- Email: [email protected]
“Crystal Dex:” Free-Base Dextromethorphan
The Journal of Emergency Medicine, Vol. 32, No. 4, pp. 393–396, 2007 Copyright © 2007 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/07 $–see front matter
doi:10.1016/j.jemermed.2007.03.010
Selected Topics: Toxicology
“CRYSTAL DEX:” FREE-BASE DEXTROMETHORPHAN Robert G. Hendrickson,
MD,*†‡
and Robert L. Cloutier,
MD, FAAEM, FAAP*‡
*Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, †Oregon Poison Center, Portland, Oregon, and ‡Center for Policy and Research in Emergency Medicine (CPR-EM), Portland, Oregon Reprint Address: Robert G. Hendrickson, Department of Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., MCCB550, Portland, OR 97201-3098
e Abstract—Dextromethorphan (DXM) is a common component of combination cold medications that has become a popular drug of abuse for young adults. Abusers of DXM have developed a simple acid-base extraction technique to “free-base,” or extract, the DXM from the unwanted guaifenesin, coloring agents, sweeteners, and alcohol that are typically included in combination cold preparations. We report a case of DXM overdose after ingestion of this purified “Crystal Dex” and discuss the “Agent Lemon” and single-phase extraction techniques that are used to freebase the dextromethorphan. © 2007 Elsevier Inc.
CASE REPORT A 20-year-old man with no past medical history was brought to the Emergency Department (ED) in the care of several friends. His friends reported that he had orally ingested approximately 1 gram of liquid “Crystal Dex.” Shortly after his ingestion he became unresponsive, at which time one of the friends manually induced vomiting. Approximately 2 h after the ingestion, he was brought to the ED, where he was obtunded on arrival and had a pulse of 99 beats/min, hypotension (70/30 mm Hg), and shallow respirations. Pupillary size was not noted on his initial examination. On arrival, 2 mg of naloxone and 1 mg of flumazenil were given intravenously, with no effect on respirations or arousal. The patient was endotracheally intubated and 50 grams of activated charcoal was instilled via nasogastric tube. Radiography of the chest revealed no infiltrates, and serum acetaminophen and salicylate concentrations were undetectable. Following 1 L of crystalloid, the blood pressure increased to 92/50 mm Hg. The pupils were “large” with sluggish response to light. The skin was dry, cool, and flushed. Axillary sweat was present, bowel sounds were hypoactive, and mucous membranes were moist. The patient remained obtunded after intubation. Approximately 5 h after admission, the patient became agitated, had increased psychomotor activity (tremors and myoclonic jerks), and became hyperten-
e Keywords— dextromethorphan; toxicity; overdose; freebase; crystal; emergency medicine
INTRODUCTION Dextromethorphan (DXM) is an anti-tussive agent that is a common component of combination cold preparations, including Coricidin® and Robitussin® products. In recent years, DXM has become popular as a recreational drug, particularly in young adults. Previously reported cases of severe DXM toxicity during abuse have involved ingestions of over-the-counter (OTC) cold preparations. We report a case of severe dextromethorphan toxicity after the use of a simple home acid-base extraction technique (known as “Agent Lemon”) to produce purified free-base dextromethorphan from an OTC cold medication.
Selected Topics: Toxicology is coordinated by Kenneth Kulig,
RECEIVED: 6 February 2005; FINAL ACCEPTED: 8 August 2006
SUBMISSION RECEIVED:
MD,
of Denver, Colorado
1 December 2005; 393
394
R. G. Hendrickson and R. L. Cloutier
Table 1. “Agent Lemon” Two-phase Acid Base Extraction* Mix equal amounts of ammonia and cold medication Add ⬃100 mL naphtha (e.g., cigarette lighter fluid) Vigorously shake Discard hydrophilic (“watery”) layer Add ⬃250 mL of water, vigorously shake, and allow to separate Discard hydrophilic (“watery”) layer Use lemon juice or make a citric acid solution (add 45 mL of commercially available citric acid solution to 250 mL of water) Add 250 mL of lemon juice or citric acid solution to the hydrophobic (“oily”) solution, shake vigorously for 5 min, then allow to separate Discard the hydrophobic (“oily”) layer Heat the hydrophilic (“watery”) layer on a stove to evaporate/ boil off any remaining naphtha * Adapted from (11).
sive (blood pressure 202/88 mm Hg) and was treated with midazolam and metoprolol. He continued to have tremor, tachycardia (120 beats/min) and agitation, which were treated with intravenous midazolam at 3 mg/h. Thirteen hours after arrival, the patient’s agitation and tachycardia resolved and he was extubated. Upon extubation, the patient confirmed his ingestion of liquid “Crystal Dex,” which he had purified from a cold preparation containing guaifenesin and dextromethorphan using the “Agent Lemon” technique. He specifically denied using a combination cold preparation that contained anticholinergic agents, decongestants, aspirin, or acetaminophen. DISCUSSION The patient described in this report developed symptoms that are consistent with previous reports of dextromethorphan toxicity (1– 4). However, we did consider that the patient might have ingested other substances or medications that would explain some of his symptoms. The patient developed some signs of anti-cholinergic toxicity, including flushing, tachycardia, mydriasis, agitation, and hypoactive bowel sounds. However, he also had axillary sweat, moist mucous membranes, and hypotension, which may not be consistent with a pure anti-cholinergic toxidrome. The patient developed signs that could also be attributed to a sympathomimetic decongestant, including tachycardia, hypertension, mydriasis, and agitation. However, all of these symptoms have been reported after dextromethorphan overdoses. It is certainly possible that the patient ingested an anti-cholinergic antihistamine (e.g., doxylamine, chlorpheniramine, diphenhydramine, etc.) or sympathomimetic decongestant (e.g., pseudoephedrine, phenylephrine) in combination with, or instead of, dextromethorphan, as many combination cold prepara-
tions contain these products. Unfortunately, serum or urine testing to exclude this possibility was not performed. The patient was questioned after his recovery and clearly described the procedure of extraction from a dextromethorphan and guaifenesin-containing product. He stated that he was careful to avoid using a product that contained any other co-ingestants. It is unclear if significant amounts of an anti-histamine or decongestant would remain after this extraction process, so it is likely prudent to consider co-ingestant toxicity, including anticholinergic antihistamine, decongestants, ethanol, salicylates, and acetaminophen in these patients. Dextromethorphan (d-3-methoxy-N-methylmorphinan, DXM) is the d-isomer of levorphanol and an analogue of codeine with minimal analgesic effects and mild antitussive effects. It is found as the hydrobromide salt (DXM hydrobromide) in many OTC combination cold preparations in doses between 2 mg and 60 mg per 20-mL dose. DXM antagonizes the phencyclidine site of the NMDA receptor and inhibits the reuptake of serotonin. DXM is metabolized by CYP 2D6 to dextrorphan and to 3-methoxymorphinan and 3-hydroxymorphinan (2,3). Dextrorphan is pharmacologically active and interacts with the sigma receptor. In overdose, DXM may lead to agitation, somnolence, ataxia, tremors, hyperreflexia, nystagmus, and hypertension (4). Pupillary effects are variable, and miosis, mydriasis, and mid-position pupils have been reported (4). Occasional cases have reported responsiveness to naloxone with increases in mental status and respiratory drive (5,6). There is no evidence that flumazenil is effective in DXM toxicity. Current knowledge of DXM’s mechanism of action suggest that its use is inappropriate. DXM does not bind to the benzodiazepine site on the GABA receptor and, in fact, DXM may lead to seizures, making flumazenil use contraindicated. Abuse of dextromethorphan has become increasingly popular in the last several years, particularly in young adults (7–10). This popularity is partially due to its availability as an over-the-counter medication. According to data from the Toxic Exposure Surveillance System (TESS), cases of intentional ingestion of cold preparations increased 58% between 1998 and 2003 (9,10). Cases involving children between the ages of 6 and 19 years increased 37% in the same time period (9,10). Abusers of DXM, particularly experienced users, may increase their doses over time in an effort to attain increased euphoria, hallucinations, and dissociation. However, this requires users to ingest ever-increasing quantities of associated guaifenesin, saccharin, propylene glycol, and alcohol included in the cold preparations they abuse to reach their target dextromethorphan dose. Ingesting larger doses of guaifenesin, ethanol, and sweeteners may lead to gastrointestinal irritation, nausea,
Crystal Dex
395
Table 2. Single-Phase Acid-Base Extraction* Make a sodium hydroxide solution by adding 15 mL of powder sodium hydroxide (e.g., lye) to 250 mL of distilled water (note: this mixture may generate heat and this should be performed in heat-resistant cookware) Add 15 mL of the sodium hydroxide solution to your cold medication in a large bottle. The sodium hydroxide will form a white precipitate that will then dissolve with swirling Continue to add sodium hydroxide solution in 15 mL aliquots until precipitate no longer dissolves Add 120 mL (⬃4 ounces) of naphtha (e.g., cigarette lighter fluid) to the solution, shake vigorously, then allow to separate Discard the hydrophilic (“watery”) layer Drain the hydrophobic (“oily”) layer into a baking dish Wear an OSHA-certified solvent mask and place the baking dish into a pan of water on a hot plate and begin heating the solution (note: this step should be performed outside with good air circulation). Run a hair dryer over the solution to increase evaporation. Continue this step until the solvent is entirely evaporated Scrape the powder dextromethorphan from the bottom of the dish * Adapted from (11).
and vomiting. Similarly, ethanol is problematic as a co-ingestant, as it reportedly adds to the dysphoria commonly experienced with dextromethorphan in higher doses (11). The extraction technique described here has recently become popular for purifying the DXM and allowing abusers to avoid co-ingestant toxicity (11). Previous reports of dextromethorphan toxicity have been the result of ingestion of combination cold preparations (1,2,12). This case illustrates dextromethorphan toxicity after the patient purified dextromethorphan from a guaifenesin- and dextromethorphan-containing cold preparation.
The technique used by this patient was the “Agent Lemon” technique (Table 1), however, the name “Crystal Dex” is derived from a single-phase extraction that yields a crystalline product (Table 2) (11). The “Agent Lemon” technique has become more popular because it yields a more palatable liquid product, it avoids the use of lye, and it eliminates the hazards of heating flammable solvents in enclosed spaces. The “Agent Lemon” technique is a simple two-phase acid-base extraction and is described in Table 1 and in Figure 1. Briefly, the cold preparation (that includes dextromethorphan) is mixed with ammonia, which raises
Figure 1. The “Agent Lemon” two-phase acid-base extraction of a guaifenesin and dextromethorphan-containing cold medication yielding dextromethorphan hydrocitrate.
396
R. G. Hendrickson and R. L. Cloutier
the pH and converts the polar (water soluble) dextromethorphan hydrobromide to the non-polar (non-water soluble) dextromethorphan free-base. Lighter fluid (e.g., naphtha) is added as a non-polar solvent, dissolving the dextromethorphan free-base. The water portion (which includes water, coloring, alcohol, etc.) is then discarded. Citric acid (e.g., lemon juice) is added to the naphtha, theoretically converting the dextromethorphan free-base to dextromethorphan hydrocitrate, a polar compound that is dissolved in the citric acid. Finally, the naphtha layer is discarded, leaving “DXemon Juice” or “Agent Lemon” (dextromethorphan hydrocitrate dissolved in citric acid). The “Agent Lemon” technique is so named due to the lemon-like taste of the final product. Sugar is typically added to the final product to make a product similar to lemonade.
CONCLUSION A simple extraction technique using common household products is available, and becoming increasingly popular, for free-basing dextromethorphan. Several questions remain concerning this extraction, including how commonly the extraction is used, the knowledge of young adults concerning these techniques, and whether other medications remain in the extracted product.
REFERENCES 1. Pender E.S, Parks B.R. Toxicity with dextromethorphan-containing preparations: a literature review and report of two additional cases. Pediatr Emerg Care 1991;7:163–5 2. Roberge RJ, Hirani KH, Rowland PL, Berkeley R, Krenzelok EP. Dextromethorphan- and pseudoephedrine-induced agitated psychosis and ataxia: case report. J Emerg Med 1999;17:285– 8. 3. East T, Dye D. Determination of dextromethorphan and metabolites in human plasma and urine by high-performance liquid chromatography with fluorescence detection. J Chromatogr 1985;338: 97–112. 4. Wolfe TR, Caravati EM. Massive dextromethorphan ingestion and abuse. Am J Emerg Med 1995;13:174 – 6. 5. Schneider SM, Michelson EA, Boucek CD, Ilkhanipour K. Dextromethorphan poisoning reversed by naloxone. Am J Emerg Med 1991;9:237– 8. 6. Shaul WL, Wandell M, Robertson WO. Dextromethorphan toxicity: reversal by naloxone. Pediatrics 1977;59:117–9. 7. Baker SD, Borys DJ. A possible trend suggesting increased abuse from Coricidin exposures reported to the Texas Poison Network: comparing 1998 to 1999. Vet Human Toxicol 2002;44:169 –71. 8. Burda A, Razo M, Wahl M. Rising abuse of Coricidin over a three-year period. J Toxicol Clin Toxicol 2004;42:757. 9. Watson WA, Litovitz TL, Klein-Schwartz W, et al. 2003 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2004;22: 335– 404. 10. Litovitz TL, Klein-Schwartz W, Caravati EM, Youniss J, Crouch B, Lee S. 1998 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1999;17:435– 87. 11. www.erowid.org/chemicals/fxm/faq/dxm_chemistry.shtml. The vaults of Erowid: DXM FAQ: DXM Chemistry and Extraction. Accessed April 11, 2007. 12. Kirages TJ, Sule HP, Mycyk MB. Severe manifestations of Coricidin intoxication. Am J Emerg Med 2003;21:473–5.
doi:10.1016/j.jemermed.2007.03.010
Selected Topics: Toxicology
“CRYSTAL DEX:” FREE-BASE DEXTROMETHORPHAN Robert G. Hendrickson,
MD,*†‡
and Robert L. Cloutier,
MD, FAAEM, FAAP*‡
*Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, †Oregon Poison Center, Portland, Oregon, and ‡Center for Policy and Research in Emergency Medicine (CPR-EM), Portland, Oregon Reprint Address: Robert G. Hendrickson, Department of Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., MCCB550, Portland, OR 97201-3098
e Abstract—Dextromethorphan (DXM) is a common component of combination cold medications that has become a popular drug of abuse for young adults. Abusers of DXM have developed a simple acid-base extraction technique to “free-base,” or extract, the DXM from the unwanted guaifenesin, coloring agents, sweeteners, and alcohol that are typically included in combination cold preparations. We report a case of DXM overdose after ingestion of this purified “Crystal Dex” and discuss the “Agent Lemon” and single-phase extraction techniques that are used to freebase the dextromethorphan. © 2007 Elsevier Inc.
CASE REPORT A 20-year-old man with no past medical history was brought to the Emergency Department (ED) in the care of several friends. His friends reported that he had orally ingested approximately 1 gram of liquid “Crystal Dex.” Shortly after his ingestion he became unresponsive, at which time one of the friends manually induced vomiting. Approximately 2 h after the ingestion, he was brought to the ED, where he was obtunded on arrival and had a pulse of 99 beats/min, hypotension (70/30 mm Hg), and shallow respirations. Pupillary size was not noted on his initial examination. On arrival, 2 mg of naloxone and 1 mg of flumazenil were given intravenously, with no effect on respirations or arousal. The patient was endotracheally intubated and 50 grams of activated charcoal was instilled via nasogastric tube. Radiography of the chest revealed no infiltrates, and serum acetaminophen and salicylate concentrations were undetectable. Following 1 L of crystalloid, the blood pressure increased to 92/50 mm Hg. The pupils were “large” with sluggish response to light. The skin was dry, cool, and flushed. Axillary sweat was present, bowel sounds were hypoactive, and mucous membranes were moist. The patient remained obtunded after intubation. Approximately 5 h after admission, the patient became agitated, had increased psychomotor activity (tremors and myoclonic jerks), and became hyperten-
e Keywords— dextromethorphan; toxicity; overdose; freebase; crystal; emergency medicine
INTRODUCTION Dextromethorphan (DXM) is an anti-tussive agent that is a common component of combination cold preparations, including Coricidin® and Robitussin® products. In recent years, DXM has become popular as a recreational drug, particularly in young adults. Previously reported cases of severe DXM toxicity during abuse have involved ingestions of over-the-counter (OTC) cold preparations. We report a case of severe dextromethorphan toxicity after the use of a simple home acid-base extraction technique (known as “Agent Lemon”) to produce purified free-base dextromethorphan from an OTC cold medication.
Selected Topics: Toxicology is coordinated by Kenneth Kulig,
RECEIVED: 6 February 2005; FINAL ACCEPTED: 8 August 2006
SUBMISSION RECEIVED:
MD,
of Denver, Colorado
1 December 2005; 393
394
R. G. Hendrickson and R. L. Cloutier
Table 1. “Agent Lemon” Two-phase Acid Base Extraction* Mix equal amounts of ammonia and cold medication Add ⬃100 mL naphtha (e.g., cigarette lighter fluid) Vigorously shake Discard hydrophilic (“watery”) layer Add ⬃250 mL of water, vigorously shake, and allow to separate Discard hydrophilic (“watery”) layer Use lemon juice or make a citric acid solution (add 45 mL of commercially available citric acid solution to 250 mL of water) Add 250 mL of lemon juice or citric acid solution to the hydrophobic (“oily”) solution, shake vigorously for 5 min, then allow to separate Discard the hydrophobic (“oily”) layer Heat the hydrophilic (“watery”) layer on a stove to evaporate/ boil off any remaining naphtha * Adapted from (11).
sive (blood pressure 202/88 mm Hg) and was treated with midazolam and metoprolol. He continued to have tremor, tachycardia (120 beats/min) and agitation, which were treated with intravenous midazolam at 3 mg/h. Thirteen hours after arrival, the patient’s agitation and tachycardia resolved and he was extubated. Upon extubation, the patient confirmed his ingestion of liquid “Crystal Dex,” which he had purified from a cold preparation containing guaifenesin and dextromethorphan using the “Agent Lemon” technique. He specifically denied using a combination cold preparation that contained anticholinergic agents, decongestants, aspirin, or acetaminophen. DISCUSSION The patient described in this report developed symptoms that are consistent with previous reports of dextromethorphan toxicity (1– 4). However, we did consider that the patient might have ingested other substances or medications that would explain some of his symptoms. The patient developed some signs of anti-cholinergic toxicity, including flushing, tachycardia, mydriasis, agitation, and hypoactive bowel sounds. However, he also had axillary sweat, moist mucous membranes, and hypotension, which may not be consistent with a pure anti-cholinergic toxidrome. The patient developed signs that could also be attributed to a sympathomimetic decongestant, including tachycardia, hypertension, mydriasis, and agitation. However, all of these symptoms have been reported after dextromethorphan overdoses. It is certainly possible that the patient ingested an anti-cholinergic antihistamine (e.g., doxylamine, chlorpheniramine, diphenhydramine, etc.) or sympathomimetic decongestant (e.g., pseudoephedrine, phenylephrine) in combination with, or instead of, dextromethorphan, as many combination cold prepara-
tions contain these products. Unfortunately, serum or urine testing to exclude this possibility was not performed. The patient was questioned after his recovery and clearly described the procedure of extraction from a dextromethorphan and guaifenesin-containing product. He stated that he was careful to avoid using a product that contained any other co-ingestants. It is unclear if significant amounts of an anti-histamine or decongestant would remain after this extraction process, so it is likely prudent to consider co-ingestant toxicity, including anticholinergic antihistamine, decongestants, ethanol, salicylates, and acetaminophen in these patients. Dextromethorphan (d-3-methoxy-N-methylmorphinan, DXM) is the d-isomer of levorphanol and an analogue of codeine with minimal analgesic effects and mild antitussive effects. It is found as the hydrobromide salt (DXM hydrobromide) in many OTC combination cold preparations in doses between 2 mg and 60 mg per 20-mL dose. DXM antagonizes the phencyclidine site of the NMDA receptor and inhibits the reuptake of serotonin. DXM is metabolized by CYP 2D6 to dextrorphan and to 3-methoxymorphinan and 3-hydroxymorphinan (2,3). Dextrorphan is pharmacologically active and interacts with the sigma receptor. In overdose, DXM may lead to agitation, somnolence, ataxia, tremors, hyperreflexia, nystagmus, and hypertension (4). Pupillary effects are variable, and miosis, mydriasis, and mid-position pupils have been reported (4). Occasional cases have reported responsiveness to naloxone with increases in mental status and respiratory drive (5,6). There is no evidence that flumazenil is effective in DXM toxicity. Current knowledge of DXM’s mechanism of action suggest that its use is inappropriate. DXM does not bind to the benzodiazepine site on the GABA receptor and, in fact, DXM may lead to seizures, making flumazenil use contraindicated. Abuse of dextromethorphan has become increasingly popular in the last several years, particularly in young adults (7–10). This popularity is partially due to its availability as an over-the-counter medication. According to data from the Toxic Exposure Surveillance System (TESS), cases of intentional ingestion of cold preparations increased 58% between 1998 and 2003 (9,10). Cases involving children between the ages of 6 and 19 years increased 37% in the same time period (9,10). Abusers of DXM, particularly experienced users, may increase their doses over time in an effort to attain increased euphoria, hallucinations, and dissociation. However, this requires users to ingest ever-increasing quantities of associated guaifenesin, saccharin, propylene glycol, and alcohol included in the cold preparations they abuse to reach their target dextromethorphan dose. Ingesting larger doses of guaifenesin, ethanol, and sweeteners may lead to gastrointestinal irritation, nausea,
Crystal Dex
395
Table 2. Single-Phase Acid-Base Extraction* Make a sodium hydroxide solution by adding 15 mL of powder sodium hydroxide (e.g., lye) to 250 mL of distilled water (note: this mixture may generate heat and this should be performed in heat-resistant cookware) Add 15 mL of the sodium hydroxide solution to your cold medication in a large bottle. The sodium hydroxide will form a white precipitate that will then dissolve with swirling Continue to add sodium hydroxide solution in 15 mL aliquots until precipitate no longer dissolves Add 120 mL (⬃4 ounces) of naphtha (e.g., cigarette lighter fluid) to the solution, shake vigorously, then allow to separate Discard the hydrophilic (“watery”) layer Drain the hydrophobic (“oily”) layer into a baking dish Wear an OSHA-certified solvent mask and place the baking dish into a pan of water on a hot plate and begin heating the solution (note: this step should be performed outside with good air circulation). Run a hair dryer over the solution to increase evaporation. Continue this step until the solvent is entirely evaporated Scrape the powder dextromethorphan from the bottom of the dish * Adapted from (11).
and vomiting. Similarly, ethanol is problematic as a co-ingestant, as it reportedly adds to the dysphoria commonly experienced with dextromethorphan in higher doses (11). The extraction technique described here has recently become popular for purifying the DXM and allowing abusers to avoid co-ingestant toxicity (11). Previous reports of dextromethorphan toxicity have been the result of ingestion of combination cold preparations (1,2,12). This case illustrates dextromethorphan toxicity after the patient purified dextromethorphan from a guaifenesin- and dextromethorphan-containing cold preparation.
The technique used by this patient was the “Agent Lemon” technique (Table 1), however, the name “Crystal Dex” is derived from a single-phase extraction that yields a crystalline product (Table 2) (11). The “Agent Lemon” technique has become more popular because it yields a more palatable liquid product, it avoids the use of lye, and it eliminates the hazards of heating flammable solvents in enclosed spaces. The “Agent Lemon” technique is a simple two-phase acid-base extraction and is described in Table 1 and in Figure 1. Briefly, the cold preparation (that includes dextromethorphan) is mixed with ammonia, which raises
Figure 1. The “Agent Lemon” two-phase acid-base extraction of a guaifenesin and dextromethorphan-containing cold medication yielding dextromethorphan hydrocitrate.
396
R. G. Hendrickson and R. L. Cloutier
the pH and converts the polar (water soluble) dextromethorphan hydrobromide to the non-polar (non-water soluble) dextromethorphan free-base. Lighter fluid (e.g., naphtha) is added as a non-polar solvent, dissolving the dextromethorphan free-base. The water portion (which includes water, coloring, alcohol, etc.) is then discarded. Citric acid (e.g., lemon juice) is added to the naphtha, theoretically converting the dextromethorphan free-base to dextromethorphan hydrocitrate, a polar compound that is dissolved in the citric acid. Finally, the naphtha layer is discarded, leaving “DXemon Juice” or “Agent Lemon” (dextromethorphan hydrocitrate dissolved in citric acid). The “Agent Lemon” technique is so named due to the lemon-like taste of the final product. Sugar is typically added to the final product to make a product similar to lemonade.
CONCLUSION A simple extraction technique using common household products is available, and becoming increasingly popular, for free-basing dextromethorphan. Several questions remain concerning this extraction, including how commonly the extraction is used, the knowledge of young adults concerning these techniques, and whether other medications remain in the extracted product.
REFERENCES 1. Pender E.S, Parks B.R. Toxicity with dextromethorphan-containing preparations: a literature review and report of two additional cases. Pediatr Emerg Care 1991;7:163–5 2. Roberge RJ, Hirani KH, Rowland PL, Berkeley R, Krenzelok EP. Dextromethorphan- and pseudoephedrine-induced agitated psychosis and ataxia: case report. J Emerg Med 1999;17:285– 8. 3. East T, Dye D. Determination of dextromethorphan and metabolites in human plasma and urine by high-performance liquid chromatography with fluorescence detection. J Chromatogr 1985;338: 97–112. 4. Wolfe TR, Caravati EM. Massive dextromethorphan ingestion and abuse. Am J Emerg Med 1995;13:174 – 6. 5. Schneider SM, Michelson EA, Boucek CD, Ilkhanipour K. Dextromethorphan poisoning reversed by naloxone. Am J Emerg Med 1991;9:237– 8. 6. Shaul WL, Wandell M, Robertson WO. Dextromethorphan toxicity: reversal by naloxone. Pediatrics 1977;59:117–9. 7. Baker SD, Borys DJ. A possible trend suggesting increased abuse from Coricidin exposures reported to the Texas Poison Network: comparing 1998 to 1999. Vet Human Toxicol 2002;44:169 –71. 8. Burda A, Razo M, Wahl M. Rising abuse of Coricidin over a three-year period. J Toxicol Clin Toxicol 2004;42:757. 9. Watson WA, Litovitz TL, Klein-Schwartz W, et al. 2003 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2004;22: 335– 404. 10. Litovitz TL, Klein-Schwartz W, Caravati EM, Youniss J, Crouch B, Lee S. 1998 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1999;17:435– 87. 11. www.erowid.org/chemicals/fxm/faq/dxm_chemistry.shtml. The vaults of Erowid: DXM FAQ: DXM Chemistry and Extraction. Accessed April 11, 2007. 12. Kirages TJ, Sule HP, Mycyk MB. Severe manifestations of Coricidin intoxication. Am J Emerg Med 2003;21:473–5.