Hi, Dr. Bernard here. Cough syrup is for coughs. It’s not for partying, it’s not for memes.
It’s not worth messing with this stuff because it will ruin lives.
A TikToker Chugged 1 Liter of Cough Syrup At Lunch Time. This Is What Happened To His
Brain.
BW is a 35 year old man, presenting to the emergency room, unconscious.
His mother Gina, tells the admitting nurse that she found her son, limp on the floor,
and blue in the face. He had an empty styrofoam cup in his hand.
Paramedics tried to give him an antidote for the medicine they thought he drank, but they
had to give it 3 times before he responded. Then his heart stopped beating in the ambulance.
You see, BW was a TikToker who played in a band. A few years ago, he was at an aftershow
party. The host was serving drinks in tall styrofoam cups. In it was soda, candy, and
prescription strength cough syrup. This mix is known as lean, or purple drank, popularized
in Houston, and well known to do terrible things to the body, but BW had no problems
with this. It’s just some candy and soda pop, he thought.
Immediately after finishing his first cup, BW felt great. He had the best sleep of his
life that night. Whatever was in that cup, he wanted more of it. And the hosts of the
party, could make that happen. BW’s friends used to make fun of him calling him a ‘light
weight’ because he only needed to drink about one fourth the amount of everyone else,
to have the same effect.
About a year ago, BW started making TikTok videos. At first, he did this to promote his
band. But then, he’d start drinking his cough syrup in his videos. People recognized
the styrofoam cups. They knew what was going on. And BW took every opportunity to meme
this..
One day, BW didn’t have any lean left. This is when he’d start to get sick. It would
start with a runny nose. A voice in his head would start to echo terrible noises before
he could feel his brain start pounding against the sides of his skull.
His stomach
would knot up, and a tinge in his cheeks would come up, bringing him down to the floor. Bile
would start to come up, And then the dark thoughts would start to settle in. But this
is a funny TikTok meme, he thought. And even though his views were good, he’d eventually
need more syrup, just to feel normal again.
Three weeks ago, BW caught pneumonia. The doctor found him to otherwise be healthy.
BW didn’t say anything about his purple drank habit. And actually, a lot of people
misusing it, look like regular people. The doctor, gave him some antibiotics. BW tried
to ask for some prescription cough syrup, but the doctor told him to get whatever was
available over the counter.
At home now, BW washed down his antibiotics with his lean. If this is cough syrup, and
antibiotics together, then I’m never going to cough ever again, he thought.
BW found that taking those antibiotics together with his drink, made him extra relaxed.
It was like he was drinking his syrup for the first time, again. He wasn’t
really drinking any more than normal.
Immediately after chugging a big cup of drink, BW felt good. He showed it all online. He
could feel the rush as the minutes passed. He tried to stand up straight. He felt like
he was upright, but he wasn’t. He walked into the bathroom. Everything was clear again.
But then he felt like he was floating himself in. His field of vision started darkening
on the sides of his eyes. He sat on the toilet, unsure of where he was, as he started nodding
off.
And as the minutes passed, BW stops breathing. His mom walks in on him. She finds him not
responsive, not breathing, cold and blue in the face as she calls for 911, and he's brought
to the emergency room where we are now.
At examination, doctors knew this was a case of cough syrup. His mom told them she found
him on the floor with a styrofoam cup in his hand. She knew about his habit, but didn’t
do much about it over the years. Exactly how much he drank she didn’t know, but it didn’t
matter. His heart had stopped in the ambulance. His skin was discolored because he had stopped
breathing for minutes. His pupils were like pin needles. All of this immediately telling
doctors exactly what they need to know.
The cough syrup in lean, or purple drank is a mix of 2 different medicines, promethazine
and codeine. Promethazine is an allergy medicine. It’s in the same group as benadryl. In large
amounts, it blocks rest and digest signals from the nervous system. Which is interesting
because that interplays with codeine.
You see, the thing about codeine is that by itself, it’s inactive in humans. But when
the liver breaks it down, it immediately becomes morphine.
Morphine is a natural product. It’s from the opium poppy. Actually, opium poppy sap
has a mix of morphine and codeine together, so codeine is natural too.
Morphine is an actual medicine used in hospitals. It’s used to relieve pain, but it does a
lot of other things to the body. A thousand years ago, Arabic doctors used it to treat
diarrhea, because morphine slows down the muscles of the gut. Slowing down the gut,
gives the bowel time to reabsorb water to form a proper stool. But if someone doesn’t
have loose stools and has morphine in their body, then that slowed down gut would reabsorb
too much water from the stools and harden them, leading to chronic constipation, which
BW had.
In the lungs, morphine interacts with the bronchioles, and that suppresses cough, so
that’s why codeine is in cough syrup. But this isn’t the reason why BW stopped breathing
this time. He stopped breathing because morphine also interacts with the brain.
When morphine is bound in to nerves that sense pain, it blocks that pain signal. That’s
why it’s a pain reliever. Actually, we haven’t really found a better medication class for
pain than opioids. But when enough morphine binds in to other parts of the brain, it releases
chemicals to deliver a rush of euphoria. Which is why when it’s paired with other things
that prevent the breakdown of those feel good chemicals, that euphoria is amplified. And
morphine binds in to the brain stem, which controls breathing. When oxygen is low in
the blood, your brain stem will tell the body to try to breathe quicker and deeper to replace
it. But BW’s brain stem can’t tell the body to do this anymore, because the codeine
in his cough syrup was turned into morphine by his body, and has blocked his brain from
telling his body to breathe.
BW was transferred in to the intensive care unit, because when anyone’s heart stops
beating, there’s always a chance that not enough oxygen reached their brain for any
period of time. The longer time, the greater chance of permanent damage. And in BW, there
was permanent damage.
A radiograph of his head, shows that parts of BW’s brain have died from a lack of oxygen.
When he regained consciousness in the ICU, his speech was slurred, and he couldn’t
hear out of his left ear. All of this happening because of brain damage caused by not breathing
for several minutes, but something’s wrong.
Codeine, in most people, is only about 10% the potency of morphine. So you’d need at
least 10 times the amount of codeine to have the same action as morphine. But since you’re
only supposed to be treating cough here with the syrup, you don’t need that big of a
dose. But the thing about codeine - promethazine cough syrup is, that one group of people who
drink it for the first time say they don’t feel anything from it. They’re still coughing
afterwards. It’s almost like it’s not working for them. Why is that? A different
group of people will become habitual users of codeine - promethazine cough syrup. They’ll
tell you that it ruined their life because they start to need it everyday, otherwise
they can’t function. So why is there a difference? And if codeine is only 10% potency of morphine,
and morphine isn’t even as strong as some other things out there, then what happened
to BW?
This brings us back to the liver. One part of the liver makes morphine out of codeine.
But a different part, uses codeine to make norcodeine, which is immediately inactive.
So this explains why codeine is only 10% potency of morphine, but why does the liver do this?
Well, the liver is the detox center of your body. You don’t need fancy supplements or
cleanses because you have a liver. Detoxing, broadly, means breaking chemicals down to
make them more stable. Stable means that it won’t react with other bodily structures.
Because if they react, that means it could be doing damage. In nature, stable usually
means simple. Breaking parts off, makes things simple. These “branches” get cleaved off.
In the top case done by one part of the liver, that’s morphine. In the bottom case by the
other part of the liver, it’s norcordeine. And nothing more can be done to each of these,
because these rings in nature are generally stable.
But if BW chugging almost a liter of syrup isn’t any more than he’d take normally,
then how did he suddenly stop breathing? How did it suddenly look like he drank 10x more
syrup than normal?
Well, we know different people are built differently. If you are someone who can drink a whole pot
of coffee at midnight at be sound asleep by 1am, you might have a friend who would take
a sip of coffee at lunchtime, and be wired until the following morning, meaning you can
handle caffeine no problem, but your friend can’t. This difference in people, is because
of differences in our genes and these variations are called mutations.
Do you remember that some people aren’t affected at all by codeine? Well, they might
have a genetic mutation that makes one part of their liver less functional. This means
codeine never gets broken down to morphine at all in these people. The entire dose gets
inactivated. If codeine never becomes morphine in these people, then that’s why the cough
syrup doesn't work in these people.
And if someone has mutations that don’t break codeine to morphine, someone else would
the opposite mutation that would break a lot of codeine to morphine. This means these overfunctional
people would turn the all of the codeine to morphine. Then it’s not 10% potency anymore,
it’s closer to 100%. Do you remember that BW was called lightweight by his friends?
Well, if you convert most of the codeine to morphine, then you don't need to drink that
much to get the same effect. This could be why he could get away with drinking less syrup
than everyone else. But if that’s the case, then that means something even more terrible
had happened when he presented to the emergency room.
You see, the antibiotics that BW took for his pneumonia also get broken down by the
part of the liver that inactivates codeine. Actually, that antibiotic packs in that entire
part of the liver, and doesn’t let anything else in. So if BW by his genetics, turns more
codeine to morphine than other people, and the other part of his liver that’s supposed
to never activate codeine at all is blocked, then virtually all of the codeine he chugged
on TikTok was converted to morphine, flooding his body with a massive amount, much more
than what he was used to. He was feeling good those first 2 days, but as more antibiotics
occupied his liver, more and more morphine collected to the point where he stopped breathing,
and parts of his brain became permanently damaged.
In the hospital, BW was transferred in to the step-down unit as his condition stabilized.
Doctors would need to refer him to rehab and more outpatient care, but his time inpatient
was coming to an end, as he was discharged back home.
As the days passed, BW tried to cope. All those years of misusing cough syrup made his
body learn and adapt. If more morphine was around to bind in to the gut to slow it down,
to bind in to pain nerves to block the signal, then the body will adapt, and create more
of those structures, for more morphine to bind in. This is how we believe tolerance
and dependence develops, manifesting as withdrawal symptoms. And when suddenly, one day there
is no more syrup available, no more slowing down of the stomach makes it move
faster, so the bile emerges from both ends. No more syrup to block the pain nerves means
big pain signals push their way through, making everything hurt. This is called withdrawal.
And after losing part of his hearing, BW still couldn’t cope with the withdrawal. His thoughts
were clouded everyday with feelings of doom. He reluctantly got back in to his drink. His
speech was still slurred, even though his thoughts were still clear enough for him to
ignore the rehab referral. He ignored any doctors’ follow ups, because he was afraid
of what they were going to do to him.
One of his friends had suggested that BW start on an over the counter medicine used for loose
stools called loperamide. This thing, he said, helped him get over the sickness and withdrawal.
And so BW tried his own rehab. At first, he took 1 box of this loperamide. He didn’t
feel great, but it was still better than nothing. Why not try 2 boxes, he thought. Eventually,
he got to a point where he didn’t feel great, but he didn’t feel too sick anymore. He
didn’t care that he needed 5 boxes each day so that he wouldn’t feel as if his brain
was smashing up against his skull. So that he wouldn’t lay in a pool of his own sweat
huddled over on the floor. But as the days passed, this loperamide caught
up with him too.
One day, BW’s mom came back from work. She walked in to the living room and found her
son again, on the floor, cold, pale and unresponsive, as she calls for 911. And he's brought to
the emergency room again.
At examination this time, BW had an abnormal heart rhythm. He was shocked back into a normal
rhythm, only for it become abnormal again. His mom showed the doctors the boxes of loperamide
he took. His heart starts shaking in place, not actually beating, and then suddenly, it
stops. Doctors rush in to give him CPR, to give him medicines to try to restart his heart.
What is loperamide? And why did it stop his heart? Well, this brings us back to morphine.
Do you remember those Arabic doctors treating loose stools? Well, morphine’s probably
not the best medicine for that, given it can form a very intense habit. Loperamide treats
loose stools without the habit forming quality because, it binds to the same structures in
the gut that morphine would. But it only binds to the gut, and not the brain. But at a dose
of 5 boxes, it behaves a little different.
One half of the loperamide molecule, looks like methadone, which is a treatment given
in rehab for opioid withdrawal. So that’s how some people think that loperamide can
treat withdrawal too. I wouldn’t do this, because the problem is, people try to take
large amounts like multiple boxes of it to try to force it in to the brain. And the brain
resists this by pumping loperamide back out. If there’s simply too much of it, those
pumps would get overwhelmed, and loperamide would bind in to the morphine receptors in
the brain to cause the same effect. But the problem is, the other half of it, looks just
like one part of an anti-psychotic medicine named haloperidol. But we don't really know
right now what that means in the brain. What we do know, is that the other half of loperamide
is also shaped like a heart rhythm medicine. It binds in to the heart when taken in large
amounts, and it blocks electrical conduction needed for muscle contraction, which is exactly
what happened to BW.
After 25 minutes of CPR, the code was called. Doctors weren’t able to resuscitate him.
Purple Drank, Lean, Syrup, or Texas Tea, whatever you want to call it, it doesn’t matter what
the name is, don’t do it. Even though it’s candy and soda pop mixed in, things associated
with enjoyment, cutesy fun time— it’s evil in the sense that over time, it can and
will cause significant suffering. It’ll slowly warp the way you live, and the way
you behave, and many people who are deep in it may not realize how twisted their lives
become. Maybe some do realize it, and one part of those people are completely helpless
in fighting it. You see this happen to even famous people because in their end, their
no different than anyone else. It’s not worth it to start. Don’t do it. And don’t
do the loperamide either, because it's way more risk than benefit, just like it
was for BW.
Thanks for watching. Take care of yourself. And be well.