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.

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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 pupils aged 14 to 17 from townships in Mpumalanga and the Free State, published in the South African 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 is 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.

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, 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.

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“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 South African 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.

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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 South African 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.

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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 prevent opioid misuse from becoming an epidemic as it is in the US, the Pharmaceutical Society of South Africa and other partners launched the Codeine Care Initiative in 2013.

Opioid abuse is so common in the US that it has contributed to a small decline in life expectancy. In 2018, about 3% of adolescents and 5% of people between 18 and 25 in the US reported misusing opioid pain relievers.

When it was launched nine years ago, the Codeine Care Initiative aimed to be a national database that pharmacists could use to review every codeine purchase someone had made in the past six months, regardless of which pharmacy or chain they had visited.

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But because the project wasn’t mandatory, only about 10% of pharmacies opted in, Eksteen says. She adds that Sahpra, as the medicines regulator, has the power to ensure the system is uniformly implemented in pharmacies, which could help to put an end to “pharmacy hopping” (when someone goes to different outlets to get their fix).

If the system alerts a pharmacist to a customer who’s been using codeine products regularly, they’ll be able to talk to them about the risks or suggest a medicine that doesn’t contain the drug. Dispensers can also refuse to hand over a medicine if they think it is in the patient’s interest to do so.

Most states in the US have similar databases, called prescription drug monitoring programmes, for medicines that carry a high risk of dependence, such as the pain medication oxycodone (OxyContin).

Says Eksteen: “Having a system like this is an opportunity to say: ‘Do you need help? Can I advise you on a different product?’”

Upscheduling vs monitoring

Making codeine-containing medicines available only on prescription is another option, which countries such as France and Australia require. In Australia, upscheduling the products led to 87.3% fewer sales of low-dose codeine medicines in the next year and cut the monthly number of overdoses by half.

Sahpra has considered changing the schedule of the products here too, but local experts advised that monitoring the sale of codeine-­containing products would be a better route for South Africa because a change in scheduling would make it impossible for people who can’t get to a doctor easily to access the drug.

Eksteen says the pharmaceutical industry, healthcare professionals and regulatory bodies will have to pull together to make this work. This is because there are no guarantees that outlets will use the system. Participation is voluntary and the products tend to be channelled to misusers from community pharmacies with unauthorised personnel. Evidence from the US shows that even prescribers who are authorised to give out these medicines don’t often use monitoring systems.

The Protection of Personal Information Act could also complicate getting South Africa’s database running. Because the act requires organisations to get people’s consent for storing their personal information, the Codeine Care Initiative would require permission from the customer, says Eksteen.

If someone is planning to misuse the medicine, they’re unlikely to allow their purchasing record to be saved. In this case, the pharmacist may still note on the registry that the patient declined to participate, but without any details as to who the customer was.

Research from the US shows that pharmacies in rural areas were less likely to participate in a prescription drug-monitoring programme than those in cities or large towns.

An even bigger factor for not using the system was not having internet access. Only one in five workplaces in South Africa’s rural areas has internet access.

Many users have already noticed loopholes like these, including Gordon.

He explains: “I just go down to the [smaller] pharmacies. If I go to [the ones in malls], I’d get denied. Those ones are a last resort.”

These days, Gordon allows himself a cup of lean only when he’s got something to celebrate.

“I know that I can’t do this forever. I want things to happen for me in this life. I can’t let lean distract me like it did in high school.” DM168

First published by bhekisisa.org.

*Kieran Gordon is a pseudonym.

This story appeared in our weekly Daily Maverick 168 newspaper, which is available countrywide for R25.