News From the World of Addiction Medicine Research

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The latest issue of the Journal of Addiction Medicine, Vol. 7 (2) March/April 2013 had several interesting articles relating to opioid addiction and its treatment. Here’s my quick summary and thoughts on one of them, “Promethazine Misuse among Methadone Maintenance Patients and Community-Based Injection Drug Users,” by Brad Shapiro et al, pp. 96-1001.

This study attempted to get an idea of the prevalence of promethazine (better known under its brand name Phenergan) use in opioid addicts both in and out of treatment.

I was interested in this article because I’ve had methadone patients misuse promethazine. Most of these patients say that Phenergan gives them sedation with methadone, but most say it’s not a true euphoria, so I’m puzzled as to why they mix the two. Since promethazine can be sedating in many people, obviously I worry about overdose deaths when it’s mixed with methadone.

The authors of this study tested for promethazine in the patients enrolled in a county hospital methadone clinic in San Francisco. Twenty-six percent were positive for promethazine and only 15% had a prescription for this medication. Also, promethazine use was associated with benzodiazepine use.

The authors then recruited two hundred intravenous drug users, and discovered that only 139 were opioid addicts. Of those 139 addicts, seventeen percent reported promethazine use in the past month. However, of the addicts who had been on methadone in the past, twenty-four percent reported promethazine use in the past month.

What does this study tell us? The authors’ conclusion was that promethazine needs to be investigated further as a drug of abuse in opioid addicts.

Well, yeah.

My clinical experience gave me some thoughts about the study. For one thing, pregnant addicts were excluded. But in my experience, pregnant patients are the ones most likely to be prescribed Phenergan because of morning sickness during pregnancy. And this study doesn’t tell us much about the overdose risk when methadone and Phenergan are combined. Early in their article, they do provide some data: In Kentucky, over 14% of decedents from methadone toxicity overdose deaths also had promethazine present in their system. In Seattle, 2.5% of fatal overdoses had promethazine present.

Promethazine, along with many other medications, prolongs the QT interval just like methadone does. I haven’t seen any studies of methadone patients comparing QT intervals before and after promethazine, which may be helpful to further assess risk.

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5 responses to this post.

  1. Posted by Joy Auren on May 23, 2013 at 11:14 am

    Good to know!

    Reply

  2. Posted by kevin on May 24, 2013 at 6:44 am

    I have been told by other a few addicts like myself that promethazine adds to the effect of some opoid medications. Especially suppository promethazine. I have never heard this to be true with methadone. I think this was demerol, morphine, and fentanyl. I never liked downers. I was prescribed clonipin at 16 for anxiety. I have only taken either prescribed or non prescribed anxiety medication as it would normally be prescribed or at night b4 bed due to opoid addiction giving me sever insaumnia.

    Reply

  3. Posted by kevin on May 24, 2013 at 6:46 am

    Could u do a blog soon on opoid addiction and the side effects of it like causing insaumnia in some people soon? Please that would b interesting

    Reply

  4. Posted by Benjamin K. Phelps on May 27, 2013 at 9:28 am

    Dr Burson… I’m not sure what emotion this article stirred up in me, other than the initial “OMG, here we go again w/something ELSE.” I, for 1, have never heard of people at my clinic using Phenergan for euphoria – but I don’t doubt that a few have tried to, since there are addicts here & everywhere that will snort Ajax or Comet if they believe it will enhance or provide a high of ANY kind. However, to automatically assume (& I’m not saying that YOU, specifically, do) that this now makes Phenergan a drug of abuse or misuse among opioid patients b/c of this is an erroneous assumption, in my opinion – & could EASILY cause more damage to the MMT advocacy issue than we really want or need. Poly-substance abuse/misuse/addiction has ALWAYS been a problem among ALL addicts of ANY drug class. There is that small group of MMT patients that aren’t altogether serious – if at all serious – about their recovery, that will attempt to use ANYTHING that will “enhance” the sedative effect of their medicine (methadone, in particular). BUT, as 1 patient told you – Phenergan is NOT a “true” euphoria. I know that might sound a little strange to some people, but what that means is that every sedating drug is not a drug of abuse or 1 that causes euphoria. Feeling tired is NOT the same as a heroin nod. Many people can’t figure this out who’ve never known the feeling of each & understood the difference through experience. If the 2 were the same, as you know, we’d have to have Benadryl not just behind the counter, but even in the safe at the pharmacies, w/the schedule II stuff! There’s a good reason Phenergan & other sedating antihistamines aren’t scheduled/controlled – they’re NOT addictive. They cause no dependency of any consequence (if any at ALL), nor do they cause any psychological cravings of any kind that I’ve ever heard of in my many years of medical reading & research, as well as MMT advocacy. Now don’t assume that b/c of my advocacy for MMT, that I automatically want to sweep any negative information under a rug somewhere to avoid any bad light on my treatment… That, while I’ll admit it has been tempting to do at times, is NOT the type of person I am. I don’t want to pretend my treatment is a panacea while ignoring any/all negative effects it may bring on, b/c I don’t want to get to age 65 or 80, should I live that long, & find out I have cancer of the toenails from it (lol, but you all know what I mean, & my meaning IS serious). But I’ve witnessed the powers that be run amok w/stories such as this that turned out to be at least mostly bull-crap, if not 100% so. 1 such story? Easy. And again, let me preface this by saying that MAYBE some of you out there have seen this. I have NEVER seen it, but have heard it until I myself have wanted to vomit from the aggravation: What I’m talking about is patients (not in prison, b/c people do things in prison that we can’t even BEGIN to reckon w/out here) selling vomit outside a clinic to people wanting illicit methadone (& I’m NOT referring to spitting methadone directly out of the person’s mouth before swallowing [most clinics require the patients to speak before walking away to verify the medication was swallowed…] I’m talking about swallowing it, & then literally vomiting directly after leaving the clinic.) I’ve read & heard these accusations, mostly from NIMBY folks not wanting a clinic in “my town”, which, btw, they always claim doesn’t have a drug problem, but will if a clinic opens up there. Anyway, police officers have made these same claims, citing them as reasons to hassle people as they leave a clinic parking lot, or reasons law enforcement doesn’t want a clinic in the area, either. I’ve been in MMT over a decade at 4 different clinics. 1995/96 in Washington, DC; 1998/99 in Greenville, NC & again in 2002; 2003-present in 2 different clinics in Raleigh, NC. For those who don’t know my story, prior to coming to the 2 clinics in Raleigh, I was in legal trouble & never got to a stable dose prior to relapsing & getting into further trouble w/the law. It wasn’t that MMT didn’t work; it was that I didn’t stop breaking the law by passing fake prescriptions long enough after starting it prior to 2003 for it to ever actually work by finding a stable dose for myself. In those cases, nobody had ever explained to me how important dose is – I believed that if you were on methadone, you were on methadone, period. So if I relapsed, it meant MMT didn’t work. Many people erroneously believe this b/c a family member relapsed or never stopped drug use during or after MMT. But after taking it TOTALLY upon myself to research & read countless HOURS’ & articles/studies’ worth of material about MMT, this time when I began (12/10/2003), I finally knew what I needed to do. First & foremost was to BE HONEST w/my counselor, dosing nurses, & doctor. In doing so, we found that stable dose very quickly, & ALL illicit drug use stopped very quickly (about 4 months). Anyway, back to my original point, I would like to know: Do any of you out there know of (for a fact – not as hear-say) this “problem” of vomit-sales occurring in your clinic? At the risk of being shown to be wrong, while there may be a person or 2 out there that have been told it happened once a long time ago, or told that it happens, but have never seen it for themselves or had anybody offer to be the vomit-er to sell to them or to buy the vomit from them directly if they would oblige (be the vomit-ee, if you will), I dare say that most, if not all, patients out there on this board haven’t seen this happen or been asked/offered. And I can darn-sure say that at the WORST of my w/d’s, when I’ve been my weakest, in the most pain, & willing to do ALMOST (that’s the operative word here, btw – “ALMOST”) anything, I’ve never-ever-ever even considered for a MOMENT buying someone’s vomit to get a little (or a lot of) methadone to make me feel better. That’s more disgusting that I can begin to even think about, & it would do me no good in the world anyway, since I’d vomit it & the rest of my stomach’s contents right out before I could swallow it. And while overseas, I’ve heard of people injecting temazepam as “the poor man’s heroin”, I’ve never EVER seen/heard of it here. Now again, that does NOT mean it hasn’t or doesn’t happen. But is it a problem that we need to be up-in-arms about? I don’t see it. Nor do I know of it being something that any of the clinics I’ve been in have had a problem with. My knowledge may not be 100% complete in these areas, as I’m quite sure the directors don’t always feel the need to share these things w/me, but I dare say that most things that become problems of any proportion at my clinic, most of the patients know about them – or at least most of the patients that care to know about such things. So when a report like this 1 comes out from a single clinic or area, I want to see a little more evidence that it’s happening in another area that’s not directly adjacent to the 1 already in question before I believe that we have something worth worrying about on our hands. And personally, I’ve been prescribed Phenergan once while on MMT b/c of a bug that was making me vomit every time I sat up in bed for about 48 hours, to the point my mother was afraid I would dehydrate & get worse off if she didn’t force me to go to the doc & drive me there herself. I took 2 of them, got absolutely ZERO effect from them – & I’m talking about the problem of vomiting, but I could also extend this to saying I got ZERO sedation from them, b/c I get ZERO sedation effect from antihistamines when I’m on opioids anyway – & I gave the rest to my mother b/c she got the bug from me & was sick the next 2 days after me. But quickly, to touch on what I just said, I can’t take antihistamines when I’m in w/d’s, b/c they have a paradoxical effect on me & the RLS/akathisia gets amplified by about 100 times, & since that’s already the worst part of w/d, it makes me literally delirious when it happens. So I leave them alone during w/d’s – including tri-cyclic & tetra-cyclic anti-depressants like amitriptyline (Elavil) & mirtazipine (Remeron), which are also VERY potent antihistamines (about 100 times the strength of Benadryl, according to pharmacology papers). While ON methadone or other opioids, antihistamines & tri-cyclic (& tetra-cyclic) anti-depressants have NO effect on me in terms of sedation, even at higher doses. I know this b/c I was on Elavil while on MMT back in the late 1990’s, & have been on low doses of Elavil for nerve pain in my leg in more recent years while on MMT. When OFF of opioids of all kinds, these drugs (antihistamines & tri/tetra-cyclic anti-depressants) DO have a sedating effect on me most of the time. Occasionally, however, they will have a horrible paradoxical effect on me that is reminiscent of w/d’s, & that is VERY dangerous for me, b/c it makes me then crave b/c I feel at that moment like opioids would get rid of the RLS/akathisia that is making me nuts. I’ve had that directly lead to a relapse for me (heroin), & I won’t take chances like that anymore. But I do, while in MMT, sometimes take Benadryl for allergies (& a couple of non-sedating antihistamines – Zyrtec & Clarinex daily) (I usually take the Benadryl if I am out of the other 2), & I can tell you that insofar as that goes, I experience ZERO sedation from it, as I said before. I realize fully that this is just MY personal experience w/antihistamines while in MMT. But why anybody would take antihistamines as a high outside of prison, where they are frequently the ONLY thing people can find to take recreationally, is beyond my comprehension. And for that matter, while I saw people take Benadryl in prison for the sedation/high several times for lack of other substances of abuse to dabble with (particularly 1 camp at which I was housed for 8 months), Benadryl capsules were held by the nurses in the nurses’ station for that reason, & had to be stolen to take that way & prescribed to even have administered to an inmate at all, in which case, they were given 1 dose at a time, whenever prescribed to be taken. I never even bothered trying them in that manner, for a few reasons, not the least of which was that I worried I’d have that darn paradoxical thing happen & would go out of my mind all night long. But the BIGGEST reason I never did (& STILL never have)? As before… That’s easy! B/c opioids are my drug-of-choice, & antihistamines are NOT opioids, nor do they even produce an effect REMOTELY CLOSE to that of an opioid. Random sedation does not cut it for me. While Lunesta did become a problem for me for a relatively short time while I took it for the insomnia another patient on this post mentioned (caused by opioids), that was directly b/c Lunesta caused a euphoria for me – not JUST sedation! But since then, I stopped the Lunesta & found a non-controlled Rx medication that helps me sleep instead. And I’ve NEVER ONCE had the SLIGHTEST urge to take more than the prescribed amount. B/c sedation is, again, NOT the same thing as euphoria. Experiences w/any of this, anybody???? Does anybody echo my sentiments on this? Does anybody disagree?

    Reply

  5. Posted by Daphne Shaw on April 10, 2014 at 1:22 pm

    My first overdose was phenergan & methadone. Very ugly. I was on methadone for 15 yrs & taking phenergan messed you up worse than benzos & methadone. Nodding, talking out of my head, totally stupid. I’m glad those days are over & I’m still alive

    Reply

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