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.
