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It may be hard to imagine that a soft drink mixed with cough syrup is a potentially deadly combination. But a drink called lean, also known as “purple drank” or “sizzurp,” is a combination drug that gained popularity in the late 1990s due to its cultural influences. Lean is blended with cough syrup—containing the opioid codeine—and various beverage ingredients. Severe or even life-threatening lean withdrawal symptoms can result from the misuse of promethazine and codeine, particularly when combined with other substances.1
The Lean Beverage
The lean drink is a party drug, primarily seen in use by a younger demographic in social situations where mind-altering substances, including alcohol, are readily available. Codeine is the drug component of lean that is responsible for its “high.” Although lean is often used socially, when consumed frequently, it can lead to physical dependency. A physical dependency can occur, particularly with drugs such as codeine, as the body naturally adapts to recurrent substance use.
Lean contains prescription cough medicine with a drug called promethazine—a prescription antihistamine and antiemetic—and codeine—a natural opioid medication that is approximately 1/10th as potent as morphine. Soda, alcohol, or candy is mixed with cough syrup to create lean. It can be customized with other drugs (e.g., hydrocodone, cocaine, or PCP) to cause psychoactive effects in addition to the sedative and euphoric effects associated with large doses of antihistamines and opioids.
The antihistamine effects of promethazine are primarily sedative. While promethazine is primarily used to treat allergy symptoms and motion sickness, it is also employed in medical settings as a mild sedative before and after outpatient surgery. Codeine is a Schedule II narcotic in the opioid class of drugs that relieves pain, promotes relaxation, and produces a euphoric effect when taken in large enough quantities.12 The Schedule II classification indicates that codeine has legitimate medical uses, but is also considered to have a high-risk profile for misuse and potential addiction. Opioids include natural and synthetic substances, including Schedule II prescription medications (e.g., morphine and oxycodone) and Schedule I narcotics (e.g., heroin) that have no accepted medical use.
According to the National Institute on Drug Abuse, a study found that 50% of Instagram messages about codeine pertained to lean.11
How Lean Got Its Name
Lean provides an inexpensive, quick “high” that is often easier to obtain than alcoholic drinks or other types of drugs. The name evolved from the need to “lean” on something to avoid falling over due to the drinks’ inebriating effects. A person is said to slouch or lean to one side after consuming the drink.
Lean Withdrawal Symptoms
Lean withdrawal symptoms may occur when you limit—or eliminate— the amount of lean you use.2, 3, 5 You must use heavy amounts of the substance for an extended time before stopping use to experience withdrawal.5
Withdrawal involves mental and physical effects after you stop or reduce using a substance—such as certain drugs or alcohol. A wide range of withdrawal symptoms can occur when quitting the use of substances with a high dependency potential. The symptoms depend on many factors, such as:
- The substance used
- The amount and duration of use
- Other factors
Withdrawal symptoms, such as those experienced in lean withdrawal, can be unpleasant or even dangerous in some instances. Consult with a healthcare provider before suddenly stopping or slowing down with regular use of lean.
Acute withdrawal symptoms usually begin within a few days or hours after discontinuing substance use. Post-acute withdrawal can involve withdrawal symptoms that occur months or longer after abstinence from a substance.
The symptoms of lean codeine withdrawal can mimic the effects of opioid or codeine withdrawal symptoms. Codeine and opioids are known for a high risk of life-threatening overdose because these drugs depress the central nervous system (CNS). CNS depression can lead to respiratory and cardiac arrest (i.e., a heart attack).
In lean misuse, if alcohol is mixed with codeine, the risk of overdose dramatically increases. According to the National Institute of Drug Abuse, “Deaths from prescription opioid medications now outnumber overdose deaths from all other drugs (including cocaine and heroin), and codeine-promethazine cough syrup has been linked to the overdose deaths of some prominent musicians.”12
Symptoms of opioid withdrawal include:5
- Aching muscles
- Runny nose
- Difficulty getting to sleep or staying asleep
- Uneasy or generally dissatisfied mood
A person must have at least three symptoms to qualify for an opioid withdrawal diagnosis.5 When alcohol is added to lean, other symptoms may develop associated with alcohol misuse. Consult with a qualified clinician to understanding the significance of lean withdrawal symptoms.
Lean Codeine and Promethazine Withdrawal
Withdrawing from codeine and promethazine can be very uncomfortable and potentially dangerous. Opioid drugs like codeine impact the brain system that controls pleasurable feelings and mood called the limbic system. When the drug is no longer available in the brain, it leads to mental and physical discomfort, typically for up to a week. Some lean withdrawal symptoms can last even after the initial withdrawal symptoms are over.
Symptoms of promethazine with codeine oral solution withdrawal may include:2
- Anxious mood
- Irritable mood
- Back pain
- Weakness or fatigue
- High blood pressure
- Increased heart rate
- Faster breathing
- Loss of appetite or weight changes
- Stomach cramps
Lean withdrawal can be dangerous; it can even be life-threatening in some circumstances. The prolonged use, misuse, or use of codeine without medical supervision could potentially result in opioid dependence.
Complications can occur if a person does not have the professional help needed when going through lean withdrawal. Having psychological or medical concerns that worsen during withdrawal can impede early recovery.6
Some psychological withdrawal symptoms (e.g., suicidal ideation or self-harm urges) could complicate the withdrawal process. When these symptoms occur, a higher level of care or professional intervention can help a person experiencing lean withdrawal get the support needed to stay safe.6
Risk of Overdose
An overdose can occur when a person consumes a toxic amount of a substance. The physiological effects of opioids can cause breathing and heart problems which can make an opioid overdose can be life-threatening. 13 According to the World Health Organization (WHO), “Worldwide, about 0.5 million deaths are attributable to drug use. More than 70% of these deaths are related to opioids, with more than 30% of those deaths caused by overdose.”13
When alcohol or other substances are added to the lean beverage, the risk of overdose and life-threatening complications increases. The combination of promethazine, codeine, and other substances lowers central nervous system functioning, which can potentially lead to complications such as:2
- Extreme sedation
- Extreme difficulty breathing
Overdose signs and symptoms associated with codeine use include:2, 3
- Dangerous reduction in heart rate
- Reduced muscle tone
- Extreme drowsiness
- Slow breathing
- Shallow breathing
- Becoming unresponsive to stimulation
- Inability to wake up
- Cold skin
- Skin that is clammy to the touch
- Fluid buildup in the lungs
- Cardiac arrest
- Low oxygen level circulation
Overdose signs and symptoms associated with promethazine use include:10
- Breathing problems, including slower breathing or stopped respiration
- Feeling light-headed
- Increased heart rate
- Dry mouth
- Constricted pupils
- Increased excitement
- Feeling flushed
- Difficulty moving
- Muscle tightness
- Losing consciousness
- Twisting motions in hands and feet
Managing symptoms of opioid overdose and promethazine overdose require different approaches.2 Effective opioid treatment can decrease the risk of overdose; for example, a medication called naloxone can prevent death from overdose by restoring normal breathing if administered in time.13 However, naloxone may not help a person experiencing breathing problems from promethazine overdose because naloxone only counteracts the effects of opioids in the body.
Treat all overdose symptoms as an emergency and seek immediate medical attention.3, 10 Giving life-saving interventions, such as CPR if you are trained to do so or are under the direction of a 911 operator, and helping a person experiencing overdose symptoms access emergency medical treatment can prevent the potentially life-threatening consequences of an overdose on lean.2
Managing Lean Withdrawal Symptoms
Detoxification (detox) is a pre-phase of treatment to keep a person medically safe while the body eliminates substances from the system. A medical term for the detox process is withdrawal management. This term helps differentiate between the word detox, which often describes the setting where a person goes through withdrawal and receives withdrawal management services.6
An accurate assessment can help you identify your needs in the detox or withdrawal management process.6
The withdrawal management process may differ depending on several factors (e.g., the type of detox facility, the severity of your withdrawal symptoms, and the substance).6
Levels of Care for Lean Withdrawal
Depending on the severity of symptoms, lean withdrawal can be managed during various levels of care, including: 6
- Inpatient hospitalization—Many inpatient rehabilitation (rehab) facilities offer withdrawal management services, including medical monitoring and medication support as needed.
- Outpatient hospitalization—Withdrawal management for symptoms of lower severity can take place in outpatient settings. Outpatient withdrawal management may include various levels of treatment to match specific needs. For example, intensive outpatient programs—including partial hospitalization—allow a person to receive care throughout the day. Withdrawal symptom monitoring can be regularly performed by qualified health care providers.
Medication Management for Lean Withdrawal
Medication management may be required at each stage of substance use treatment.6 Only a qualified professional can prescribe medications to manage the lean withdrawal process.
Medications beneficial in managing opioid or codeine withdrawal symptoms include:7
Some medications can treat the immediate withdrawal symptoms, while others can help facilitate ongoing recovery after detox.7 It’s important to note that while these drugs may be helpful when taken on a short-term basis, they have a potential for dependence and other health complications when taken long-term, misused, or when taken with other substances (e.g., alcohol, benzodiazepines, or opioids).8 It’s crucial to talk with a qualified prescriber about the risks and benefits of using medications for lean withdrawal.
Transition From Lean Withdrawal to Addiction Treatment
Beyond crisis intervention and withdrawal management, many people who want to recover from lean withdrawal and misuse benefit from engaging in substance use or addiction treatment programs.6 Services offered in many inpatient or outpatient rehab programs include:6
- Personal therapy
- Medication management
- Medical support
- Family therapy
- Group therapy
- Mutual support groups
- Case management services
- Skills training
- Holistic and complementary interventions
- Relapse prevention
Recovery does not start or end with detox or withdrawal.6 It may take some planning and consideration to discover which type of treatment program best meets your needs in recovery. If you would like more information on recovery options, call 800-405-1685 (Who Answers?) today to speak with a treatment specialist about treatment programs available to you.
- Miuli, A., Stigliano, G., Lalli, A., Coladonato, M., D’Angelo, L., Esposito, Di Giannantonio, M.(2020). “Purple Drank” (Codeine and promethazine cough syrup): a systematic review of a social phenomenon with medical implications. Journal of Psychoactive Drugs, 52(5), 453–462.
- S. National Library of Medicine. (2020, May 5). LABEL: PROMETHAZINE WITH CODEINE- promethazine hydrochloride and codeine phosphate solution. DAILYMED.
- S. National Library of Medicine. (2020, December 15). Codeine. MedlinePlus.
- S. Drug Enforcement Administration Community Outreach and Prevention Support Section.(2020). Drugs of Abuse. A DEA RESOURCE GUIDE/2020 EDITION.
- American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association Publishing.
- Miller, W. R., Forcehimes, A. A., & Zweben, A. (2019). Treating addiction: A guide for professionals. (2nd ed.). The Guilford Press.
- S. National Library of Medicine. (2021, July 02). Opiate and opioid withdrawal. MedlinePlus.
- Miller, N. S., & Kipnis, S. S. (Eds.) (2021). Medications for Opioid Use Disorder. Treatment Improvement Protocol (TIP) Series, No. 63. Rockville, MD: Center for Substance Abuse and Mental Health Services Administration.
- World Health Organization (2021, August 4). Opioid overdose.
- S. National Library of Medicine. (2020, December 15). Promethazine. MedlinePlus.
- The National Institute on Drug Abuse. (2020, July 13). What Is Lean?
- National Institute on Drug Abuse. “Syrup,” “Purple Drank,” “Sizzurp,” “Lean.”
- World Health Organization (2021, August 04). Opioid overdose.