Promethazine On The Street

For the kids who can’t manage to keep appointments — let alone blood tests — there are lots (and I mean lots) who qualify for the anti-psychotics that are also FDA approved as mood stabilizers.

Those who know me as The Renegade Doctor sometimes get the mistaken idea that I am against all prescription drugs and that pharmaceutical treatment should always be avoided.  That could not be further from the truth.  I believe in the proper treatment for the proper condition.  At times, I may disapprove of the methods and conduct of “Big Pharma,” but I will always use the best treatment for my patients – especially if it is FDA approved and a legitimate indication.

My favorite mainstream choice in the above example is usually arapiperazole (Abilify). The case study I’ll share with you is a patient who sometimes hears some voices and would like to get rid of them. So that is the medicine I offer this 22 year old hip hop composer with one of those cylindrical “spreaders” that resembles a manhole cover in his right ear lobe (I wouldn’t have picked it myself, but he told me his girlfriend thought it was real hot).  Now sometimes this drug is stimulating and people have trouble sleeping.  So my usual suggestion with this would be a touch of Benadryl (diphenhydramine) – an over-the-counter allergy pill – which causes drowsiness and could help him sleep.  It’s even available in those “99-cent” stores that dot the countryside.

“Can’t I just use some promethazine syrup for sleep?” Saints preserve us from street pharmacologists.  They know more drugs than third-year pharmacy students and their guidelines are urban-legends rather than the Physician’s Desk Reference.

“Probably not a good idea,” I say.  I restrain my shudder, as I don’t consider pharmacology an amateur sport – as opposed to skateboarding down the courthouse steps. I knew he wasn’t asking for a prescription for promethazine syrup.  I may be too old to be his “homie” but I knew he could easily “score” it on the street — on the street in even a small rural California town. You don’t have to live in LA or SF to find this stuff.

I looked it up at one of my online references, even though I knew perfectly well what it was.  How desperate, how poor the choice to make this a drug of abuse. This is used for sleep sometimes in other countries.  An over the counter antihistamine, an anti-vomiting drug, used in other countries where they can’t get the powerful and addictive benzodiazepines that seem to be the current backbone of American medicine.

Not MY medicine, you understand, but ubiquitous in American pharmacopaeia. The drug I’m talking about is a phenothiazine –10H-Phenothiazine-10-ethanamine, to be exact. They are drugs that are used to treat psychosis, which means hearing voices when nobody is there.  Like haloperidol (Haldol) it has been used in the “good old days” (ie France prior to Estelle) to put a quick end to diarrhea, but the physical effects were so horrible that the few old-timers who still had a bottle sitting around the house in rural France usually dumped it down the drain.

How bad did it make you feel? The first French Medical joke I remember went something like: “Why did the farmer tie a string around the neck of the bottle of Phenergan (promethazine) and hang it from the porch?” Answer: “Because the doctor told him if it made him feel sick, he should suspend treatment.”

It is not much funnier in French, but the guy who told it to me really knew how to deliver a joke.

A lot of the old-time drugs are horrible to take.  Sure – they may stop the symptoms of the illness, but they make the patient so miserable that people stop taking the drugs.  They would rather be tormented by mental illness.  I’m talking about Thorazine (chlorpomazine),  Serentil (mesoridazine), even Navane (Thiothixene)? I haven’t prescribed any of these drugs for many years, but I still run into them in systems where patients aren’t given a choice of better treatments – prison, military service, government welfare clinics and cheap HMOs.

This particular family of drugs originated in the German dye industry.  I guess it killed all kinds of parasitic worms and was used as an antimalarial. Any French pharmacology course would start with Laborit, Delay and Deniker and the French pioneers who in the early 50s – about the time I happened to be occupied being born.  The docs started giving this stuff to the grossly psychotic.

I had a friend once, a wonderful friend, in the wonderful rural town of Winfield, KS where they have a world-famous bluegrass picking festival and also a state hospital. When she first started working there, it was a self-sufficient, economically productive working farm.  When the people who lived there — the “residents”  –were not calm, there were a lot of what she described as  humane and loving treatments like water and baths.

Sure, it sounded a little primitive, perhaps, but there were blankets and music and baths but most of all — she told me — a lot of interpersonal contact. It even sounded almost “loving,” like a surrogate family.

It was difficult to introduce Thorazine — chlorpromazine, the flagship of this group of phenothiazines which have some antihistaminic and antiemetic and other effects. America was more psychoanalytic than drug-based, but their advisors decided to move forward and she remembers what happened. The population was silenced.

She remembered the sounds of the psychotic patients who would yell and need comfort. They stopped yelling.  The silence was eerie — a relief to some staffers, but my friend felt there was some kind of loss, of identity, even of humanity. There was, nevertheless, a sense of peace. They went “forward.”

The analytical capital of psychiatry was in nearby Topeka, KS, at the Menninger Institute.  Yes, I went to some lectures there when I was hanging out in Kansas learning all the psychiatry I possibly could.

Meninger’s analysts  were different from us pill-pushing folks.  These guys seemed to talk forever, and depended on understanding to make people well. While our analytic colleagues seemed to talk people to death, we pharmacologists made them “better” faster — and admittedly, sometimes may have thought ourselves superior.

Back at the state hospital, my friends and her colleagues noticed something else curious. Everybody who took chlorpromazine started to walk funny — shuffling, kind of stiff — a walk we can find now only the oldest of state hospital patients, or former patients of the veteran’s system released into nature.

The neuromuscular side effects of this group of drugs include — besides the infamous Thorazine shuffle — muscle aches and stiffness and the inability to sit still.  Sometimes, muscles are contorted into strange postures.  In many cases, patients will be afflicted with a twisted neck that needs an injection, fast, because people are in pain. Side effects of these drugs were routinely treated with – you guessed it – more drugs.  One such — muscle relaxants that were cholinergic could give the patients occasional delirium.  So the chain of side-effects and more drugs mounted.

I think this is terrible, but I remember one couple in rural Oklahoma who learned to live with it. The wife suffered with occasional transitional delirium and I offered to help solve this. The husband told me that he hadn’t realized this was a problem.  When she acted out, he said, “I just thought she was a fun date.”

Usually it is taken far more seriously, as people can forget some pretty basic things such as who and where they are. The most feared side effect of this group of drugs — the one that at one point at least was the major cause of lawsuits against psychiatrists — is something called “tardive dyskinesia.”  It means flapping and twitching of mostly face, tongue, hands and feet and it does NOT go away when you stop the drug.  It is an inheritance for the rest of one’s life.

There are ways to treat this – at least that I use — with vitamins and other natural stuff.  But healthcare systems that don’t meddle with such common sense results tell patients that it is their cross to bear and there is nothing that can be done.

(NOTE: If a patient is told that there is nothing that can be done for them, it usually means “we can’t be bothered with it,” or “we never heard of it” or “we just don’t offer it” – or maybe “your coverage doesn’t pay for it.”  I always recommend a second opinion in these cases).

So in my current practice I am saving people from this drug — promethazine– trying to get them on something else to get them moving and functional and new and figuring out who is going to pay for it, and getting people fixed and looking good. And yet some other people are seeking and joyously abusing this drug.

In the case history above, I took a little time to tell my little hip hop composer with the ear spreader an abbreviated form of what I’ve just shared with you. That is part of my standard “advantages and risks” talk.

He looked at me incredulously.  None of his friends had problems, only a nice sleep.  And a nice sleep it was, too. Sometimes muscle twitches and there were no problems, just kind of fun, when a limb jumped, but then you had this really mellow sleep. I realized since he was not the most verbally articulate person I had ever met, that he was rattling off patter from some drug dealer whom he trusted more than me. In such cases, my diplomas are not of much help.

I just don’t have the “street cred.”