What is the treatment for dextromethorphan (DXM) withdrawal?

Treatment for Dextromethorphan (DXM) Withdrawal

Buprenorphine is the recommended first-line treatment for dextromethorphan withdrawal, administered only when the patient is in active withdrawal and following a gradual tapering schedule over 8-12 weeks.

Clinical Presentation of DXM Withdrawal

Dextromethorphan withdrawal presents with symptoms similar to opioid withdrawal, including:

• Craving
• Diaphoresis (excessive sweating)
• Nausea
• Hypertension
• Tachycardia
• Agitation
• Sleep disturbances

Assessment and Monitoring

Before initiating treatment:

• Confirm DXM dependence through history and urine toxicology
• Assess withdrawal severity using a standardized tool like the Clinical Opiate Withdrawal Scale (COWS)
• Screen for comorbid psychiatric conditions (DXM abuse is associated with psychosis)
• Evaluate for polysubstance use

Treatment Algorithm

First-Line Treatment: Buprenorphine

1. Initial Assessment:

   • Administer buprenorphine ONLY when patient is in active withdrawal
   • Use COWS score to confirm withdrawal state
   • Start with 2-4mg sublingually and observe for 1-2 hours

2. Titration:

   • Additional 2-4mg may be given if withdrawal symptoms persist
   • Total first-day dose typically 8-16mg

3. Maintenance and Tapering:

   • Convert to a stable daily dose
   • Implement gradual tapering schedule: reduce dose by 10-20% every 1-2 weeks over 8-12 weeks 1
   • Monitor weekly during first month, then every 2 weeks during subsequent months

Alternative Approaches

If buprenorphine is contraindicated or unavailable:

1. Symptomatic Management:

   • α2-adrenergic agonists (clonidine or lofexidine) for autonomic symptoms 2
   • Antiemetics for nausea/vomiting
   • Loperamide for diarrhea
   • Non-benzodiazepine sleep aids for insomnia

2. Adjunctive Medications:

   • Dextromethorphan combined with clonidine has shown efficacy in opioid withdrawal and may be particularly effective for DXM withdrawal 3
   • Avoid benzodiazepines if possible due to risk of cross-dependence

Special Considerations

Severe Cases

For patients with severe withdrawal or complications:

• Consider inpatient management
• Monitor for seizures (reported in DXM overdose cases) 4
• Assess for psychosis which may require antipsychotic medication 5

Comorbid Conditions

• For patients with comorbid psychiatric disorders, coordinate care with psychiatry
• Patients with history of DXM-induced psychosis may require continued antipsychotic treatment 5

Follow-up Care

• Regular monitoring during and after tapering
• Psychosocial support and counseling
• Screening for relapse
• Address underlying factors that led to DXM abuse

Cautions and Contraindications

• Buprenorphine should not be administered to patients currently intoxicated with DXM
• Patients with severe liver disease may require dose adjustments
• Be aware that DXM is not detected on standard urine drug screens 5

DXM withdrawal is a serious condition that can lead to significant morbidity if not properly managed. The evidence suggests that a structured approach using buprenorphine for detoxification, followed by gradual tapering, provides the best outcomes for patients with DXM dependence 2, 1, 6.