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Career Choices: Directorship/leadership
Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.
In this Career Choices, Cornel Stanciu, MD, talked with Thomas Penders, MS, MD. For most of his career, Dr. Penders has practiced in directorship roles. He currently serves as the leader of an addiction consultation service at the Walter B. Jones Center in Greenville, North Carolina, as well as working at the state level with federally qualified health centers to develop collaborative care models.
Dr. Stanciu: What led you to decide to pursue a director role?
Dr. Penders: Early in my career, I was offered opportunities to provide leadership for an organization in its efforts to assure quality and availability of appropriate medical and psychiatric care.
Dr. Stanciu: How has the director role evolved over the years?
Dr. Penders: Thirty years ago, when I got started, hospital administrations depended heavily on medical directors to provide advice on new service initiates. Medical directors were frequently provided with support by health care organizations when recommendations were made based on patient and community need as perceived by medical staff providers. There has been a dramatic shift in the relationship and role of medical directorship, particularly over the past decade. Budgetary constraints have influenced planning and operational decisions to the extent that these decisions are much more likely to be made based on financial analyses rather than on clinical needs identified by physicians. As a result, medical directors are encouraged to be mindful of the effect of their suggestions on the bottom line of the organization. This has resulted in a very significant shift away from programs that are needed but not funded, and toward programs that are revenue-positive or at least neutral.
Medical directors who do not conform in this way are unlikely to be part of the administration for very long in the present environment.
Continue to: What training qualifications are required or desirable to assume a medical leadership role (post residency fellowship, MBA, etc.)?
Dr. Stanciu: What training qualifications are required or desirable to assume a medical leadership role (post-residency fellowship, MBA, etc.)?
Dr. Penders: In addition to a foundation in evidence-based practices and knowledge of regulatory requirements, general leadership skills are probably the most important qualities for medical leadership. Hospitals are complex organizations with confusing reporting relationships. Negotiation skills and communication skills are critical to success. Because most modern health care organizations are well staffed with administrative personnel trained in business and finance, I would not suggest that an MBA is necessary or even important to a medical director’s success. Having said that, there are an increasing number of physicians assuming the role of chief executive officer in complex health care systems. In this case, MBA training will likely be advantageous.
I would suggest that the focus of training that occurs in MPH programs would provide more relevant tools for those in positions of medical leadership. Skills such as biostatistics and epidemiology provide those in such positions with the perspective required to understand the effectiveness of health care systems, and to relate to changes that might be beneficial to the populations they serve. A firm foundation in information systems and data analysis is becoming increasingly important as the payment system moves toward one that is value-based. Increasingly, health care systems decisions will be guided by the analysis of aggregated information gathered from electronic medical records.
Dr. Stanciu: What personal qualities makes a psychiatric physician well-suited for the role of a medical director?
Dr. Penders: Medical directors will confront a variety of difficult situations with colleagues, administrative staff, patients, and family members. A calm demeanor with an ability to reflect rather than react is important. As I previously mentioned, an ability to communicate, including strength as a listener, is another personality trait valued in this position.
Continue to: What are some of the challenges you face on a daily basis?
Dr. Stanciu: What are some of the challenges you face on a daily basis?
Dr. Penders: There are challenges in multiple areas. First and foremost, medical leadership is responsible for maintaining and improving the quality of patient care and experience. One can expect frequent conflicts to arise when providers vary from established standards or disagree with established policies.
Additionally, there appears to be an increasing lack of a distinct line between administrative and patient care decisions. It is often a challenge to manage the conflicting incentives involved when cost containment and quality care are seen to diverge.
Dr. Stanciu: What are the metrics that measure success by a medical administrator?
Dr. Penders: Some would say that the financial status of the organization is an important metric. Measures such as length of stay, patient satisfaction, and numbers of clinically relevant adverse events are how the success of medical leadership is assessed.
I would argue that patient outcomes as measured by standard clinical tools are the true measure of the success of the efforts of medical providers led by a medical director. Increasingly, measures of population health will likely be used to measure the overall success of health care organizations.
Continue to: How do you keep up-to-date on the latest rules and regulations to ensure facility compliance?
Dr. Stanciu: How do you keep up-to-date on the latest rules and regulations to ensure facility compliance?
Dr. Penders: Medical directors attend many professional meetings, both within their organizations and outside, which assures that information is provided on regulatory initiatives from government bodies and organizations such as the Joint Commission.
Hospital risk managers and attorneys also play a part in keeping everyone honest when it comes to changes in laws governing our work.
Dr. Stanciu: How is it working in a supervisory capacity with other physicians and the growing number of mid-level providers and their expanding scope of practice?
Dr. Penders: There is a variety of opinions today about the relationship between physicians and mid-level providers. Fairly recently, nurse practitioners and physician assistants were known as “extenders.” We don’t hear that term as much anymore, as these providers are becoming increasingly independent in their practice roles.
The supervisory challenge varies with each situation. Most hospital organizations have medical staff rules and regulations that define the relationships within hospitals. Efforts in outpatient care are often less well defined, and supervisory relationships can be tailored to the specific effort involved.
Continue to: Is there a stipend or additional compensation for administrative duties?
Dr. Stanciu: Is there a stipend or additional compensation for administrative duties?
Dr. Penders: Always. There is considerable time and effort needed on a flexibly “as needed” basis that serves as a justification for administrative compensation.
Dr. Stanciu: Any major differences when working in an independent facility vs a large corporation?
Dr. Penders: As health care organizations become larger and more complex, the role of medical directorships in the larger systems are generally defined by policies that can be restrictive. Small organizations may have less formal rules and allow some flexibility for the role of medical leadership in general.
Dr. Stanciu: What preparation do you suggest for trainees and early career psychiatrists who are contemplating such a role?
Dr. Penders: Become involved in quality and organizational initiatives whenever they are available. Generally, organizations will invite and value the input trainees can provide to these efforts. Functioning as a chief resident is real-world experience that can be invaluable.
Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.
In this Career Choices, Cornel Stanciu, MD, talked with Thomas Penders, MS, MD. For most of his career, Dr. Penders has practiced in directorship roles. He currently serves as the leader of an addiction consultation service at the Walter B. Jones Center in Greenville, North Carolina, as well as working at the state level with federally qualified health centers to develop collaborative care models.
Dr. Stanciu: What led you to decide to pursue a director role?
Dr. Penders: Early in my career, I was offered opportunities to provide leadership for an organization in its efforts to assure quality and availability of appropriate medical and psychiatric care.
Dr. Stanciu: How has the director role evolved over the years?
Dr. Penders: Thirty years ago, when I got started, hospital administrations depended heavily on medical directors to provide advice on new service initiates. Medical directors were frequently provided with support by health care organizations when recommendations were made based on patient and community need as perceived by medical staff providers. There has been a dramatic shift in the relationship and role of medical directorship, particularly over the past decade. Budgetary constraints have influenced planning and operational decisions to the extent that these decisions are much more likely to be made based on financial analyses rather than on clinical needs identified by physicians. As a result, medical directors are encouraged to be mindful of the effect of their suggestions on the bottom line of the organization. This has resulted in a very significant shift away from programs that are needed but not funded, and toward programs that are revenue-positive or at least neutral.
Medical directors who do not conform in this way are unlikely to be part of the administration for very long in the present environment.
Continue to: What training qualifications are required or desirable to assume a medical leadership role (post residency fellowship, MBA, etc.)?
Dr. Stanciu: What training qualifications are required or desirable to assume a medical leadership role (post-residency fellowship, MBA, etc.)?
Dr. Penders: In addition to a foundation in evidence-based practices and knowledge of regulatory requirements, general leadership skills are probably the most important qualities for medical leadership. Hospitals are complex organizations with confusing reporting relationships. Negotiation skills and communication skills are critical to success. Because most modern health care organizations are well staffed with administrative personnel trained in business and finance, I would not suggest that an MBA is necessary or even important to a medical director’s success. Having said that, there are an increasing number of physicians assuming the role of chief executive officer in complex health care systems. In this case, MBA training will likely be advantageous.
I would suggest that the focus of training that occurs in MPH programs would provide more relevant tools for those in positions of medical leadership. Skills such as biostatistics and epidemiology provide those in such positions with the perspective required to understand the effectiveness of health care systems, and to relate to changes that might be beneficial to the populations they serve. A firm foundation in information systems and data analysis is becoming increasingly important as the payment system moves toward one that is value-based. Increasingly, health care systems decisions will be guided by the analysis of aggregated information gathered from electronic medical records.
Dr. Stanciu: What personal qualities makes a psychiatric physician well-suited for the role of a medical director?
Dr. Penders: Medical directors will confront a variety of difficult situations with colleagues, administrative staff, patients, and family members. A calm demeanor with an ability to reflect rather than react is important. As I previously mentioned, an ability to communicate, including strength as a listener, is another personality trait valued in this position.
Continue to: What are some of the challenges you face on a daily basis?
Dr. Stanciu: What are some of the challenges you face on a daily basis?
Dr. Penders: There are challenges in multiple areas. First and foremost, medical leadership is responsible for maintaining and improving the quality of patient care and experience. One can expect frequent conflicts to arise when providers vary from established standards or disagree with established policies.
Additionally, there appears to be an increasing lack of a distinct line between administrative and patient care decisions. It is often a challenge to manage the conflicting incentives involved when cost containment and quality care are seen to diverge.
Dr. Stanciu: What are the metrics that measure success by a medical administrator?
Dr. Penders: Some would say that the financial status of the organization is an important metric. Measures such as length of stay, patient satisfaction, and numbers of clinically relevant adverse events are how the success of medical leadership is assessed.
I would argue that patient outcomes as measured by standard clinical tools are the true measure of the success of the efforts of medical providers led by a medical director. Increasingly, measures of population health will likely be used to measure the overall success of health care organizations.
Continue to: How do you keep up-to-date on the latest rules and regulations to ensure facility compliance?
Dr. Stanciu: How do you keep up-to-date on the latest rules and regulations to ensure facility compliance?
Dr. Penders: Medical directors attend many professional meetings, both within their organizations and outside, which assures that information is provided on regulatory initiatives from government bodies and organizations such as the Joint Commission.
Hospital risk managers and attorneys also play a part in keeping everyone honest when it comes to changes in laws governing our work.
Dr. Stanciu: How is it working in a supervisory capacity with other physicians and the growing number of mid-level providers and their expanding scope of practice?
Dr. Penders: There is a variety of opinions today about the relationship between physicians and mid-level providers. Fairly recently, nurse practitioners and physician assistants were known as “extenders.” We don’t hear that term as much anymore, as these providers are becoming increasingly independent in their practice roles.
The supervisory challenge varies with each situation. Most hospital organizations have medical staff rules and regulations that define the relationships within hospitals. Efforts in outpatient care are often less well defined, and supervisory relationships can be tailored to the specific effort involved.
Continue to: Is there a stipend or additional compensation for administrative duties?
Dr. Stanciu: Is there a stipend or additional compensation for administrative duties?
Dr. Penders: Always. There is considerable time and effort needed on a flexibly “as needed” basis that serves as a justification for administrative compensation.
Dr. Stanciu: Any major differences when working in an independent facility vs a large corporation?
Dr. Penders: As health care organizations become larger and more complex, the role of medical directorships in the larger systems are generally defined by policies that can be restrictive. Small organizations may have less formal rules and allow some flexibility for the role of medical leadership in general.
Dr. Stanciu: What preparation do you suggest for trainees and early career psychiatrists who are contemplating such a role?
Dr. Penders: Become involved in quality and organizational initiatives whenever they are available. Generally, organizations will invite and value the input trainees can provide to these efforts. Functioning as a chief resident is real-world experience that can be invaluable.
Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.
In this Career Choices, Cornel Stanciu, MD, talked with Thomas Penders, MS, MD. For most of his career, Dr. Penders has practiced in directorship roles. He currently serves as the leader of an addiction consultation service at the Walter B. Jones Center in Greenville, North Carolina, as well as working at the state level with federally qualified health centers to develop collaborative care models.
Dr. Stanciu: What led you to decide to pursue a director role?
Dr. Penders: Early in my career, I was offered opportunities to provide leadership for an organization in its efforts to assure quality and availability of appropriate medical and psychiatric care.
Dr. Stanciu: How has the director role evolved over the years?
Dr. Penders: Thirty years ago, when I got started, hospital administrations depended heavily on medical directors to provide advice on new service initiates. Medical directors were frequently provided with support by health care organizations when recommendations were made based on patient and community need as perceived by medical staff providers. There has been a dramatic shift in the relationship and role of medical directorship, particularly over the past decade. Budgetary constraints have influenced planning and operational decisions to the extent that these decisions are much more likely to be made based on financial analyses rather than on clinical needs identified by physicians. As a result, medical directors are encouraged to be mindful of the effect of their suggestions on the bottom line of the organization. This has resulted in a very significant shift away from programs that are needed but not funded, and toward programs that are revenue-positive or at least neutral.
Medical directors who do not conform in this way are unlikely to be part of the administration for very long in the present environment.
Continue to: What training qualifications are required or desirable to assume a medical leadership role (post residency fellowship, MBA, etc.)?
Dr. Stanciu: What training qualifications are required or desirable to assume a medical leadership role (post-residency fellowship, MBA, etc.)?
Dr. Penders: In addition to a foundation in evidence-based practices and knowledge of regulatory requirements, general leadership skills are probably the most important qualities for medical leadership. Hospitals are complex organizations with confusing reporting relationships. Negotiation skills and communication skills are critical to success. Because most modern health care organizations are well staffed with administrative personnel trained in business and finance, I would not suggest that an MBA is necessary or even important to a medical director’s success. Having said that, there are an increasing number of physicians assuming the role of chief executive officer in complex health care systems. In this case, MBA training will likely be advantageous.
I would suggest that the focus of training that occurs in MPH programs would provide more relevant tools for those in positions of medical leadership. Skills such as biostatistics and epidemiology provide those in such positions with the perspective required to understand the effectiveness of health care systems, and to relate to changes that might be beneficial to the populations they serve. A firm foundation in information systems and data analysis is becoming increasingly important as the payment system moves toward one that is value-based. Increasingly, health care systems decisions will be guided by the analysis of aggregated information gathered from electronic medical records.
Dr. Stanciu: What personal qualities makes a psychiatric physician well-suited for the role of a medical director?
Dr. Penders: Medical directors will confront a variety of difficult situations with colleagues, administrative staff, patients, and family members. A calm demeanor with an ability to reflect rather than react is important. As I previously mentioned, an ability to communicate, including strength as a listener, is another personality trait valued in this position.
Continue to: What are some of the challenges you face on a daily basis?
Dr. Stanciu: What are some of the challenges you face on a daily basis?
Dr. Penders: There are challenges in multiple areas. First and foremost, medical leadership is responsible for maintaining and improving the quality of patient care and experience. One can expect frequent conflicts to arise when providers vary from established standards or disagree with established policies.
Additionally, there appears to be an increasing lack of a distinct line between administrative and patient care decisions. It is often a challenge to manage the conflicting incentives involved when cost containment and quality care are seen to diverge.
Dr. Stanciu: What are the metrics that measure success by a medical administrator?
Dr. Penders: Some would say that the financial status of the organization is an important metric. Measures such as length of stay, patient satisfaction, and numbers of clinically relevant adverse events are how the success of medical leadership is assessed.
I would argue that patient outcomes as measured by standard clinical tools are the true measure of the success of the efforts of medical providers led by a medical director. Increasingly, measures of population health will likely be used to measure the overall success of health care organizations.
Continue to: How do you keep up-to-date on the latest rules and regulations to ensure facility compliance?
Dr. Stanciu: How do you keep up-to-date on the latest rules and regulations to ensure facility compliance?
Dr. Penders: Medical directors attend many professional meetings, both within their organizations and outside, which assures that information is provided on regulatory initiatives from government bodies and organizations such as the Joint Commission.
Hospital risk managers and attorneys also play a part in keeping everyone honest when it comes to changes in laws governing our work.
Dr. Stanciu: How is it working in a supervisory capacity with other physicians and the growing number of mid-level providers and their expanding scope of practice?
Dr. Penders: There is a variety of opinions today about the relationship between physicians and mid-level providers. Fairly recently, nurse practitioners and physician assistants were known as “extenders.” We don’t hear that term as much anymore, as these providers are becoming increasingly independent in their practice roles.
The supervisory challenge varies with each situation. Most hospital organizations have medical staff rules and regulations that define the relationships within hospitals. Efforts in outpatient care are often less well defined, and supervisory relationships can be tailored to the specific effort involved.
Continue to: Is there a stipend or additional compensation for administrative duties?
Dr. Stanciu: Is there a stipend or additional compensation for administrative duties?
Dr. Penders: Always. There is considerable time and effort needed on a flexibly “as needed” basis that serves as a justification for administrative compensation.
Dr. Stanciu: Any major differences when working in an independent facility vs a large corporation?
Dr. Penders: As health care organizations become larger and more complex, the role of medical directorships in the larger systems are generally defined by policies that can be restrictive. Small organizations may have less formal rules and allow some flexibility for the role of medical leadership in general.
Dr. Stanciu: What preparation do you suggest for trainees and early career psychiatrists who are contemplating such a role?
Dr. Penders: Become involved in quality and organizational initiatives whenever they are available. Generally, organizations will invite and value the input trainees can provide to these efforts. Functioning as a chief resident is real-world experience that can be invaluable.
‘Robotripping’: What residents need to know
Dextromethorphan (DXM) is commonly found in over-the-counter (OTC) cold and cough preparations. When used at the therapeutic doses DXM has cough-suppressant properties through its action on the medulla. However, OTC preparations containing DXM are being increasingly used recreationally for the drug’s psychoactive effects, a practice referred to as “robotripping.” Such use can result in a toxidrome of delirium with agitation, paranoia, and hallucinations.1 Residents need to be able to recognize the signs of DXM abuse and manage its potentially serious complications.
How DXM works
DXM has a wide therapeutic window. A typical therapeutic dose for cough is up to 120 mg/d. The most common adverse effects are mild (fever, diaphoresis, dizziness, nausea). At higher dosages, it acts as a nonselective serotonin reuptake inhibitor, a sigma-1 receptor agonist, and an N-methyl-
Adverse effects include hallucinations, disorientation, mania, and aggression with delusions of supernatural abilities and insensitivity to pain; these effects are similar to those produced by phencyclidine (PCP).2-4 Physiologically, diaphoresis, hyperthermia, and tachycardia are often observed.3,5 These presentations carry a significant risk of mortality, and appropriate recognition and management is needed.
4 Phases of intoxication
DXM users have described 4 progressive behavioral phases that vary with dosage.3,6,7 First, at 1.5 to 2.5 mg/kg, users report stimulating effects with perceptual alterations similar to those produced by 3,4-methylenedioxymethamphetamine (“ecstasy”). The second phase, reached at 2.5 to 7.5 mg/kg, is similar to alcohol and marijuana intoxication but includes more pronounced dysfunction in motor, cognitive, and perceptual skills, and perhaps visual hallucinations.3,6,7 The third phase, noted at 7.5 to 15 mg/kg, resembles ketamine intoxication, with strong dissociation and hallucinations.3,6,7 At greater doses, out-of-body, trance-like experiences may occur. Delirious misperceptions often lead to violent behavior and limited perception of pain. Users may experience a long course of any of these phases, with presentations lasting for up to 1 to 2 weeks after discontinuing use.8
Management is mainly supportive
Early recognition of DXM use is essential for treatment. Unfortunately, without collateral reports, this can be challenging because specialized toxicology screens are needed to detect DXM. Basic screens sometimes show a false positive for PCP. Take an inventory of all substances in the patient’s possession, either by examining the patient’s belongings or by obtaining collateral information from the patient’s family or friends.
Supportive care should be implemented, with a primary goal of controlling agitation. Short-acting benzodiazepines are helpful. Low-dose, short-term antipsychotics have shown benefit when hallucinations and paranoia are prominent.3 Decreasing stimulation and avoiding physical restraints while attempting to control aggression and psychosis with these medications is recommended. Using physical restraints on an individual who is in a state of agitated delirium can lead to severe injuries, cardiac and respiratory arrest, and death.9-11
Patients typically experience rapid and complete remission of symptoms after discontinuing DXM use. However, evidence suggests DXM users can develop tolerance as well as psychological and physiological dependence. DXM withdrawal can be quite protracted and may include anxiety, dysphoria, insomnia, and suicidality.
1. Stanciu CN, Penders TM, Rouse EM. Recreational use of dextromethorphan,“Robotripping”-A brief review. Am J Addict. 2016;25(5):374-377.
2. Martinak B, Bolis RA, Black JR, et al. Dextromethorphan in cough syrup: The poor man’s psychosis. Psychopharmacol Bull. 2017;47(4):59-63.
3. Logan BK, Yeakel JK, Goldfogel G, et al. Dextromethorphan abuse leading to assault, suicide, or homicide. J Forensic Sci. 2012;57(5):1388-1394.
4. Dextromethorphan (Street names: DXM, CCC, Triple C, Skittles, Robo, Poor Man’s PCP). Drug Enforcement Administration. Office of Diversion Control. Drug & Chemical Evaluation Section. https://www.deadiversion.usdoj.gov/drug_chem_info/dextro_m.pdf. Published March 2014. Accessed April 22, 2018.
5. Reissig CJ, Carter LP, Johnson MW, et al. High doses of dextromethorphan, an NMDA antagonist, produce effects similar to classic hallucinogens. Psychopharmacology (Berl). 2012;223(1):1-15.
6. Boyer EW. Dextromethorphan abuse. Pediatr Emerg Care. 2004;20(12):858-863.
7. Drug Fact Sheet: Dextromethorphan (DXM). Drug Enforcement Administration. https://www.dea.gov/druginfo/drug_data_sheets/Detromethorphan.pdf. Accessed April 22, 2018.
8. Jacob R, Nicholapillai JN. Dextromethorphan induced bipolar disorder. Int Clin Psychopharmacol. 2012;28:e37-e38.
9. Hick JL, Smith SW, Lynch MT. Metabolic acidosis in restraint-associated cardiac arrest: a case series. Acad Emerg Med. 1999;6(3):239-243.
10. Mohr WK, Petti TA, Mohr BD. Adverse effects associated with physical restraint. Can J Psychiatry. 2003;48(5):330-337.
11. Otahbachi M, Cevik C, Bagdure S, et al. Excited delirium, restraints, and unexpected death: a review of pathogenesis. Am J Forensic Med Pathol. 2010;31(2):107-112.
Dextromethorphan (DXM) is commonly found in over-the-counter (OTC) cold and cough preparations. When used at the therapeutic doses DXM has cough-suppressant properties through its action on the medulla. However, OTC preparations containing DXM are being increasingly used recreationally for the drug’s psychoactive effects, a practice referred to as “robotripping.” Such use can result in a toxidrome of delirium with agitation, paranoia, and hallucinations.1 Residents need to be able to recognize the signs of DXM abuse and manage its potentially serious complications.
How DXM works
DXM has a wide therapeutic window. A typical therapeutic dose for cough is up to 120 mg/d. The most common adverse effects are mild (fever, diaphoresis, dizziness, nausea). At higher dosages, it acts as a nonselective serotonin reuptake inhibitor, a sigma-1 receptor agonist, and an N-methyl-
Adverse effects include hallucinations, disorientation, mania, and aggression with delusions of supernatural abilities and insensitivity to pain; these effects are similar to those produced by phencyclidine (PCP).2-4 Physiologically, diaphoresis, hyperthermia, and tachycardia are often observed.3,5 These presentations carry a significant risk of mortality, and appropriate recognition and management is needed.
4 Phases of intoxication
DXM users have described 4 progressive behavioral phases that vary with dosage.3,6,7 First, at 1.5 to 2.5 mg/kg, users report stimulating effects with perceptual alterations similar to those produced by 3,4-methylenedioxymethamphetamine (“ecstasy”). The second phase, reached at 2.5 to 7.5 mg/kg, is similar to alcohol and marijuana intoxication but includes more pronounced dysfunction in motor, cognitive, and perceptual skills, and perhaps visual hallucinations.3,6,7 The third phase, noted at 7.5 to 15 mg/kg, resembles ketamine intoxication, with strong dissociation and hallucinations.3,6,7 At greater doses, out-of-body, trance-like experiences may occur. Delirious misperceptions often lead to violent behavior and limited perception of pain. Users may experience a long course of any of these phases, with presentations lasting for up to 1 to 2 weeks after discontinuing use.8
Management is mainly supportive
Early recognition of DXM use is essential for treatment. Unfortunately, without collateral reports, this can be challenging because specialized toxicology screens are needed to detect DXM. Basic screens sometimes show a false positive for PCP. Take an inventory of all substances in the patient’s possession, either by examining the patient’s belongings or by obtaining collateral information from the patient’s family or friends.
Supportive care should be implemented, with a primary goal of controlling agitation. Short-acting benzodiazepines are helpful. Low-dose, short-term antipsychotics have shown benefit when hallucinations and paranoia are prominent.3 Decreasing stimulation and avoiding physical restraints while attempting to control aggression and psychosis with these medications is recommended. Using physical restraints on an individual who is in a state of agitated delirium can lead to severe injuries, cardiac and respiratory arrest, and death.9-11
Patients typically experience rapid and complete remission of symptoms after discontinuing DXM use. However, evidence suggests DXM users can develop tolerance as well as psychological and physiological dependence. DXM withdrawal can be quite protracted and may include anxiety, dysphoria, insomnia, and suicidality.
Dextromethorphan (DXM) is commonly found in over-the-counter (OTC) cold and cough preparations. When used at the therapeutic doses DXM has cough-suppressant properties through its action on the medulla. However, OTC preparations containing DXM are being increasingly used recreationally for the drug’s psychoactive effects, a practice referred to as “robotripping.” Such use can result in a toxidrome of delirium with agitation, paranoia, and hallucinations.1 Residents need to be able to recognize the signs of DXM abuse and manage its potentially serious complications.
How DXM works
DXM has a wide therapeutic window. A typical therapeutic dose for cough is up to 120 mg/d. The most common adverse effects are mild (fever, diaphoresis, dizziness, nausea). At higher dosages, it acts as a nonselective serotonin reuptake inhibitor, a sigma-1 receptor agonist, and an N-methyl-
Adverse effects include hallucinations, disorientation, mania, and aggression with delusions of supernatural abilities and insensitivity to pain; these effects are similar to those produced by phencyclidine (PCP).2-4 Physiologically, diaphoresis, hyperthermia, and tachycardia are often observed.3,5 These presentations carry a significant risk of mortality, and appropriate recognition and management is needed.
4 Phases of intoxication
DXM users have described 4 progressive behavioral phases that vary with dosage.3,6,7 First, at 1.5 to 2.5 mg/kg, users report stimulating effects with perceptual alterations similar to those produced by 3,4-methylenedioxymethamphetamine (“ecstasy”). The second phase, reached at 2.5 to 7.5 mg/kg, is similar to alcohol and marijuana intoxication but includes more pronounced dysfunction in motor, cognitive, and perceptual skills, and perhaps visual hallucinations.3,6,7 The third phase, noted at 7.5 to 15 mg/kg, resembles ketamine intoxication, with strong dissociation and hallucinations.3,6,7 At greater doses, out-of-body, trance-like experiences may occur. Delirious misperceptions often lead to violent behavior and limited perception of pain. Users may experience a long course of any of these phases, with presentations lasting for up to 1 to 2 weeks after discontinuing use.8
Management is mainly supportive
Early recognition of DXM use is essential for treatment. Unfortunately, without collateral reports, this can be challenging because specialized toxicology screens are needed to detect DXM. Basic screens sometimes show a false positive for PCP. Take an inventory of all substances in the patient’s possession, either by examining the patient’s belongings or by obtaining collateral information from the patient’s family or friends.
Supportive care should be implemented, with a primary goal of controlling agitation. Short-acting benzodiazepines are helpful. Low-dose, short-term antipsychotics have shown benefit when hallucinations and paranoia are prominent.3 Decreasing stimulation and avoiding physical restraints while attempting to control aggression and psychosis with these medications is recommended. Using physical restraints on an individual who is in a state of agitated delirium can lead to severe injuries, cardiac and respiratory arrest, and death.9-11
Patients typically experience rapid and complete remission of symptoms after discontinuing DXM use. However, evidence suggests DXM users can develop tolerance as well as psychological and physiological dependence. DXM withdrawal can be quite protracted and may include anxiety, dysphoria, insomnia, and suicidality.
1. Stanciu CN, Penders TM, Rouse EM. Recreational use of dextromethorphan,“Robotripping”-A brief review. Am J Addict. 2016;25(5):374-377.
2. Martinak B, Bolis RA, Black JR, et al. Dextromethorphan in cough syrup: The poor man’s psychosis. Psychopharmacol Bull. 2017;47(4):59-63.
3. Logan BK, Yeakel JK, Goldfogel G, et al. Dextromethorphan abuse leading to assault, suicide, or homicide. J Forensic Sci. 2012;57(5):1388-1394.
4. Dextromethorphan (Street names: DXM, CCC, Triple C, Skittles, Robo, Poor Man’s PCP). Drug Enforcement Administration. Office of Diversion Control. Drug & Chemical Evaluation Section. https://www.deadiversion.usdoj.gov/drug_chem_info/dextro_m.pdf. Published March 2014. Accessed April 22, 2018.
5. Reissig CJ, Carter LP, Johnson MW, et al. High doses of dextromethorphan, an NMDA antagonist, produce effects similar to classic hallucinogens. Psychopharmacology (Berl). 2012;223(1):1-15.
6. Boyer EW. Dextromethorphan abuse. Pediatr Emerg Care. 2004;20(12):858-863.
7. Drug Fact Sheet: Dextromethorphan (DXM). Drug Enforcement Administration. https://www.dea.gov/druginfo/drug_data_sheets/Detromethorphan.pdf. Accessed April 22, 2018.
8. Jacob R, Nicholapillai JN. Dextromethorphan induced bipolar disorder. Int Clin Psychopharmacol. 2012;28:e37-e38.
9. Hick JL, Smith SW, Lynch MT. Metabolic acidosis in restraint-associated cardiac arrest: a case series. Acad Emerg Med. 1999;6(3):239-243.
10. Mohr WK, Petti TA, Mohr BD. Adverse effects associated with physical restraint. Can J Psychiatry. 2003;48(5):330-337.
11. Otahbachi M, Cevik C, Bagdure S, et al. Excited delirium, restraints, and unexpected death: a review of pathogenesis. Am J Forensic Med Pathol. 2010;31(2):107-112.
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4. Dextromethorphan (Street names: DXM, CCC, Triple C, Skittles, Robo, Poor Man’s PCP). Drug Enforcement Administration. Office of Diversion Control. Drug & Chemical Evaluation Section. https://www.deadiversion.usdoj.gov/drug_chem_info/dextro_m.pdf. Published March 2014. Accessed April 22, 2018.
5. Reissig CJ, Carter LP, Johnson MW, et al. High doses of dextromethorphan, an NMDA antagonist, produce effects similar to classic hallucinogens. Psychopharmacology (Berl). 2012;223(1):1-15.
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7. Drug Fact Sheet: Dextromethorphan (DXM). Drug Enforcement Administration. https://www.dea.gov/druginfo/drug_data_sheets/Detromethorphan.pdf. Accessed April 22, 2018.
8. Jacob R, Nicholapillai JN. Dextromethorphan induced bipolar disorder. Int Clin Psychopharmacol. 2012;28:e37-e38.
9. Hick JL, Smith SW, Lynch MT. Metabolic acidosis in restraint-associated cardiac arrest: a case series. Acad Emerg Med. 1999;6(3):239-243.
10. Mohr WK, Petti TA, Mohr BD. Adverse effects associated with physical restraint. Can J Psychiatry. 2003;48(5):330-337.
11. Otahbachi M, Cevik C, Bagdure S, et al. Excited delirium, restraints, and unexpected death: a review of pathogenesis. Am J Forensic Med Pathol. 2010;31(2):107-112.
