In 2013, when rapper Lil Wayne was hospitalized after a seizure, there was much speculation that something called “sizzurp” was to blame. Sizzurp, also known as “lean” or “purple drank,” is a dangerous combination of the opioid form of codeine and promethazine that is often mixed into a drink with alcohol and soda. Lil Wayne and other rappers – including DJ Screw, Big Moe, Pimp C, and 2 Chainz – have often mentioned it in their music. 

In 2014, following Lil Wayne’s seizure and the attention it received, tighter restrictions were placed on the availability of over-the-counter promethazine/codeine in the USA. However, the use of this drug by young people is still widely reported across the United States and beyond. In what follows, we’ll explore the prevalence of lean, its origins, its alternate names, and why it is so popular with some young people, particularly in relation to their musical tastes. We’ll also take a look at some of the dangers of this drug, which research has suggested is one of the more insidious forms of substance abuse in young Americans.

What Is “Lean”?

Fundamentally, lean is the combination of cough syrup and alcohol. It is said to have originated in Houston, Texas, as part of the blues music scene in the 1960s. At that time, artists would combine Robitussin cough syrup with beer to get through long, grueling sets in sometimes hazardous environments. Young people growing up in Houston at that time began to mimic the behavior of these musicians, as teenagers often do, and the combination of cough syrup and alcohol became common practice across the community. 

Robitussin contains an active ingredient called dextromethorphan, which is of the antitussive (anti-tousse, or cough in French) drug class. While dextromethorphan can have hallucinatory effects in excessive doses, it does not present a severe health hazard. However, in the 1980s, a new formula for cough syrup became available, and it had a far more powerful active ingredient: codeine. 

Codeine is classed as an opioid, and opioid-based drugs have many dangers, which I have written about before. The sudden availability of these over-the-counter codeine cough syrups was part of the broader changing landscape of drug use in the United States, and it changed the formula for lean, which had by this time become popular across the Southern United States and beyond.[1] By the 1990s, lean was both widely used by young people and made of a dangerously addictive opioid combination.

By the time Lil Wayne began referencing lean in his songs, the drug had many alternative names, including (but not limited to):

• Lean
• Purple drank
• Sizzurp
• Jelly
• Mud
• Texas tea
• Dirty Sprite
• Purp
• Double cup

The Popularity of Lean Among Teens

Because of its origins in Houston, where much of the early American rap and hip-hop scene emerged, lean is broadly associated in the media with African-American youth culture. 

In 2020, Canadian researchers surveyed 40 songs that referenced lean. They found that it was most often mentioned in relation to other drugs but was also very frequently mentioned in reference to sexual activity, as a sleep aid, as an alternative to alcohol, and to aid with mental distress.[2] Another study found that lean was referenced positively in 49 rap songs between 2011 and 2017, noting that mentions actually increased following the regulation of over-the-counter codeine cough syrups in 2014.[3]

Additional studies have shown that lean is frequently, but not exclusively, used by African-American teenagers and athletes,[4] which follows its popularity in rap music. It is also extremely popular among Native American and Hispanic Americans, and LGBT and urban teens were more likely to have tried lean than heterosexual teens or teenagers from rural areas.[5] 

The Dangers of Lean

Lean has been the cause of many medical emergencies for significant figures in the rap community. Big Moe died of a heart attack, reportedly in relation to his lean use, at age 33 in 2007.[6] Pimp C also died of the effects of lean in 2007,[7] and in 2018, Fredo Santana died of liver and kidney problems which were related to his use of lean.[8] 

The combination of codeine and antihistamines, often with alcohol, is extremely dangerous and has a number of adverse health effects. French researchers found that there are two main stages associated with lean use: drowsiness and delirium. 

The drowsy stage has obvious hazards, as it slows the function of the body, which can lead to heart problems. However, it is the hallucinogenic stage that presents the majority of danger to users because it is accompanied by widespread toxicity across the body that can cause seizures.[9] 

In addition, lean was also found to be highly addictive, which is not surprising given its high opioid content. Its use is also associated with a high mortality rate; in one study of European healthcare data, nearly half of cases of lean overdose treated in European hospitals resulted in death.[10]

2014-related regulations have made it more difficult to create lean legally; however, this is only the first step in dealing with this widespread phenomenon. We need to have tough conversations about the prevalence of opioid medicines across our communities and about who benefits from the sales of the medicines that are being turned into dangerous recreational drugs.

Understanding what lean, or purple drank, is and the dangers it poses to teens is vital if we hope to stop its spread among youths, especially in already vulnerable communities. 

If you or anyone you know is struggling with substance misuse, please contact us. Our team is here to offer compassionate support, and we can help guide you through the next steps on your journey to recovery.

Sources:

[1] Eakin, Marah (March 26, 2013). “Learn all about the long, lean history of “sizzurp” with this 7-minute audio primer”. A.V. Club. Archived from the original on August 17, 2017. Retrieved January 20, 2014.

[2] Tettey, N.-S., Siddiqui, K., Llamoca, H., Nagamine, S., & Ahn, S. (2020). Purple Drank, Sizurp, and Lean: Hip-Hop Music and Codeine Use, A Call to Action for Public Health Educators. International Journal of Psychological Studies, 12(1), Article 1. https://doi.org/10.5539/ijps.v12n1p42

[3] Roberts, E., & Byars, K. (2019). Codeine References in Rap Music Increase after Codeine Availability Decreases. Showcase of Undergraduate Research and Creative Endeavors (SOURCE). https://digitalcommons.winthrop.edu/source/SOURCE_2019/posterpresentations/76

[4] Miuli, A., Stigliano, G., Lalli, A., Coladonato, M., D’Angelo, L., Esposito, F., … 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. https://doi-org.ezproxy.uio.no/10.1080/02791072.2020.1797250

[5] Agnich, L. E., Stogner, J. M., Miller, B. L., & Marcum, C. D. (2013). Purple drank prevalence and characteristics of misusers of codeine cough syrup mixtures. Addictive Behaviors, 38(9), 2445–2449. https://doi.org/10.1016/j.addbeh.2013.03.020

[6] DJs – Rapper Big Moe Dies Archived April 8, 2009, at the Wayback Machine, contactmusic.com, October 15, 2007.

[7] “Cough syrup cited in rapper Pimp C’s death”. Los Angeles Times. February 5, 2008. Archived from the original on February 12, 2008. Retrieved March 15, 2008.

[8] “Rapper Fredo Santana Dead from Fatal Seizure”. TMZ.com. January 20, 2018. Archived from the original on January 21, 2018. Retrieved January 20, 2018.

[9] Garcin, L., Le Roch, M., Agbessi, C.-A., Lobut, J.-B., Lecoeur, A., & Benoist, G. (2016). Purple drank: A dangerous cocktail. Archives de pédiatrie : organe officiel de la Société française de pédiatrie, 23(11), 1165–1168. https://doi.org/10.1016/j.arcped.2016.08.007

[10] Chiappini S, Schifano F, Corkery JM, Guirguis A. (2021) Beyond the ‘purple drank’: Study of promethazine abuse according to the European Medicines Agency adverse drug reaction reports. Journal of Psychopharmacology. 35(6):681-692. doi:10.1177/0269881120959615