“Purple Drank” (Codeine and Promethazine Cough Syrup): A Systematic Review of a Social Phenomenon with Medical Implications

Miuli, Andrea; Stigliano, Gianfranco; Lalli, Aliseo; Coladonato, Massimiliano; Esposito, Fabiana; Cappello, C.; Pettorruso, Mauro; Martinotti, Giovanni; Schifano, Fabrizio; Giannantonio, Massimo Di

doi:10.1080/02791072.2020.1797250

Cited by 19 publications

(41 citation statements)

References 53 publications

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“…Often available with codeine in common cough suppressants, its abuse potential appears related to its calming and sedating effect, and enhancement of other co-ingested substances, such as benzodiazepines and opioids [34,48,117]. The abuse of promethazine mixed with a soft drink and candy with some variants including purple coloured alcohol ("purple drank") has become popular in young people for its euphoric effects and easy accessibility [12,28,37]. Despite being preferred to other substances, such as benzodiazepines, for the treatment of anxiety and sleep disorders in substance-dependent patients, promethazine has been reported to be misused among people with a SUD or an opioid dependence as a substitute for another drug (e.g.…”

Section: Promethazinementioning

confidence: 99%

Misuse of prescription and over-the-counter drugs to obtain illicit highs: how pharmacists can prevent abuse

Chiappini¹,

Guirguis²,

Corkery³

et al. 2020

The Pharmaceutical Journal

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There have been increasing reports of misuse of a range of prescription and over-the-counter (OTC) drugs for recreational purposes. The use of psychoactive pharmaceuticals and 'pharming' are new, widespread phenomena involving the non-medical use of prescription and OTC drugs, which are recreationally used to achieve psychoactive effects either on their own or in combination with other substances. This article provides an overview of the topic, focusing on a range of medicines (e.g. prescription medicines such as quetiapine, gabapentinoids, Z-drugs, bupropion, venlafaxine, and over-thecounter medicines such as loperamide, dextromethorphan, benzydamine, promethazine, chlorphenamine, diphenhydramine and hyoscine butylbromide) that have emerged as misused and diverted, or already described through the literature, as well as recorded by drug users' online websites reporting new trends and experimentations of drug abuse. This rapidly changing drug scenario represents a challenge for pharmacy, psychiatry, public health and drug control policies. Moreover, possibly resulting from the COVID-19 pandemic, drug use-habits and availability have changed, causing a shift in behaviours relating to both prescription and OTC medicines. Healthcare professionals should be aware of potential prescription drugs diversion, recognise misuse cases, consider the possibility of polydrug misuse, and prevent it where possible. Pharmacists can play a key role in preventing and reducing drug abuse and should be involved in evidence-based actions to detect, understand and prevent drug diversion activities and the adverse effects of drug-misuse.

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Section: Promethazinementioning

confidence: 99%

Misuse of prescription and over-the-counter drugs to obtain illicit highs: how pharmacists can prevent abuse

Chiappini¹,

Guirguis²,

Corkery³

et al. 2020

The Pharmaceutical Journal

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“…Conversely, promethazine is used in cough syrups for its antihistaminic, antiemetic, and sedative effects, available with codeine in common cough suppressants (128); its abuse potential appears related to its calming and sedating effect and enhancement of other coingested substances (Table 1). A recreational use of promethazine mixed with a soft drink and/or alcohol ("purple drank") is currently popular among young people for its euphoric effects and easy accessibility (19,20,(129)(130)(131). Promethazine has been reported in SUD clients and is misused as a substitute for another drug or to increase the effects of inadequate dosing (i.e., to delay the onset of opioid withdrawal or to potentiate the sedating effect of benzodiazepines/Z-drugs) (13,19,20,103,129,130,132,133).…”

Section: Discussionmentioning

confidence: 99%

“…A recreational use of promethazine mixed with a soft drink and/or alcohol ("purple drank") is currently popular among young people for its euphoric effects and easy accessibility (19,20,(129)(130)(131). Promethazine has been reported in SUD clients and is misused as a substitute for another drug or to increase the effects of inadequate dosing (i.e., to delay the onset of opioid withdrawal or to potentiate the sedating effect of benzodiazepines/Z-drugs) (13,19,20,103,129,130,132,133). Overdose of promethazine is associated with an antimuscarinic delirium, agitation, and neuroleptic malignant syndrome (100, 102,104,133).…”

Section: Discussionmentioning

confidence: 99%

Focus on Over-the-Counter Drugs' Misuse: A Systematic Review on Antihistamines, Cough Medicines, and Decongestants

et al. 2021

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Background: Over the past 20 years or so, the drug misuse scenario has seen the emergence of both prescription-only and over-the-counter (OTC) medications being reported as ingested for recreational purposes. OTC drugs such as antihistamines, cough/cold medications, and decongestants are reportedly the most popular in being diverted and misused.Objective: While the current related knowledge is limited, the aim here was to examine the published clinical data on OTC misuse, focusing on antihistamines (e.g., diphenhydramine, promethazine, chlorpheniramine, and dimenhydrinate), dextromethorphan (DXM)- and codeine-based cough medicines, and the nasal decongestant pseudoephedrine.Methods: A systematic literature review was carried out with the help of Scopus, Web of Science databases, and the related gray literature. For data gathering purposes, both the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and PROSPERO guidelines were followed (PROSPERO identification code CRD42020209261).Results: After completion of the selection, eligibility, and screening phases, some 92 articles were here taken into consideration; case reports, surveys, and retrospective case series analyses were included. Findings were organized according to the specific OTC recorded. Most articles focused here on DXM (n = 54) and diphenhydramine (n = 12). When specified, dosages, route(s) of administration, toxicity symptoms (including both physical and psychiatric ones), and outcomes were here reported.Conclusion: Results from the systematic review showed that the OTC misusing issues are both widespread worldwide and popular; vulnerable categories include adolescents and young adults, although real prevalence figures remain unknown, due to a lack of appropriate monitoring systems. Considering the potential, and at times serious, adverse effects associated with OTC misusing issues, healthcare professionals should be vigilant, and ad hoc preventative actions should be designed and implemented.

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“…Although codeine is most often found in cough preparations, these products are not benign. A recent systematic review of 137 articles on codeine misuse found that the phenomenon was widely prevalent across socioeconomic strata and is becoming more prevalent nationwide with increasing presentations of codeine misuse in social media 17 . The argument may be made that because codeine is a schedule three substance that it has lower abuse potential and thus warrants less concern from providers, however, this is invalidated by the fact that providers are more likely to query both buprenorphine products indicated for opioid use disorder and tramadol, both schedule three, than they are codeine.…”

Section: Discussionmentioning

confidence: 99%

Factors associated with the use of the prescription monitoring program by prescribers and pharmacists in Texas

Thornton

Varisco

Downs

2021

Pharmacoepidemiology and Drug

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Purpose To describe Texas Prescription Monitoring Program (PMP) use and identify predictors of PMP query for opioid and benzodiazepine prescriptions by prescribers and pharmacists. Methods Dispensation and query records from the Texas PMP for opioid and benzodiazepine medications dispensed between October 1, 2016 and December 31, 2018 were linked using common patient identifiers. Autoregressive linear regression was used to assess trends in utilization. Hierarchical logistic models were specified to identify factors associated with provider and pharmacist query of opioid and benzodiazepine prescriptions. Results Despite a significant increase in the total number of pharmacists (β = 169.85, p < 0.0001) and prescribers (β = 301.59, p < 0.0001) who used the PMP every month, the ratio of active to registered pharmacists (β = −0.0001, p = 0.75) and prescribers (β = −0.0015, p = 0.10) did not change. Pharmacists and prescribers were significantly more likely to query opioid and benzodiazepine prescriptions of 14 days or more, and those issued to patients new to their practice. Pharmacists were most likely to query opioid prescriptions for oxycodone (aOR = 4.51, 95%CI = 4.42–4.60) and prescribers were most likely to query prescriptions for buprenorphine (aOR = 2.24, 95%CI = 2.15–2.35) compared to codeine. Conclusion Changes in PMP utilization between October 2016 and December 2018 were driven by increasing registration, not increasing frequency of use among registered users. Use of the PMP is inconsistent and dependent upon patient characteristics thus limiting the utility of the PMP as a decision support tool. These results support the need for policy mandating PMP use in Texas and provide a useful baseline and framework to evaluate the effectiveness of mandate implementation.

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“Purple Drank” (Codeine and Promethazine Cough Syrup): A Systematic Review of a Social Phenomenon with Medical Implications

Cited by 19 publications

References 53 publications

Misuse of prescription and over-the-counter drugs to obtain illicit highs: how pharmacists can prevent abuse

Misuse of prescription and over-the-counter drugs to obtain illicit highs: how pharmacists can prevent abuse

Focus on Over-the-Counter Drugs' Misuse: A Systematic Review on Antihistamines, Cough Medicines, and Decongestants

Factors associated with the use of the prescription monitoring program by prescribers and pharmacists in Texas

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