Sizzurp, Promethazine, and Neuroleptic Malignant Syndrome

Sizzurp is a common slang term for a recreational drug concoction based on promethazine/codeine syrup, a prescription medication used to control coughs and other symptoms related to allergies, colds, and certain additional upper respiratory ailments. In early 2013, this concoction gained new prominence in the media through its connection with a popular hip-hop performer named Lil’ Wayne, who suffered a series of seizures believed to be directly related to his sizzurp intake. In addition to seizures, use of sizzurp can potentially trigger the onset of neuroleptic malignant syndrome, a sometimes fatal condition linked to the intake of the medication promethazine.

Sizzurp Basics

Sizzurp qualifies as a recreational drug of abuse because it contains codeine, an opioid narcotic that can produce addiction through repeated use by altering the way the brain creates and uses dopamine, a neurotransmitting chemical responsible for triggering a profound form of pleasure called euphoria. Although specific formulas for making the concoction vary, most batches of sizzurp are based on promethazine/codeine syrup, which contains roughly 6 parts of promethazine for every 10 parts of codeine; the syrup also contains a small amount of alcohol. Other common ingredients in a sizzurp mixture include clear sodas, clear types of alcohol, and melted candies or some other additional source of sugar. People who drink sizzurp often display a characteristic loss of body balance and associated walking difficulties. Apart from these balance changes and euphoria, effects of the concoction typically include a sleep-promoting state called sedation and impairment of the brain’s higher mental faculties.

Promethazine Basics

Promethazine (known more formally as promethazine hydrochloride) is an antihistamine; this means that it counters the effects of histamine, a naturally occurring substance in the body that triggers sneezing, a runny nose, and other symptoms that commonly appear in people who have certain types of allergies. Chemically speaking, promethazine is also classified as a phenothiazine and a neuroleptic. The term phenothiazine describes a variety of substances that act as antihistamines or antipsychotic drugs when they enter the human body. Doctors and scientists sometimes use neuroleptic as an alternative term for any antipsychotic drug.

Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome (NMS) is a rare but very serious medical condition that occurs when the effects of promethazine or some other neuroleptic or antipsychotic medication make certain unwanted changes in the normal function of the central nervous system (brain and spinal cord). Although no one knows for sure what causes these changes, one likely candidate appears to be alteration of the brain’s ability to properly process dopamine, the same neurotransmitting chemical linked to the onset of codeine addiction (as well as addiction to almost all other well-known substances of abuse). This connection to NMS is possible because dopamine has other important functions inside the brain, including assisting in the regulation of normal body temperature and regulation of the basic ability to control muscle movement. When dopamine levels change, they can produce profound alterations in these functions.

The National Institute of Neurological Disorders and Stroke lists potential symptoms of NMS that include abnormal muscle rigidity, dangerously elevated body temperature (known medically as hyperthermia or hyperpyrexia), and reduced or altered mental awareness. NMS can also produce significant changes in the normal function of the autonomic nervous system, an involuntary nerve network that helps control ongoing function in the body’s vital organs. Specific changes in this system associated with the effects of NMS can include a rapid heartbeat (tachycardia), unusually rapid breathing, an unstable pulse, unstable blood pressure, abnormally high sweat output, and a form of heartbeat irregularity known variously as an arrhythmia or a dysrhythmia. Ultimately, the effects of neuroleptic malignant syndrome can escalate to a point where they become deadly.

Considerations in Sizzurp Users

Normally, doctors control the risks for neuroleptic malignant syndrome in promethazine/codeine syrup users by limiting the prescribed intake of the medication and screening their patients for the presence of underlying factors that can contribute to the development of the disorder. However, since sizzurp users take promethazine/codeine outside of the context of medical treatment, they don’t receive the benefits of a doctor’s guidance. This makes it likely that very few people who use sizzurp have ever heard of NMS, or have any understanding of the risks they’re taking by using promethazine without a prescription or a physician’s input. It also means that affected individuals may fail to recognize the initial effects of NMS, and therefore may fail to seek help for their condition until serious or severe health complications arise. Since sizzurp use is fairly new from a medical research standpoint, no one really knows how many people are at risk for the unexpected onset of NMS.