Lean, also known as purple drank, sizzurp, purple jelly, dirty Sprite, and dozens of other slang terms, is a new combination drug that has raised alarm for its innocuous appearance and deadly effects. Lean is made from simple ingredients, but it is abused for the euphoric sensations that entice increased consumption, often leading to painful physical conditions and, in some cases, even death.

A Very Dangerous Drug

A doctor told the Today Show that lean is “a very dangerous drug” that can cause respiratory depression and seizures because of its chemical origins. Leanis made, in part, with codeine, a popular opioid. This type of drug is typically used in prescription medication for pain relief, which also has the effect of producing feelings of euphoria. These effects explain, in part, the opioid epidemic in which prescription medications are abused for recreational purposes, leading to tens of thousands of deaths across the country.

The Drug Enforcement Administration put codeine on its Schedule III list of drugs, which denotes a moderate risk of physical and psychological dependence compared to Schedule I and II drugs, where the risk of developing dependence is significantly higher. This means that while someone who legitimately has a cough can get a bottle of codeine cough syrup from a local pharmacy, someone who wants to get the narcotic rush from drinking a lot of the syrup can do so with the same ease of access.

Codeine is not the only drug in prescription cough syrup, however. The other active substance is promethazine, a sedative that is effective in treating allergy symptoms, such as a runny nose, and is sometimes prescribed to help people sleep while they are suffering from the common cold. When codeine is combined with promethazine, the sedative and narcotic effects can make those who use it drowsy and lethargic to the point of leaning over, which is where the nickname lean comes from. Additionally, the dyes in the cough syrup are often purple, out of which emerged the alternative name, purple drank.

What Is In Lean?

Cough syrup abuse is nothing new, but what makes lean different is that people who take it combine it with alcohol, candy, soda, and other ingredients to make it taste better. This gives lean a very sweet flavor, which may encourage people—particularly teens—to drink more of the concoction than usual. This blend of ingredients may be more likely to cause an quick high. The doctor speaking to Today said that hours of such consumption can pass with users completely unaware of how much codeine they are putting into their bodies, increasing the chance of intoxication or overdose.

An exacerbating factor of sizzurp abuse is that some teenagers and young adults post videos of their consumption on social media channels, presenting the experience as fun and harmless because the materials involved are so easily obtainable and not traditionally associated with harmful drug use. But a report from the Drug Enforcement Administration found that 1 in 10 teenagers has abused cough syrup to get high, and fads like sizzurp contribute to that ratio. Prescription medications are by nature still dangerous when abused, even if they can be obtained for the most basic of reasons (the common cold).

The Roots of Purple Drank

There is a strong culture of purple drank abuse in hip hop culture, which further adds to its popularity. Elite Daily explains that “the origins of the drink go as far back as the 1970s”, and in some parts of the American South, “homemade [lean] is still part of the laid-back culture.” A new generation of hip hop artists not only grew up with lean, they started mentioning it in their music. This led to the development of entirely new subgenre of rap music that is “chopped and screwed” to be more relaxed. The idea was that the effects of purple drank was best enjoyed with music that was altered to play at a slower, more mellow tempo.

In writing how “lean became hip hop’s heroin,” Splinter News explains that in the early 1990s, purple drank grew out of its Houston origins into a drink that was enjoyed and unofficially promoted by some of the biggest names in hip hop, such as Lil’ Wayne, a best-selling artist, who suffered two seizures after consuming lean in 2016.

The use of this codeine concoction in hip hop music and music videos has been connected to a 286% spike in emergency room visits between 2004 and 2011 as a result of sizzurp consumption, quotes Splinter News. After a number of young artists fatally overdosed on lean in the early 2010s, some other members of the southern hip hop community changed their position on the substance, writing songs or posting messages on social media about how dangerous it is. One of them told Splinter News that lean is nothing more than “liquid heroin.”

But the problem still persists, especially in an era when an online video showing the seemingly amusing side effects of purple drank can go viral in a matter of minutes. Users are often shown becoming drowsy, slurring their speech, or having difficulty coordinating their motor movements, which may make for funny videos that encourage their viewers to try lean themselves.

Unlikely Icons

Like any drug, people who regularly abuse lean may develop a tolerance for it. The initial effects are diminished with continued exposure to the cocktail, so they keep drinking in the hope that they can recapture the highs and the aftereffects they did when first using it. But even though the effects aren’t as strong as the first time, the codeine is still impacting the person’s mind and body. As an opioid, it pushes the brain to keep an excess amount of neurotransmitters flowing that communicate feelings of pleasure and reward, so users associate their consumption of lean with positive experiences. As a result, they keep drinking, even as the opioid impacts the central nervous system by slowing down the heart, in some cases, to the point where the respiratory system is depressed and, as USA Today explains, the heart may cease to beat altogether.

One way of viewing this is as pharmaceutical companies and distributors laid the groundwork for the opioid epidemic that would sweep across the country, lean users caught the first wave. In 2000, Houston residents bought more cold medicine in the summer than they did in the winter, the season usually associated with colds.

In 2014, Project Know reported that the number of references to codeine in rap music tripled between 2000 and 2007, with performers and their record labels mentioning the drug cocktail in songs and marketing materials. The National Institute of Health stated that codeine’s legal status “helped fuel its recreational use.” Not only did this make it possible for lean to be abused far away from its Texan roots, it made codeine manufacturers and distributors very rich. In 2008, Barr Pharmaceuticals made $7.46 billion on the drug and other such manufacturers among “hip hop’s unlikeliest icons,” in the words of Bloomberg magazine.

And where there was money to be made, there were people willing to get into the business. The Miami New Times covered the existence of a “purple drank ring” that supplied high-profile clients—primarily musicians and athletes with connections to local hip hop scenes—with a steady flow of codeine syrup. The arrest of a 26-year-old music producer on the charge of intent to sell purple drank shone a harsh light on what the Times called “the outsized role cough syrup plays in Southern hip-hop culture [and] the black market that feeds it.”

Amid negative publicity, as well as more overdose deaths and hospitalizations, some manufacturers stepped back. Allergan elected to discontinue its line of codeine-based cough syrups in 2014, however, the damage was done, and the artists who advocated against sizzurp abuse lamented to Splinter News that their peers and fan bases resorted to “tinkering with homemade lean recipes made from pure codeine, mixed with corn syrup and purple coloring,” even coming up with new nicknames to describe these improvised formulas.

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The Same as Being Addicted to Heroin

In 2013, George Fallieras, an emergency room doctor in Los Angeles told the Los Angeles Times that in many cases, the people who drink lean are also taking other substances, such as alcohol and illicit drugs, at the same time. While lean is deadly in and of itself, opioids like codeine and alcohol are an exceptionally “dangerous cocktail,” in the words of WebMD. Both opioids and alcohol are central nervous system depressants, so a person taking the 2 in combination drastically increases the likelihood of experiencing respiratory failure. The risk becomes even more pronounced if other drugs such as marijuana are simultaneously consumed.

Fallieras told the Times that people often assume that even though codeine is an opioid, its relative weakness compared to an illicit opioid like heroin makes it safer to consume, especially because of the pleasant taste and benign use in normal circumstances. The difference is that when people consume lean, they take a massive amount of codeine, which leads to effects that are “just the same as someone being addicted to heroin.” To that point, some of the hip hop artists who drank lean told Splinter News that they experienced withdrawal symptoms similar to those felt by heroin users who were cut off from their supply: severe flu-like symptoms, vomiting, deep pain in the bones and muscles, insomnia, and an intense craving for more drugs under the belief that a single pill, hit, or swallow will make all the pain go away.

Robberies and Arrests

Lean has made the transition from a drug embedded in rap culture to viral social media content to an actual crime. In New Mexico, a 22-year-old man was arrested after an attempted robbery of promethazine and codeine from a pharmacy went wrong. A 51-year-old man in California was arrested after robbing 3 pharmacies for promethazine.

Given the public safety implications of an addictive substance being this commonly available, law enforcement has started to move against using codeine cough syrup for recreational purposes. In January 2018, police in Arlington, Texas, confiscated materials that would have made more than 4,700 bottles of purple drank.

Anti-Energy Drinks

But even as the tide has turned against purple drank in rap culture, there are attempts to sell legal versions of the cocktail. In Dallas, public health advocates reacted in shock to “Drank,” an “anti-energy” drink that is deliberately made to resemble purple drank. The product is marketed as an “extreme relaxation beverage,” warning users not to consume more than 2 servings in a single 24-hour-period.

For a behavioral science professor at the University of Texas Health Science Center at Houston, Drank is “the worst thing [he has] ever seen on the streets,” for the blatant marketing ploy toward teenagers and youths. Drank may present itself as a harmless counterpart to codeine syrup, but it is nonetheless a very thin gateway between a “safe” product and “the real stuff.”

The CEO of Innovative Beverage Group of Houston, the company that makes Drank, disagreed, saying that his drink “was created as an alternative to drugs and alcohol,” and is a positive way for people to relax with no suggestions or encouragement of illegal drugs implied. The company says Drank was meant to be a mainstream product that appeals to professionals, parents, athletes, students, “and anyone else looking for a way to relax.”

People who work with teenagers struggling with substance abuse problems aren’t convinced, believing that Drank acts as a gateway drug. Two teenagers at a Dallas-area treatment center admitted to trying Drank numerous times “because it does advertising like lean.” They felt that Drank might make people want to try actual codeine to get similar effects.

There still remains the danger that Drank is, in and of itself, powerful. The melatonin in the liquid will make someone sleepy very quickly, and this can cause impairment when driving. A clinical associate professor of neurology at the University of Texas Southwestern Medical Center in Dallas noted that, as with purple drank, people will try to augment their experience by consuming the drink with alcohol or other substances, potentially leading to the same problem of compounding effects.

The Huffington Post listed some signs for parents and caregivers to look for if they suspect that a teenager or youth is abusing codeine cough syrup, including:

Persistent coughing (possibly faked) and a request for a particular (codeine-based) syrup.
Slurred speech and difficulty concentrating.
Constant drowsiness and fatigue.
Loss of balance and coordination.
Constipation.

Codeine abuse can be effectively treated if it is caught early on. Teaching teenagers that despite the name, the taste, and the appearance of purple drank, it is still a very powerful and potentially dangerous substance is an important part of using education as a preventative intervention.

For others, age-appropriate treatment and rehabilitation programs can break the physical need for codeine as well as the psychological causes and effects of its use. Users can work with counselors, peers, and loved ones to repair the damage of lean abuse, so they can live healthy and positive lives without dependence on cough syrup.

What Is Lean Made From?