"I have a prescription for Promethazine with Codeine. Do you stock the "XYZ" brand? That’s what I want — it tastes better." This statement hopefully raises a red flag to everyone in the pharmacy profession. Abuse of promethazine with codeine is increasing at an exponential rate. The state of Texas, according to the Drug Enforcement Administration Diversion Control Program, and especially Houston and southeast Texas, is experiencing a greater problem than anywhere else in the entire nation. This area is not one where we want to be a leader! Arrest trends indicate that people are traveling in from out of state because the drug is so easy to obtain in Texas.

The drug Promethazine with Codeine is commonly known "on the street" as "syrup" and/or "lean," the latter due to the abusers’ propensity of having difficulty in standing up straight. Syrup is abused across all ethnic and cultural boundaries and its popularity is growing rapidly. Syrup has been glorified in musical lyrics with references to "sippin’ syrup" and "smoking’ sweets." The term "smoking’ sweets" refers to the soaking of a marijuana cigar/cigarette in syrup prior to smoking. Older abusers typically drink their syrup "straight up" while younger abusers like to mix the syrup into "cocktails" using alcohol or popular soft drinks.

Drug dealers are collecting "syrup" from as many sources as possible for re-sale, including legitimate prescriptions, forged prescriptions, and importation from other countries. Current street values for "syrup" range from $25 and up — per ounce! We don’t normally think of "syrup" (or any other pharmaceutical product for that matter), when we think of a street corner drug dealer, but increasingly these people are also dealing in pharmaceutical products. DEA estimates that fully 30% of the drug problem in the nation is directly attributable to pharmaceutical substances like promethazine with codeine and hydrocodone and NOT marijuana, cocaine, and designer drugs.

Abuse frequently coincides with other drug abuses, of both legal and illegal substances. For examples, persons who smoke crack cocaine like "syrup" for the mitigating effects it has on the chest congestion and coughing from smoking the crack. Heroin dealers routinely deal in hydrocodone products including "syrup" and CNS depressants as well. Many pharmaceutical substances are finding their way into the school systems at lower and lower grade levels, because they aren’t "drugs" in the stereotypical sense, but "medicine that helps you to feel better" and because they are "legal" even though the way they are being obtained and/or used is illegal.

A person who is illegally attempting to obtain syrup normally makes use of one of the following methods: (1) forged written prescriptions; (2) fraudulent telephonic orders for new prescriptions or refills; and/or (3) written prescriptions from questionable prescribers.

Any prescription for a controlled substances bears scrutiny for fraud/forgery. Board rules require a pharmacist who has any question regarding the authenticity of a prescription to contact the prescriber before dispensing the prescription.

If the prescription is questionable, a pharmacist has a corresponding responsibility with the prescriber to ensure that the prescription is issued in accordance with an accepted course of treatment. For example, a single prescription issued for an antibiotic, alprazolam, diazepam, carisoprodol, and a hydrocodone product may be questionable considering the extreme CNS depressant additive effects of combining these substances. Even if the prescriber verifies the prescription, caution should be exercised if the same person returns to the pharmacy every few days with an identical prescription, or if a majority of the prescriptions from a particular prescriber are issued for the same medications/quantities/strengths.

A prescription for Promethazine with Codeine can also be checked by observing whether or not the presenter has symptoms consistent with the medication requested. Sometimes, a simple question that has no bearing on "syrup" (e.g., "How bad is the ear infection?") can reveal an attempt to obtain syrup illegally.