Case Reports

Case Studies in Toxicology: Sippin’ on Some “Sizzurp”

He rolled up, asked him what he was sipping onHe said, “Lean, you want to hit it, dawg?”“That’s the same stuff Weezy’s sipping, huh?And tons of other rappers that be spitting hard?”—Macklemore, Otherside

A 19-year-old man was found unresponsive by his girlfriend after ingesting a combination of soda, codeine/promethazine hydrochloride cough syrup, and hard candy the previous evening.




A 19-year-old man was found unresponsive by his girlfriend. They both attended a party the previous night where a number of people were drinking alcohol and cough syrup to get “high.” When emergency medical technicians arrived at the patient’s house, they administered naloxone, which somewhat improved the patient’s level of consciousness; oxygen was also delivered via facemask.

Upon arrival to the ED, the patient complained of hearing loss and tinnitus. His initial vital signs were: blood pressure, 99/60 mm Hg; heart rate, 110 beats/minute; respiratory rate, 20 breaths/minute; temperature, 96.8°F. Oxygen saturation was 80% on room air. On examination, he was lethargic but responsive to voice and oriented to time, place, and person. His pupils were pinpoint; his hearing was decreased bilaterally; his breathing was shallow, with rales audible at both lung bases; his bowel sounds were hypoactive; and his skin was warm and moist. The rest of the examination was otherwise unremarkable.

What cough and cold products are commonly abused with the intent to get high?

Hundreds of nonprescription pharmaceutical products—each with the potential for misuse or abuse—are available to consumers in retail stores and online. These products can be classified by expected clinical effect, which helps clinicians with the diagnosis and management of these patients (Table).


Of the antitussive products currently available over the counter (OTC), those that contain dextromethorphan have the widest abuse potential. Referred to as “dex,” “DMX,” or “tuss,” this drug is widely abused among adolescents and young adults due to its easy availability. In therapeutic doses, dextromethorphan suppresses cough via the medullary cough center. Ingesting dextromethorphan at higher doses, a practice referred to as “Robo tripping,” can produce hallucinations and a dissociative state marked by alterations in consciousness and impaired motor control. Dextromethorphan is a structural analog of ketamine and phencyclidine, which accounts for their similar clinical effects.


Codeine is another drug added to various cough medications for its antitussive properties. An opioid, it acts centrally to suppress cough and has mild analgesic properties. It is available only by prescription in the United States, but can be purchased as an OTC product in other countries. Recently, it has come into the media spotlight as the starting product to make “Krokodil” (see Emerg Med. 2014;46[2]:76-78).

Case Continuation

While undergoing his workup in the ED, the patient became increasingly lethargic with persistent hypoxia. Although initially
responsive to naloxone, his respirations became more labored, requiring intubation. Prior to intubation and while awake, the patient mentioned that he was drinking “sizzurp” the evening prior. He denied the use of other drugs or of having any suicidal intent. A postintubation chest X-ray revealed a left-sided retrocardiac infiltrate consistent with aspiration pneumonitis.

What is sizzurp?

Sizzurp is a slang term used to describe a beverage that is most frequently comprised of fruit-flavored soda, codeine/promethazine hydrochloride cough syrup (CPHCS), and hard candy (classically a Jolly Rancher).1 This combination is ingested by the user with the intent of achieving a unique high—attributable to the combined effects of codeine, an opioid, and promethazine, an antihistamine (with antipsychotic properties). According to user reports, CPHCS induces a deep sense of euphoria, relaxation, and a slowed sense of time.2 Additional slang terms used to describe this product include “lean,” “purple drank,” “purp,” “drank,” “syrup,” “barre,” and “Texas tea.”

According to one source, purple drank originated in Houston, Texas around the 1960s, when blues musicians would combine dextromethorphan with beer.3 Over time, the recipe was modified, and by the 1980s, when purple drank was adopted by hip-hop musicians from the same Houston neighborhoods, the name sizzurp took hold.

In the 1990s, one Houston-based hiphop artist, DJ Screw, developed a genre of music called “chopped and screwed,” inspired by the CPHCS high and notable for its slowed-down tempo that fit the sedation and decreased motor activity induced by the drug. As chopped and screwed music became popularized, so too did the recreational use of CPHCS. In 2000, “Sippin’ on Some Sizzurp,” a hit song by southern hip-hop group Three Six Mafia, introduced CPHCS to more mainstream hip-hop audiences.

Despite the CPHCS-related deaths of a number of hip-hop musicians, including DJ Screw, as well as the arrests of professional
football players linked to abusing the drug, CPHCS continues to be glorified by a number of hip-hop and pop musicians.

Unfortunately, media attention of these events often has the paradoxical effect of promoting use among adolescents and young adults, and CPHCS has become a drug of choice for black adolescents in many Texas communities.4 However, one study attempting to define a purple drank user profile among college students at a large public university in the southeastern United States revealed that use was most prevalent among urban male youth primarily from Hispanic, Native American, and white ethnic backgrounds—challenging the notion that it is confined to the black community.5


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