August 27, 2009
ROYAL PAINS MEDICAL BLOG
By Dr. Irving Danesh

Hi, this is Doctor Irv and I hope you have had a happy and healthy week.

In this week's episode of Royal Pains ("Wonderland"), Hank discovers the cause of Zoey's bizarre hallucinations. Zoey has a condition called Alice in Wonderland Syndrome (AIWS) caused by overdosing on cough medicine.

Alice in Wonderland Syndrome affects the patient's perception of her environment. Patients with this syndrome "see" objects bigger than reality (macropsia) or smaller than reality (micropsia). The problem is not with her eyes, but her brain's interpretation of the data coming from the eyes. AIWS is associated with migraine headaches, brain tumors and use of mind-altering drugs. AIWS is also known as Todd's Syndrome.

In this episode, the drug that causes Zoey's problem is dextromethorphan. It is a common ingredient in over the counter cough medicine that is typically abused by adolescents because of its easy availability and legality. In a 2006 study, about 3 million people in the 12 to 25 year age group reported the use of OTC cough and cold medications to get high.

Dextromethorphan is known on the street as DXM, Tripe C, Skittles, Robo and Poor Man's PCP. In addition to Dextromethorphan being a dangerous overdose, it is often combined with other medications in cold preparations such as acetaminophen (Tylenol), antihistamines and decongestants. All can be dangerous in overdose scenarios.

The normal dose of dextromethorphan is 15-30 mg per dose. It is usually taken three or four times a day and its effects last about six hours. Taken properly, problems rarely occur. Many sites on the Internet discuss dosing to attain its euphoric and hallucinatory effects. Dextromethorphan can also be bought legally over the Internet in a powdered form. Since the FDA doesn't regulate these powders, it is hard to estimate the amount of drug being abused.

Dextromethorphan, in addition to AIWS, causes difficulty in muscle coordination (ataxia), lethargy, high blood pressure, and involuntary eye movements called ataxia. Patients who abuse the drug achieve "plateaus". These plateaus are dose dependent and define certain behavioral effects.

The first plateau is reached in the 100-200 mg range and is described as mild stimulation. The second plateau is in the 200-400 mg range and gives the patient euphoria and hallucinations. The third plateau is in the 300-600 mg stage and gives the patient AIWS and ataxia. The fourth plateau is in the 500-1500 mg range and causes a dissociative sedation. Dissociative sedation by definition means that the patient is in a trance-like state with a loss of sensation. The patient is able to breathe on his own and is stable from a cardiovascular prospective.

Finally, as with all drugs with an abuse potential, combining dextromethorphan with alcohol or other drugs of abuse can increase the potential for greater harm.

I would like to take this opportunity to thank everyone who has read this blog over the weeks. It has been fun and educational for me as a first time blogger. I hope it has answered some of the medical questions in the show. I wish everyone a happy and healthy Fall, Winter and Spring.

Till next summer...

Dr. Irv