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Toxicology Rounds

Toxicology Rounds

What Do Sizzurp, Synthetic Cannabinoids, and Bath Salts Have in Common? They're Coming to Your ED

Gussow, Leon MD

Author Information
Emergency Medicine News: June 2013 - Volume 35 - Issue 6 - p 8
doi: 10.1097/01.EEM.0000431339.53269.2d
    Rapper Lil Wayne.

    Rapper Lil Wayne was admitted to the intensive care unit of Cedars-Sinai Medical Center in Los Angeles in March for recurrent seizures, making rumors fly across the Internet that his hospitalization was related to the abuse of a street drug called “sizzurp.”

    Sizzurp, also referred to as “Texas tea,” “lean,” “drank,” “purple drank,” and “syrup,” is commonly abused in certain areas of the country, and is especially prominent in the hip-hop music community around Houston. It consists of cough syrup containing codeine and the antihistamine promethazine, often mixed with a soft drink such as Sprite or Mountain Dew and further sweetened by adding Jolly Rancher or other hard candy.

    Lil Wayne has denied that his well-documented seizure disorder is related to “sizzurp,” attributing the illness rather to stress and overwork, but his fondness for the mixture is evident in many of his songs. Consider the lyrics for “Me and My Drank:”

    Up in the studio me and my drank...

    My home [boys] say I should slow down a little

    But this [stuff] that I'm on make me slow down a lot

    You bottle pop, I buy a bottle pop

    Drop some syrup in it...

    One more ounce will make me feel so great I can't feel my face

    Up in the studio me and my drank.

    Use of sizzurp became popular in the Houston area in the early 1990s, and is often associated with making or listening to the so-called “chopped and screwed” style of hip-hop. The tempo in these songs drags and pitch is lowered, an effect similar to slowing down an LP record. (Remember those?) The sensation of listening to this music is like swimming through a pool of molasses, a feeling that would be enhanced by the opiate and CNS depressant effects of sizzurp.

    Many kids who listen to “chopped and screwed” hip-hop believe use of “sizzurp” is safe, but it is not. In fact, at least two key figures in the Houston hip-hop community, DJ Screw (Robert Davis Jr.) and Pimp C (Chad Butler), died of causes attributed to abuse of sizzurp.

    Promethazine, one of the active ingredients, is a phenothiazine derivative that acts primarily as a histamine (H1) antagonist, and is now used to treat nausea, motion sickness, and allergy symptoms. Manifestations of overdose include central nervous system depression and the anticholinergic toxidrome. The most frequently reported signs and symptoms in a case series of 237 promethazine exposures were tachycardia, altered mental status, and delirium. Seizures were distinctly unusual, with only one case exhibiting seizure activity thought possibly related to promethazine. (QJM 2009;102[2]:123.)

    Codeine overdose, of course, presents with signs and symptoms of the opiate toxidrome — CNS depression, miosis, decreased respiratory rate, and hypoventilation. Any seizure activity from opiate toxicity is likely related to hypoxia.

    Synthetic Cannabinoids

    The Wyoming Department of Health reported four cases of acute kidney injury in March 2012 occurring in previously healthy young adults shortly after they smoked a synthetic cannabinoid. These patients had presented with nausea, vomiting, and flank pain, and were found to have elevated creatinine levels.

    An additional 12 cases were identified after this association was publicized. (MMWR 2013;62[6]:93.) Peak creatinine levels occurred one to six days after exposure to the synthetic cannabinoid product. Five patients required temporary hemodialysis, but all rapidly regained normal renal function. Workups did not reveal any other cause of acute kidney injury.

    Synthetic cannabinoids consist of cannabinoid-receptor agonists, originally developed as research chemicals added to mixtures of herbs or tobacco. They are often distributed in colorful packages, sold as “incense,” and labeled “Not for human consumption” in an attempt to skirt drug laws.

    Some of the products involved in these 16 cases were labeled “Spice Gold,” “Phantom Wicked Dreams,” “Mr. Happy,” “Clown Loyal,” “Lava,” and “Flame 2.0.” Tests on the implicated product and clinical specimens, which were performed in seven cases, revealed the presence in all but one of XLR-11, a fluorinated compound that had not been previously identified in synthetic cannabinoids.

    The take-home lesson for clinicians: Take a careful drug history, and ask specifically about use of synthetic cannabinoids if a young person presents with otherwise unexplained acute kidney injury.

    Bath Salts

    • Many incidents of bizarre behavior associated with bath salts have continued to pop up in the news over the past year:
    • Altoona, PA: A naked man was arrested after chasing cars down a street.
    • Puyallup, WA: A 27-year-old naked man was arrested after breaking into a private house.
    • Calgary, Canada: A naked man was apprehended by police after repeatedly ramming his face into a barbed wire fence.
    • Robinson, IL: A hallucinating naked man scrambled onto the hood of a moving car and hung on for a wild four-mile ride.
    • Lilburn, GA: A naked man, found running and screaming around a golf course, threatened to eat the faces of police officers who tried to subdue him.

    These incidents all were associated with use of bath salts, and you don't have to be Sherlock Holmes to detect the unifying feature. Stripping naked seems to be a not-infrequent manifestation of agitated delirium caused by bath salts, a finding probably explained by the combination of hyperthermia and altered mental status.

    Bath salts are still widely available over the Internet and on the street despite being banned in many states. These products contain a variety of synthetic cathinones, predominantly MDPV and mephedrone. These chemicals are hallucinogenic stimulants, similar to but often more powerful than ecstasy (MDMA), and can precipitate agitated delirium, seizures, rhabdomyolysis, and severe hyperthermia. (I am aware of one case where the core temperature was 109F.) Additional adverse reactions first reported within the past year include compartment syndrome and bleeding abnormalities.

    President Obama signed a bill last July banning a number of known chemicals associated with bath salts and synthetic cannabinoids, along with analogue drugs that might surface in the future. A number of the incidents I have cited took place long after the ban was in place. Unfortunately, bath salt-induced agitated delirium is frightening and lethal, and it might be coming to your emergency department.

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