgreen Co., the nation's largest drugstore chain, has limited purchases of Coricidin HBP Cough & Cold tablets -- a DXM product known to abusers as "triple C's" -- to three packages per customer.
Ounce of prevention
Manufacturers, meanwhile, have embarked on education efforts, changed packaging to discourage shoplifting and even cut back on the ingredient in some products.
"We recognize there's a role for us to play," said Mary-Fran Faraji, spokeswoman for Schering-Plough Health Care Inc. of Kenilworth, N.J., which makes Coricidin. Schering-Plough is distributing fact sheets to pharmacists and parents who buy dextromethorphan products. The guide for parents urges them to talk to their children about drug abuse and to know their children's friends and their parents.
Wyeth Consumer Healthcare of Madison, N.J., which makes Robitussin cough syrup, recently enlarged the packaging of its newest DXM product, anti-cough gel tabs, while reducing the amount of the drug compared with the bottled version, spokesman Fran Sullivan said.
State lawmakers in New York and California want to go further, introducing legislation that would ban sales to minors of products containing DXM.
Meanwhile, pharmacies in some areas with reports of abuse are stocking Coricidin and other products containing dextromethorphan behind the counter, selling them only on request.
Dan Kennedy, manager of a Portland pharmacy, said he took action after hearing about problems with DXM in the area several months ago.
"There were some high schoolers who were abusing it," he said. "At that point, we pulled Coricidin behind the counter and posted a sign saying that it's available with a pharmacist's assistance."
But some pharmacists are uneasy about making the practice widespread; they note that more than 100 products contain the drug.
"At a practical level, it raises a difficult set of issues," said Tom Holt, executive director of the Oregon State Pharmacy Association. "Take Robitussin: It's not one product; it's a couple of dozen."
'Scary as hell'
Heavy dextromethorphan users describe the sensation as a series of "plateaus" that can range from a mildly stimulating effect to a sense of being completely disassociated from their bodies. "I thought I was a flower; I could feel myself swaying (in) the wind," one anonymous user posted in a message to a Web site after drinking an eight-ounce bottle of Robitussin.
Steve, 19, a student in Boston, said he began taking DXM at the urging of a classmate. He used it for two years -- usually Coricidin and 12-hour cough syrup, washed down with Mountain Dew soda -- before quitting.
"I can remember plenty of times I thought I would die, most often from taking too much," said Steve, who spoke on the condition that his last name be withheld. "DXM is tricky. You can take a strong dose of 500 milligrams" -- about 15 tablets or 6 ounces of cough syrup -- "and not feel anything for two hours, decide to take more and before you know it, you're someplace you've never been before, and I'll tell you what, that's scary as hell."
Some avid users, however, said media accounts usually mention that the serious danger lies with cold medicine ingredients other than dextromethorphan.
Dr. In-Hei Hahn, a medical toxicologist at St. Luke's-Roosevelt Hospital in New York, agreed that the antihistamines and other ingredients in cold and cough medicines with DXM can be lethal.
"If you take a large dose of DXM in a drug that contains Tylenol, the Tylenol can cause liver failure," she said.
But, Hahn said, that doesn't mean DXM alone is harmless: "Everything can be a poison, depending on what the dose is."
Word on Web
Several operators of Web sites devoted to the drug say they have taken steps to caution curious visitors.
One, Erowid.org, groups submissions into categories ranging from "Bad Trips" to "Mystical Experiences." The site includes a question-and-answer section describing DXM as "a unique and uniquely powerful mind-altering drug and one which I think most people would do best to avoid."
The drug "should be limited to people who are willing to use it responsibly and in an educated manner," said Michael Mason, 24, of Pittsburgh, a contributor to a site called Dextroverse.
Drug-abuse experts, however, worry that Web-browsing teenagers will ignore such advice in their quest for a new high, especially because some sites contain step-by-step recipes for extracting DXM from cold and cough medicine.
The Partnership for a Drug-Free America is using the Internet to launch a new educational effort about DXM. It has set up a site for parents at www.drugfree.org/dxm and another for teenagers at www.dxmstories.com.
The teen site includes a photo of a youth passed out on a couch after vomiting, along with a cautionary essay by a former user illustrated with a set of skulls that begins, "You gotta be sick in the head to drink cough syrup."
Partnership spokeswoman Lisa Merchant said the site has received more than 22,000 visits this year, a number she called encouraging. Merchant compared the educational push to an initiative launched several years ago to warn about "huffing" spray paint and other household products.
"The idea was to get information to parents to realize that spray paint isn't something you should just keep lying around the house," she said. "It's the same with over-the-counter drugs."