Drug Risk: Benadryl® (diphenhydramine) overdoses in Oregon, Robotripping, and Purple Drank

DrugMonkey just had an interesting post about the potential influence of cocaine use trends following the 1986 death of Maryland college basketball player, Len Bias, just days after his being selected in the NBA draft by the Boston Celtics. DM's post and the ensuing discussion got me thinking tonight about a variety of issues in substance abuse, realistic assessment of risk and, ultimately, parenting.

In the comments, I mentioned that Heath Ledger's recent death might be a trigger for pop culture to pay more attention to the risks of recreational use of prescription and over-the-counter drugs as the attitudes toward illegal substances have grown less favorable.

Related to the DrugMonkey post, PharmGirl just tipped me off to this Benadryl nightmare at the Sweet Hill (OR) High School. Students have turned up in local emergency rooms after having taken 20 to 30 of the tablets, each containing 25 mg of diphenhydramine HCl.

At high doses, diphenhydramine's central antimuscarinic effects become apparent as hallucinations but this is a terribly risky approach. Suppression of parasympathetic drive to the heart can cause tachycardia and lead to fatal cardiac arrhythmias. The story is deeply concerning:

Anastasia Park, 15, said she decided to try Benadryl after hearing about it from a friend. I took 30 the first time and 20 the second time," Park said. "I got sent to the (emergency room) both times."

Yes folks, she ended up in the ER once and still tried it again, this time taking "only" 20 tablets.

To their credit, the school district is educating students on the risks of ODing on Benadryl/diphenhydramine and sent letters home to parents advising them of this dangerous trend.

While on this topic, I thought I'd say a few words about a couple other drug trends among adolescents and young adults. A common practice among high school and college kids is Robotripping, taking high doses of dextromethorphan-containing cough syrup with the intent of drifting off into a dissociative mental state. While dextromethorphan, or DXM, can have its own toxic effects the dangers of robotripping can also result from other drugs present in OTC cough syrups.

According to my University of Florida pharmacy colleague Paul Doering from an interview late last month:

[R]obotripping is another example that teens regularly "find new and creative ways to hurt themselves. They have a crazy notion that if something is in a drug store, it has to be safe. That's what is driving this trend among teens and young adults away from street drugs and to prescription or over-the-counter drugs."

Doering said the ingredient dextromethorphan, also known as DXM, can drastically increase heart rate and blood pressure and can induce life-threatening effects such as seizures and elevated blood pressure. Other ingredients in cough and cold medicines also can create serious problems. For example, large doses of pseudoephedrine and antihistamines can cause high blood pressure and seizures, and acetaminophen can cause liver failure.

Sippin' Syrup: Purple Drank
In the southern and southwestern US, codeine-containing prescription cough syrups have been popularized since the beginning of the decade by rap artists who often sing/sang of "Sizzurp," "Lean," or "Purple Drank," the latter in reference to the purple-colored label or dye present in these products. These syrups often also contain antihistamines like promethazine (to offset the nausea-inducing effects of the opiate in sensitive individuals).

Houston-based rapper, Pimp C (Chad Butler), was found dead in his Los Angeles hotel room last December at age 33 from partaking in a codeine-containing cough syrup which, together with his history of sleep apnea, led to fatal respiratory depression. The Dallas Morning News noted that the bottle of syrup found in Pimp C's hotel room did not contain a prescription label - not a surprise, as they report:

Houston has dealt with an epidemic of the illegal use of cough syrup for several years. In 2006, four local pharmacists were found guilty of drug conspiracy for selling more than 2,500 gallons of it to people without prescriptions.

Pimp C was not the first high-profile cough syrup-related casualty in the rap community: he was preceded in death by other Houston rappers, DJ Screw and Big Moe.

This discussion thread from 2004 (still live at faqs.org) gives some sobering insight on the rap community's syrup scene.

Telling kids the truth
As DrugMonkey co-blogger PhysioProf noted,

Kids try to get high on Robitussin!? What the fuck ever happened to just raiding your parents' liquor cabinet and smoking some doobs?

Kids are always going to, as Prof Doering said, "find new and creative ways to hurt themselves." And kids are always going to experiment with various mind-altering substances, but there are some that can hurt much, much more than others. As a parent of someone who is not yet of that experimenting age, I often think about how we will negotiate these challenges in a very few short years.

Adopting a parental attitude of complete substance abstinence is likely to be as successful as endorsing sexual abstinence, but condoning any substance use in minors will get you thrown in the slammer and have your kids taken away. Of course, you'd love for your kids to stay clean and not use alcohol until they are 21. You want to tell your kids how cough syrup can kill you and how huffing solvents will give you extremely serious brain damage.

But it's stepping over the line to tell them if they're going to choose any illicit behavior, there are far safer alternatives.

How do other parents ethically approach this conundrum?

Addendum: Frequent and thoughtful commenter, DuWayne Brayton, expounds at his blog Inalienable Rights on "Drugs and Children, the Conversation that Never Ends."


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Yes folks, [Anastasia Park, 15] ended up in the ER once and still tried it again, this time taking "only" 20 tablets.

And yet, five years from now, she'll probably have more children than me. This is proof that Darwin is wrong.

Like you, I have these dilemmas to look forward to a few years from now. I don't think anything I say will stop my son experimenting, because nothing my parents ever said to me stopped me.

All I can do is provide education about the risks and dangers, and a trusting environment where he feels comfortable enough to talk to us about what he has done or what he's planning to do. I hope advising against things without expressly forbidding them will be enough.

Alcohol is the easiest one to deal with. I was given wine or beer at special occasions and dinners from a fairly early age, so it was never "forbidden fruit" for me. When I reached the legal drinking age (18 where I came from) I didn't feel the need to go crazy on drink (well, not as crazy as some of my peers anyway).

Arghh...I have a little one, and I hope she is smarter than, well, others when she gets older.

I see a lot of drug abuse, but i don't see adolescents, so most of it is the "usual" stuff, plus heavy duty prescription narcotics.

teens regularly "find new and creative ways to hurt themselves.

This is a total fucking lie. Teenagers find new and creative ways to get high, which happen to be dangerous, for the sole reason that the known relatively safe ways to get high--moderate alcohol and weed use--are demonized with demented "zero tolerance" and "just say no" approaches.

Human beings have been getting high for thousands of years. The idea that we're somehow going to convince teenagers not to get high is fucking delusional. If we want them not to go to the drug store and start buying and ingesting huge quantities of over-the-counter shit that can seriously harm them in the quest to get high, then we should allow them to use marijuana and alcohol moderately.

Derek---This is proof that Darwin is wrong---

No, this is proof that Darwin was right. Nature does not have to follow some morality-based (or even rational) design or logic.

PP--it is kind-of a lie, not a total fucking lie. It is hard to separate out the self-harm aspect---Teens do show abnormal predisposition towards highly risky pursuits (I'll try to dig up the study--someone help if you have it handy). But it may all be to, essentially, 'get high' like you said.

Abel---Ultimately a great question; tough to come up with a universal answer. A lot of this will be kid-specific. But to the extent we can generalize, I agree with PP that education and moderation are the best approach. At least it will be mine---and I expect to be presented with this situation anyday now in my home.
Abstinence-based approaches will, in my experience, be more often disastrous than not. I commented on DM's post to the effect that discouraging experimentation is no substitute for aggressively pursuing the understanding the basis of addiction and the best way to treat addicts. Of course, I am probably preaching to the choir here.

and I expect to be presented with this situation anyday now in my home

if you have not taken the initiative you may already be a bit late on the topic...

In my home, we have opted for a completely honest approach. While we have plenty of time to deal with the issue, it's also never too early to lay the groundwork.

First, we have already broached the topic by discussing people we observe in public. Mostly this involves talking about people who are more obviously intoxicated, but we have also observed people smoking crack in the streets, a couple of times. Not only have we discussed the people we've seen, but after the second time he observed someone smoking crack in a doorway, while on our way to the park, I allowed the (then) five year old to question the person we observed. Later I also had him discuss addiction with a gent who occasionally works for me, who is also a recovering crack/meth addict.

Next, we also discuss the experiences of both his mother and I. We talk about the drinking we both used to indulge in, to some excess. We talk about the vast array of drugs that I have used over the years. And we talk about the marijuana that momma and I still occasionally indulge in. I especially, have rather a lot of experience with the use of enthogens, I'll be damned if I'm not going to use that experience as part of the discussion.

Most importantly, we focus on the real-world consequences of using various substances, from the most likely consequences, to the least likely consequences. The strongest focus is placed on the damage that drug use will cause a developing brain. So rather than saying that smoking a little weed is going to turn one into a crack whore in a few years, I say that smoking pot before one is in their early to mid twenties, is very likely to prevent the brain from developing to it's full potential. It isn't until the end of the list, that we mention the potential for eventually becoming a crack whore.

I think that the most important thing though, is helping kids develop strong self-esteem and confidence in their ability to talk to you about absolutely anything they want. You won't get a lot of options for approaching the issue, if they aren't comfortable discussing tough subjects with you.

In short, this is a topic that we have already started on, when the oldest was three. Nothing huge, just laying a foundation for it. At the very least, we are making it clear that this is not an issue we are afraid to discuss. We are also making this discussion a familiar one, a habit if you will. We are doing the same thing with the sex/reproduction/venereal disease discussion, as well as other "hotbutton" topics. Making these sorts of discussions a habit, can only work for the positive.

The most important aspect of this approach, is that it removes the mystery from these "forbidden" topics. Even if your a parent who never really got into experimenting with substances, you can find out about them, even with your child. You can find people who do know about these issues to talk to your kids, narcotics anonymous is a great organization to call for help in finding appropriate people.

I also have to disagree with this assessment; But it's stepping over the line to tell them if they're going to choose any illicit behavior, there are far safer alternatives. I just don't buy it. There is absolutely nothing wrong with trying to protect one's child and the honest truth of it is, there are safer alternatives out there. Just like there is absolutely nothing wrong with encouraging ones kids to wait until they are a little older and more mature, before they have sex - while at the same time educating them about using condoms. It is not an endorsement to tell them to us protection, if they decide to have the sex in spite of your encouragement towards waiting. Neither is it an endorsement to say that having a beer or two, is safer than huffing nail polish remover. Or that smoking a joint is far prefferable to taking massive overdoses of cough suppressant.

Clarifying that not all substances are as likely to be lethal as others, doesn't mean one has to endorse the use of less dangerous ones. This is where I think the honest risk assessment is most important. More important than anything you can do in this discussion, is never, never ever overstate the risks. Kids will learn eventually is an assessment is bullshit or not. If you use the scare tactics, you will lose all credibility, something we can ill afford as parents who love and want what's best for our children.

It's a tough balancing act, but I am a firm believer in giving kids a full arsenal of information, honest risk assessments, confidence in your ability not to freak out when they broach hard subjects and above all, maintaining credibility.

"find new and creative ways to hurt themselves.

That certainly is not the intent in the vast majority of cases> And the majority of cases occur because adolescents often have the impression that they are bulletproof: "It won't [of can't] happen to me.

By natural cynic (not verified) on 02 Mar 2008 #permalink

All right, I tried to post a rather more coherent response to this on my own blog. Not sure if it worked or not, but I think I was a little more clear.

Sorry to miss all of your great comments today - tried an 18 hr internet-free day.

@lambic - I agree that the approach taken by the British and other Europeans toward alcohol is far more healthier than the zero tolerance mindset in the US whereby one suddenly becomes capable of managing drinking at age 21. As you note the age being 18 when you were coming up, I know that many US university presidents and administrators quietly advocate for a reduction in the US drinking age from 21 to 18.

@Prof Redfield - honored to have you stop by. Indeed, DXM has been a favorite but I don't believe it was called Robotripping in the 60s. Codeine cough syrup mongering was also quite prevalent in those days, particularly when it wasn't Rx and merely had to be signed for (like today's pseudoephedrine but with no formal ID). Not sure if anyone's read Jim Carroll's Basketball Diaries but he spoke of his adolescent days trolling every pharmacy in the neighborhood and signing for codeine syrup as Abe Lincoln or some other pseudonym - often the pharmacist would say, "Sorry, Abe's already been here today."

@PalMD - you are doing yeoman's work; my hat's off to you.

@PhysioProf - yes, I agree that lawmakers fail to recognize the basic tendency of humans to seek out intoxicants. I couldn't agree more with your statement, "If we want them not to go to the drug store and start buying and ingesting huge quantities of over-the-counter shit that can seriously harm them in the quest to get high, then we should allow them to use marijuana and alcohol moderately."

@Anonymoustache and DrugMonkey - the post didn't start off as thinking about parenting but that's how it ended up. My guess is that DM knows about good info sources for starting the conversation with your kids - I've even seen some sources describing what to do with kids aged 4-7.

@natural cynic - yes, the immortality factor also plays into it - heck, the rappers promote "sippin' syrup" despite several high profile deaths - even kids in their 20s think it'll never happen to them.

@duwayne - before I saw your second comment I was going to e-mail you that this would be a great post at Inalienable Rights. Thanks for starting the discussion here.

Indeed, I was very ambivalent in writing, But it's stepping over the line to tell them if they're going to choose any illicit behavior, there are far safer alternatives, and changed it many times before posting. My intended meaning was that if I were to counsel my kid about it being okay to smoke weed or drink but not to huff glue or gulp DXM syrup and it got back to school and/or other parents, all hell might break loose (depends on where one lives, of course). The issue gets back to PP's comment that the laws almost force kids to go and do stupid, risky things when a more realistic assessment of national drug and alcohol policy might lead to more responsible behaviors than this zero tolerance atmosphere.

A friend told me about a situation involving a friend of his: the mother doesn't talk to her 8-year-old son about drugs, although she smokes marijuana (and apparently grows it in the basement), because he's in DARE at school. DARE teaches you to turn people in who take drugs, and she's afraid that if the kid knows, he'll turn her in.

I have no idea how widespread this situation is, but there are many, many parents out there who take drugs, so it perhaps sheds some light on why parents are not open with their kids. They don't want to get caught, and they think that if they tell their kid they do these things the kid's "Just Say No" DARE education will come to naught. They certainly don't want their 8-year-old saying to their class, "But my mom smokes marijuana and it's fine."

In my opinion, though, when the kids inevitably find out later on that Mom was smoking/drinking/whatever the whole time, it leads to even more devastating consequences. Parents should be honest.

When my son was in middle school we went through a period where I kept finding empty aerosol cans. I'd read some accounts of kids sniffing the refrigerant in air conditioners and had this horror that maybe they were sniffing stuff from these cans.

Of course I mentioned that this was dangerous and damaging and that they should not be experimenting with this! They swore to me that they didn't know a thing about it.

I come home from work early one day and caught them in the backyard with the cans. They were using a lighter to light them and make a torch.

I was so relieved, they were just risking death by fire, not brain damage by sniffing. Then I pointed out that was dangerous too and they'd better stop it immediately!

My feeling is that it's always something and you have to stay on top of things. I also got some advice from my kids' psychiatrist who said don't let on how snoopy you are being they'll hide what they're doing from you more and then it'll be hard to find out.

It's not ideal, but I grew up in the 60s and knew kids who did too much LSD and never were the same, so I'm happy that they got through their teenage d years with most of their brain cells intact.

I also don't think it's accurate to say that kids are looking for new and inventive ways of hurting themselves. There have been plenty of studies done which show what most folks have intuitively known for years -- that the ability to really be aware of long-term consequences does not develop fully until the mid-20s. So even an 18-year-old isn't completely mature....

Of course, this is precisely why the military likes to recruit 18-year-olds. They make very good soldiers because they are willing to do or die. They know they might die, but they don't quite completely *feel* that "or die" part. They don't think enough about what it is they'll be losing. And with the exception of a few early bloomers, there is absolutely nothing you can do to make them understand. And I mean really understand.

That is, of course, the problem with expecting kids to take the right message home from sex ed, and anti-drug programs. Even knowing the consequences, many of them will still brush it off. When I was in high school, I didn't do drugs (illegal, legal, or homemade) to get high. Nor did I have sex. But I wasn't avoiding drugs to avoid long-term health consequences, nor was I avoiding sex to avoid an eighteen year commitment to a new human being. I was avoiding doing those things because they were wrong and I'd get in trouble if I did them and I wanted to be a good girl, not like those losers who were stoned all the time or sleeping around for kicks. In short, I stayed clean because of a very immature but quite characteristically teenaged mentality -- because I didn't want to be a loser.

(Of course, many kids who *do* do drugs and/or get pregnant do it because they don't want to be a loser. It's a bitter irony.)

This is why abstinence programs fail, and why it's so hard to teach kids to stay away from drugs. I personally think the best approach is to teach them about drugs (equip them with science, basically) and then go on to teach them that there are better ways to have fun, ways that don't end up with you lying in a puddle of your own vomit. I remember being particularly influenced by a short story about a girl in her school's swim team who did amphetamines. It made her feel like she could beat anybody, but her actual athletic performance dropped considerably -- and because she was on drugs, she couldn't tell. Her friends could tell something was wrong with her, but the tragedy was that she couldn't, and so she kept using the drugs. I don't recall how the story ended, but I remember that image of a pathetic kid trying so hard to succeed but shooting herself in the foot. A classical tragedy, structurally speaking. I was on the swim team myself, so that probably made the story hit closer to home.

By Calli Arcale (not verified) on 04 Mar 2008 #permalink