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    Dextromethorphan (DXM or DM) is a medication most often used as a cough suppressant in over-the-counter cold and cough medicines. It is sold in syrup, tablet, spray, and lozenge forms. It is in the morphinan class of medications with sedative, dissociative, and stimulant properties (at lower doses). In its pure form, dextromethorphan occurs as a white powder. When exceeding approved dosages, dextromethorphan acts as a dissociative anesthetic. It has multiple mechanisms of action, including actions as a nonselective serotonin reuptake inhibitor DXM and its major metabolite, dextrorphan, also act as an NMDA receptor antagonist at high doses, which produces effects similar to, yet distinct from, the dissociative states created by other dissociative anesthetics such as ketamine and phencyclidine. The metabolic pathway continues from dextrorphan to 3-methoxymorphinan to 3-hydroxymorphinan. The 3-methoxymorphinan metabolite produces local anesthetic effects in rats, with potency between dextrorphan and DXM. Comparatively, hydromorphone is to morphine as hydrocodone is to codeine – it is a hydrogenated ketone thereof. In medical terms, it is an opioid analgesic, and in legal terms, a narcotic. Hydromorphone is commonly used in the hospital setting, mostly by injection into a vein because its bioavailability is very low orally, rectally, and intranasally. Administration under the tongue is usually superior to swallowing for bioavailability and effects; however, hydromorphone is bitter and hydrophilic, so it is absorbed poorly and slowly through mouth membranes. In 2016, it was the 212th most prescribed medication in the United States, with more than 2.5 million prescriptions. Hydromorphone is much more soluble in water than morphine and, therefore, hydromorphone solutions can be produced to deliver the drug in a smaller volume of water. The hydrochloride salt is soluble in three parts of water, whereas a gram of morphine hydrochloride dissolves in 16 ml of water; for all common purposes, the pure powder for hospital use can be used to produce solutions of virtually arbitrary concentration.

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