Codeine can be a dangerous opioid, especially when mixed with other central nervous system depressants. A codeine overdose is a medical emergency.

Article at a Glance:

  • Although codeine is considered a mild opioid, it is possible to overdose on the drug.
  • Codeine is especially dangerous when mixed with other central nervous system depressants, like in “lean,” a recreational concoction combining promethazine and codeine.
  • A codeine overdose is a medical emergency.

Codeine Overdose Risk

Overdoses on opioids like codeine claimed more than 14,000 American lives in 2019, the most recent year for which data is available. Although widely considered a comparatively weak opioid, codeine can still be dangerous and can lead to overdose and death.

Each dose of codeine lasts up to six hours, and in that time, the liver rapidly breaks its chemical structure down into morphine. From here, morphine binds to mu-opioid receptors in the central nervous system to induce pain relief. This process takes as little as 30 minutes from one’s very first ingestion.

Codeine may suppress coughs, but it can snuff out life as well. Like other opiates, it can lead to potentially deadly overdoses, and so its potency should never be underestimated.

Drug overdose can be fatal. If you suspect someone is experiencing an overdose, call 911immediately. Do NOT be afraid to seek help. If you do not have access to a phone contact Web Poison Control Services for online assistance.

What To Do During an Opioid Overdose

  • Call 911 immediately.
  • Administer naloxone, if it is available. Naloxone is a safe medication that can quickly stop an opioid overdose for a short time. 
  • Try to keep the person awake and breathing.
  • Lay the person on their side to prevent choking.
  • Stay with the person until emergency workers arrive.

Codeine Overdose Symptoms

Like other opioids and opiates, codeine overdose symptoms are very real indicators of a medical emergency.. Examples of exhibited signs include:

  • Irregular breathing: Slowed breathing can result from codeine misuse. This is without a doubt the most life-threatening gauge of an overdose.
  • Blue lips and fingernails: Discoloration of any kind is a sure sign of oxygen deprivation. Expect this and irregular breathing to go hand in hand.
  • Cool to the touch: This may be due to sweaty or clammy skin.
  • Uncoordinated behavior: loss of oxygen can lead to confusion, cloudy thoughts, and fatigue.
  • Tiny pupils: Small pupils are a common sign of an opioid overdose.
  • Cardiovascular changes: A weak pulse and low blood pressure are signs of an overdose.

Can You Overdose on Lean (Promethazine with Codeine)?

People have died from overdosing on lean, also known as purple drank. Lean is a combination of codeine with an anti-nausea medication known as promethazine to form an ingestible syrup. This liquid concoction is then consumed for recreational purposes.

Such a combination, known informally as ‘lean’, has gained a popular following among individuals with codeine substance use disorders. Both promethazine and codeine function as depressants, and this is even more the case when alcohol is involved. Combining these agents makes them more potent, which makes them a lethal combination.

How Much Codeine Is Too Much?

The amount of codeine it takes to overdose has everything to do with one’s genes. Codeine is broken down into morphine by an enzyme called CYP2D6 in the liver. However, this enzyme is more active in some people than in others. This means that codeine may be far more or far less potent than expected in some people.

Depending on whether it is being used for a cough or for pain, codeine doses range from 15 to 60 mg every four to six hours as needed. The max dose of codeine should not exceed 360 mg per day. However, the amount of codeine a person can tolerate before an overdose can vary widely depending on their CYP2D6 genetics.

When codeine is combined with other central nervous system depressants to make substances like purple drank, the mixture has an additive effect. For this reason, it may take less codeine than normal to achieve potent effects.

Where Codeine is Found

Codeine is found in many prescription medicines, including:

  • Codeine pills
  • Acetaminophen and codeine phosphate (formerly known as Tylenol 3)
  • Butalbital with codeine
  • Chlorpheniramine with codeine
  • Promethazine with codeine cough syrup
  • Guaifenesin with codeine cough syrup

Other medicines may also contain codeine.

Codeine Overdose Treatment

A codeine overdose is a medical emergency. If you suspect a loved one is overdosing on codeine, you should immediately give the opioid reversal agent naloxone (Narcan) if it is available and call 911. If the person is overdosing on a combination substance like lean, it is important to remember that naloxone will only work on the codeine component. For this reason, it is very important to seek emergency medical attention. You will not get in trouble for seeking help.

Know someone who needs professional help for a codeine addiction? The Recovery Village is a great resource. With individualized care plans ranging from medical detox through outpatient and aftercare, this renowned network of treatment centers can provide you or a loved one with effective drug or alcohol rehabilitation. Call today to learn more.

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Editor – Rob Alston
Rob Alston has traveled around Australia, Japan, Europe, and America as a writer and editor for industries including personal wellness and recovery. Read more
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Medically Reviewed By – Dr. Jessica Pyhtila, PharmD
Dr. Jessica Pyhtila is a Clinical Pharmacy Specialist based in Baltimore, Maryland with practice sites in inpatient palliative care and outpatient primary care at the Department of Veteran Affairs. Read more

Serwer, Jesse. “DJ Screw: from cough syrup to full-blown fever,” The Guardian, November 11, 2010.  Accessed May 8, 2021.

Pratt, VM; Scott, SA; Pirmohamed, M.; et al. “Codeine Therapy and CYP2D6 Genotype.” March 30, 2021. Accessed May 8, 2021.

U.S. National Library of Medicine. “Codeine Overdose.” May 4, 2021. Accessed May 8, 2021. “Codeine.” October 30, 2020. Accessed May 8, 2021.

Centers for Disease Control and Prevention. “Prescription Opioid Overdose Death Maps.” March 24, 2021. Accessed May 8, 2021.

American Academy of Family Physicians. “Opioid Conversion Table.” Accessed May 8, 2021.

Medical Disclaimer

The Recovery Village aims to improve the quality of life for people struggling with substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare providers.