Hey everyone, Dr Bernard here. Cough syrup is for coughs. The over-the-counter stuff
can have particularly nasty effects, just like what happened to this patient. Don't
do it.
A Student Chugged 2 Bottles Over The Counter Cough Medicine. This Is What Happened To Her
Brain.
GG is a 21 year old woman, presenting to the emergency room, unconscious.
Her dad Jeff, tells the admitting nurse that he saw her legs shaking before she had at
least 2 seizures, in the last 10 minutes.
You see, GG was a college student on summer break, but something was wrong.
When she was younger, she experienced random bouts of low energy. Whenever this would happen,
she wouldn’t be able to concentrate on anything. She felt down, and hopeless and an overarching
sense of doom would blanket over her. During these episodes, she wouldn’t sleep for more
than two weeks at a time.
Her parents thought she may have had depression. Her doctor’s findings were consistent with that and she was diagnosed with it.
GG thought it’d be funny if she chugged a bottle of
over the counter cough syrup, called dextromethorphan. She heard her friends talk about it. She felt
like she didn’t have anything to lose, so why not just wash it all away with some syrup
she thought.
Immediately after finishing a bottle of over the counter cough medicine, GG felt it burn
on the way down in to her stomach. She felt the muscles in the back of her head pull on
her forehead as she started smiling with her eyes. She felt like there was a soft wind
blowing in her hair, even though she was sitting inside, knees to her chest in the dark. She
felt a positive mood and the sense of doom washed away. She was able to sleep that night,
and she just didn’t feel sad anymore, as she tried it again at least 4 more times that
month.
But things weren’t much brighter for very long. When she started college GG was drinking
a bottle of over the counter cough syrup almost every day. If she went for too long without
it, she’d start to get the shakes. She thought these were chills. But her stomach and intestines
would start to shake pushing out watery movements from both ends, all while leaving her with
a sense of hopelessness and doom much worse than what she experienced before trying the
syrup in the first place.
Sometimes, the store would be out of syrup. Unwilling to deal with withdrawals, she’d
resort to buying the caplets of the cough medicine, but she really didn’t like these.
Her experience was always negative with these, but less negative than taking nothing at all.
One day, the pharmacy had run out of the syrup for more than 2 weeks. She felt physically
ill and she was confused about it because everything she found online said that withdrawals
on cough syrup don't happen with the over the counter stuff. But in a desperate attempt
to just make it all go away, she took the whole bottle of dextromethorphan caplets.
On the floor now, with knees up to her chest, GG felt like a void was chewing out her insides.
She hoped it would all go away, and the last thing she could remember was looking down,
as she started to have a seizure. GG’s parents find her on the floor unresponsive and shaking.
At the doctor’s office, no one knew that GG had a cough syrup habit. It looked like
she was taking her medicines appropriately. Her prescriptions were getting filled and
her parents saw the medicines in the bottle depleting everyday but they didn't realize
she was just slowly throwing them away to make it look like she was taking them. And
after some tests, doctors thought that GG probably had a seizure disorder.
At home now, with seizure medicines, GG refused to take them too, and she also hid that from
her parents. To her, dextromethorphan cough medicine that was the only thing that could
fix her, but it didn’t dawn on her that the dose in the combined caplets she took
may have been so much higher than drinking a bottle of the syrup, and that that could
have caused her seizure.
On the internet, GG started looking for her own medicines. In her own reasoning after
doing her own research, she concluded that herbal medicines were the only way forward
for her, as she started taking some, combined with her over the counter cough medicine.
And things were going OK, but only for about 3 days. GG had just gotten a fresh supply
of syrup to drink, and as she got ready to drink 2 whole bottles having taken those herbal
medicines earlier in the day, everything was going to be alright.
And 30 minutes after finishing almost 2 whole bottles, GG started to have seizures again.
Her parents find her convulsing on the floor, as they call for 911, and she’s brought
to the emergency room, where we are now.
At examination, doctors find GG had a fever. She was confused and had a tremor. When doctors
asked her “where are you and what’s your name” she told the doctors that she had
been tricked. She had been backstabbed, and she had been quite possibly bamboozled. She
was able to say this before suddenly vomiting, and the medical team gave her some medicines
for that. No one knew about her cough syrup or herbal medicines, and she wasn’t going
to tell them about those anyway.
Because GG had a history of depression, doctors had some concerns about a possible intentional
ingestion of something. But it’ll take some time for a screen to come back, so they weren’t
for sure.
But what they were sure about, was that her blood pressure, heart rate and body temperature
had increased in the last few hours. Her muscles were rigid except, when the doctors checked
her ankles, and pushed her feet down, her feet just wouldn’t stop shaking. When the
doctors asked her parents how long this had been going on, they said this was just something
that happened suddenly. And this gives doctors some clues as to what’s happening.
Some depression medicines are called SSRI’s. Selective Serotonin Reuptake Inhibitors. Serotonin
is a chemical in the brain that sends signals. When not enough is around, then not many signals
get sent. When something gets Reuptake, it means that that something gets reabsorbed back
in somewhere. If it's serotonin, that means it can’t be around to send signals. So inhibiting
the Reuptake, or stopping the reabsorption means more Serotonin can be around to send
signals, which gives way to the name Selective Serotonin Reuptake Inhibitor.
But what if the reuptake isn’t selective? That all reuptake is stopped. Then that could
mean there’s too much serotonin, meaning too many signals are getting sent.
Signals from the brain can tell the heart to beat faster and harder. It can cause GG
to become confused, and possibly have a seizure. And it could also cause some of her nerves
to fire off in a way that would cause her feet to flutter on her ankles while her muscles
become stiff.
And because all of this happened suddenly, doctors suspect that something caused GG to
have too much serotonin floating around, but something’s wrong. If GG never took her
depression medicines, then where did all that serotonin coming from?
A drug screen was negative for almost everything, but doctors still suspect that whatever is
happening to GG, is happening because of an inappropriate ingestion.
Sometimes when cough syrup is misused, people think of purple drink or lean, which is based
off codeine syrup. Codeine gets broken down to morphine in the body, the basis for all
opioid pain meds.
Dextromethorphan is the over the counter stuff. It’s not purple drink. It’s not codeine.
But, if some parts of codeine are removed, it leaves another opioid medicine named levorphanol,
that can be used for pain. Levo from Latin laevus referring to the left hand side. And
if you reflect levorphanol in a mirror, you get dextrorphan. Dextro from Latin dexter
referring to the right side. This happens to be the active version of the cough medicine,
dextromethorphan.
The interesting thing about geometry in nature, is that levorphanol and codeine are both opioids,
but dextrorphan, which is the right hand to levophanol’s left hand, it’s a mirror
image, is just different enough of a shape to not fit in to that part of the body that
would signal a painkilling, like how an opioid would. So Dextromethorphan is not an opioid.
It can’t relieve pain.
But what dextromethorphan can do is suppress cough, actually, it can do that better than
codeine can. But it does that at the dose on the label.
At doses just a little higher, it can start to inhibit serotonin reuptake, while also
promoting serotonin release, and it can stimulate the same parts of the brain that serotonin
does. So as the cough syrup dose keeps increasing, it prevents serotonin from getting reabsorbed
increasing the signals that get sent in the brain. It promotes the release of more serotonin,
increasing the signals that get sent in the brain. And it interacts with the same structures
in the brain that serotonin interacts with, increasing the signals that get sent in the
brain.
And at even higher doses, it just keeps going. Serotonin isn’t the only chemical in the
brain that sends signals. When you get scared, you jump and your heart races. This fight
or flight response is because of norepinephrine among other things, and dextromethorphan cough
medicine can block norepinephrine reuptake, so that signal gets pushed up, causing an
increase in heart rate, blood pressure, and body temperature, bringing us back to GG.
In the medicine unit, doctors give GG medicines to sedate her. They try to hydrate her. Even
if they didn't know exactly what she had taken, they realize that her serotonin syndrome shouldn’t
worsen so long as she doesn't take more of it. But then she started having tremors. She
was found cracking her teeth and shaking, while her liver and kidneys were shutting
down and she was transferred in to the intensive care unit.
When the body temperature gets too high for too long, the organs start to shut down. It’s
almost like one is getting “cooked” alive. 2 bottles of dextromethorphan alone could
have released all this serotonin, but adding other things on top of it would make things
so much worse, which brings us to those herbal medicines.
The thing about these herbal medicines and supplements, is that you dont always know
what you’re getting. And especially in the context of herbals that might help with depression,
those could cause a massive, uncontrolled release of serotonin, among other things,
that when combined with misuse of over the counter cough syrup, caused GG’s serotonin
syndrome. But this isn’t the only problem.
Do you remember that medicine that GG was given for vomiting when she presented to the
emergency room? Well, ondansetron stops vomiting and nausea by blocking something called 5-HT3,
in the vagus nerve, which connects the brain to the guts. Another name for 5-HT is, serotonin,
which means that medicine she was given to stop her nausea, also blocks the receipt of
serotonin in the stomach. This would allow it to send signals elsewhere, during a time
when there’s already too much serotonin from the cough syrup and herbal medicines
that GG took, all of this happening because no one ever knew about GG’s habits because
she hid them so well, up to the point where she couldn’t tell anyone about it, even
if it would save her life.
When it comes to over the counter cough medicine like dextromethorphan, conventional wisdom
says it doesn't cause a dependency, but that might not always be true. Also when it comes
to serotonergic agents, some can have long term effects when used inappropriately, and
that has been documented. I discuss how over the counter cough syrup can cause permanent
damage with a psychiatrist, on my second channel Heme Review, link in the description below.
This stuff doesn't come risk free when misused, just like in GG’s case.
After 2 weeks in intensive care and after all serotonin related medicines were halted,
GG’s symptoms slowly cleared up as she regained consciousness. It was after all of this that
she mentioned her cough syrup and herbal medicines to both her family and the doctors. Luckily
for her, her care from her doctors, and her care of herself could be continued in a much
more sustainable way.
Thanks so much for watching. Take care of yourself. And be well.