Lean, also known as purple drank or sizzurp, is a recreational drug concoction that originated in the Southern United States. It is made by mixing prescription-grade cough syrup with a soft drink, often lemon-lime soda, and sometimes hard candy for flavoring. The primary danger stems from consuming high concentrations of active pharmaceutical ingredients far exceeding therapeutic doses. This mixture bypasses dosing safeguards, leading to profound and unpredictable physiological effects. The purple color, which gives the substance its common monikers, comes from dyes in the cough syrup.
The Active Ingredients and Their Pharmacological Classifications
The psychoactive effects are driven by two main pharmaceutical components: codeine and promethazine. Codeine is an opioid, structurally similar to morphine, that functions primarily as a depressant. It binds to mu-opioid receptors in the central nervous system (CNS) to inhibit pain pathways and suppress the cough reflex, leading to euphoria and relaxation.
Promethazine is a first-generation antihistamine that acts as an H1-receptor antagonist, reducing allergy symptoms. It also possesses anticholinergic properties, blocking acetylcholine receptors, which contributes to its pronounced sedative and anti-nausea effects.
When combined in high doses, their depressant actions are synergistic, meaning the combined effect is greater than the sum of their individual effects. Promethazine heightens codeine’s euphoric effects while increasing overall sedation. Adding alcohol further compounds this CNS depression, elevating the risk of adverse outcomes.
Acute Effects on the Central Nervous System
The most immediate impact occurs within the central nervous system (CNS), where combined depressant effects rapidly slow brain function. Codeine induces euphoria, relaxation, and a noticeable slowing of cognitive processes. This altered mental state is accompanied by confusion, impaired judgment, and extreme drowsiness, sometimes progressing to stupor or loss of consciousness.
The primary acute danger is respiratory depression, the slowing and shallowing of breathing that can lead to death. Opioids suppress the brainstem’s ability to regulate breathing, and promethazine’s sedative effects exacerbate this suppression. This effect is dose-dependent, meaning large, uncontrolled amounts can quickly reduce the respiratory rate to a life-threatening level.
In extreme toxicity, the resulting lack of oxygen (hypoxia) can lead to severe complications. High doses of promethazine increase the risk of seizures, especially when combined with other CNS depressants. Using this combination with sedatives like benzodiazepines or alcohol elevates the risk of profound sedation, coma, and respiratory failure.
Physical Manifestations and Acute Danger Signs
The mixture produces several immediate and observable physical effects across the body. Users frequently exhibit significant motor impairment, including slurred speech, loss of coordination, and a characteristic leaning to one side. Due to deep sedation, eye movement may become uncontrolled, and eyelids often appear droopy.
Gastrointestinal function is severely impacted by codeine’s effect on the digestive tract. A common short-term side effect is profound constipation, as the opioid slows the muscular contractions of the bowels. Nausea and vomiting can also occur, which is dangerous if the user is heavily sedated or unconscious, raising the risk of aspiration.
Recognizing signs of acute toxicity is important for emergency intervention. Danger signs include a blue or pale tint to the lips or fingernails, indicating poor oxygen circulation, and cold, clammy skin. The pupils may become constricted, appearing as tiny pinpoints, a classic physical sign of opioid intoxication. These physical markers indicate a medical emergency.
Dependence and Long-Term Health Risks
Regular consumption carries a significant risk of developing physical dependence and addiction due to the high concentration of codeine. The brain quickly adapts to the opioid, leading to tolerance, where increasingly larger amounts are needed for the same effect. Stopping use can trigger withdrawal symptoms typical of opioid cessation, such as intense cravings, muscle aches, anxiety, and severe gastrointestinal distress.
Chronic use can lead to long-term health complications involving multiple organ systems. The constant processing of high drug doses strains the liver and kidneys, potentially resulting in organ damage. The mixture’s high sugar content, combined with the dry mouth effect caused by promethazine, creates a destructive environment leading to severe tooth decay. Long-term abuse is also associated with neurological issues, including memory impairment and changes in cardiovascular function.