Dirty Sprite: the DIY high that is

South Africa’s teenagers are enchanted by ‘lean’, an intoxicating drink made by mixing easily accessible and

Kieran Gordon* woke up dazed and freezing. He was in his underwear, lying on the floor at a friend’s house in Johannesburg. Someone was fumbling with keys at the front door. A few of the other passed-out party guests stirred.

Gordon, then 14, says he couldn’t remember what had happened the night before, but he recalls seeing chip packets and about 20 empty two-litre bottles of Sprite strewn on the floor.

Patting around him looking for his clothes, the only thing he found was a half-full polystyrene cup – and there wasn’t time to look any further.

“What’s going on here?” an angry female voice demanded. Gordon’s friend’s parents were back home.

“What’s this purple stuff?” his friend’s mother wanted to know.

Gordon sat up and scanned the room. His vision was blurry, he recalls, but on the kitchen counter, next to some Sprite, he saw about 10 empty bottles of cough syrup.

They had all been drinking “lean” the night before. Also known as “purple drank” or “sizzurp”, lean is a typically purple drink made by mixing medicine containing codeine, such as cough syrup, with a soft drink or alcohol.

Codeine is a mild painkiller of the same type as morphine, called opioid drugs. When taking opioid-based drugs, your brain releases feel-good chemicals and it doesn’t take too much to get to a drowsy, pleasurable high. Which is exactly what mixing 100ml of codeine-containing medicine with two litres of soft drink does.

No one else responded to his friend’s mother so Gordon fumbled for an excuse and said: “The cool drink must be expired, ma’am.”

‘A pharmacy is not a kiosk’

It’s nine years since Gordon (23) had his first cup of lean, and he is still struggling to kick the habit.

“It was unlike anything I’d ever tasted before,” Gordon says of his first experience.

It’s a trap that’s difficult to escape, because opioid drugs – such as codeine, morphine and heroin – are addictive. Over time, your brain needs more of it to get the same high.

A 2020 study of 144 learners aged 14 to 17 from townships in Mpumalanga and the Free State, published in the SA Journal of Child Health, shows that other South African teenagers are similarly enchanted.

Young people told researchers they first saw people using lean on social media: “Anything that is trending on Instagram is the one that we’d like.”

Adolescents are particularly vulnerable to addiction because the part of the brain that controls rational decision-making not yet fully developed.

Getting hooked on drugs early in life can also lead to long-term dependence and psychiatric disorders such as depression.

A codeine high comes not only cheap – R20 to R30 for a 100ml bottle of the pain medication Stilpane or cough syrup Broncleer, plus R20 for a bottle of Sprite – but also easy.

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These medicines are available over the counter at pharmacies, with little oversight of who buys them.

The day after his first taste of lean, Gordon walked into a pharmacy in his school uniform, asked for a 100ml bottle of Broncleer, and got it. Teens who participated in the local study on cough syrup misuse reported that “you just go to the pharmacy and buy”.

Although it’s mostly codeine-containing syrups being misused, tablets have as much potential for abuse. In a 2015 study titled ‘Codeine Is My Helper’: Misuse of and Dependence on Codeine-Containing Medicines in South Africa, a third of the participants reported abusing codeine tablets such as Stilpane and Adcodol.

But it shouldn’t be that simple, says Mariet Eksteen, professional development officer at the Pharmaceutical Society of South Africa.

Broncleer and Stilpane syrups are Schedule 2 medicines in South Africa because they contain little enough codeine to be considered safe if used as intended. (Codeine on its own is a Schedule 6 drug, because of its potential for addiction if used at more than 20mg per dose).

Still, a pharmacy is not a kiosk, Eksteen says. And even though Schedule 2 medication can be bought over the counter without a doctor’s prescription, the dispenser has to record the name, ID number and address of the person it was sold to.

“You don’t just hand it over,” Eksteen says. According to good practice guidelines published by the South African Pharmacy Council, pharmacists are supposed to make sure patients know how to use self-administered medicines safely.

Gordon says he has “never signed any [log] books”.

For the (lack of) record

A retrospective observational study across 31 countries published in January 2022 found that South Africa (the only African nation in the study) accounted for almost a third of all over-the-counter sales of codeine, almost one-and-a-half times as much as the second-highest consumer, France, between 2013 and 2019.

So where is it all going?

Many people buy these medicines because they’re in pain: nearly one in five people in South Africa experience constant discomfort, mostly in their backs and limbs, reports a study of more than 10 000 people, published in 2020 by the International Association for the Study of

Pain.

But health professionals and regulators worry that the amount of codeine consumed in South Africa isn’t all for legitimate use.

And, says Daphney Fafudi, manager of regulatory compliance at the SA Health Products Regulatory Authority (Sahpra), its data show that most of the codeine products that are misused come from pharmacies. Sahpra tracks every batch of codeine-containing painkiller, from manufacture to sale.

Sahpra noticed something amiss at some dispensaries in 2019. “You wonder [why] when a person should be getting one bottle, the establishment is giving a box or more than one box,” says Fafudi.

Not only was codeine being sold in bulk, but some pharmacies were not recording the details of the people they sold the products to, she adds.

But it doesn’t seem to be pharmacists who are dishing out codeine indiscriminately; instead, the issue seems to be at outlets where there is no pharmacist on duty.

In 2019, the SA Pharmacy Council investigated 14 chemists for allowing unauthorised personnel to do things that only a pharmacist should, such as dispensing over-the-counter medication and offering health advice to patients. It was the highest number of this sort of contravention in five years.

When a fix can break you

More codeine-dependent teenagers are beginning to show up at drug treatment centres, says Siphokazi Dada, a researcher formerly at the South African Community Epidemiology Network on Drug Use.

In 2016, about one in five people admitted for codeine dependency was between 10 and 19 years old; by 2019, this number had jumped to about one in three.

Once, when Gordon was about 16, he added two bottles of cough syrup instead of just one to two litres of Sprite – essentially double strength. After a few moments, he realised he had accidentally overdosed: “I couldn’t talk. I felt paralysed. I couldn’t even feel my heartbeat.”

Overdosing on codeine can cause damage to the respiratory system and the kidneys, as well as unconsciousness, a weak pulse and slow heartbeat.

The incident, however, didn’t slow Gordon down. He kept drinking about four litres of lean every day, which amounts to consuming about 14 bottles – close to one-and-a-half litres – of cough syrup a week. The safe maximum adult daily dose for over-the-counter codeine is 80mg. A full bottle of cough syrup can contain up to 200mg of codeine, so Gordon, as a teenager, was consuming as much as 400mg of the drug a day, five times the recommended safe dose in this form.

Gordon says his codeine habit has messed up a lot of things in his life.

“I almost failed Grade 11. I couldn’t study while I was on lean; my mind wasn’t right. I couldn’t fall asleep without it,” he says.

His relationship with his parents also took strain. His mother once found about 30 empty bottles of Stilpane in a bag in his cupboard and threatened him with rehab. He decided to “put his head down and stop for a while”, but it was difficult to regain his parents’ trust.

A possible solution

To curb the abuse of codeine and help