Fake cough syrup could cause overdose, death: Montreal Public Health

Montreal Public Health warns counterfeit “Promethazine with Codeine” bottles contain opioids and other drugs that can cause fatal overdoses.

Montreal Public Health is warning of a mysterious and dangerous purple syrup being sold in a bottle parading as an approved pharmaceutical medication.

The product, known as “Lean” or “Sizzurp,” is labelled as a “promethazine with codeine oral solution” — cough syrup.

“Over time, different mixtures have been identified in containers that appear identical,” said Public Health.

Officials say that some confiscated products have been shown to contain protonitazene, a toxic opioid, and bromazolam, a benzodiazepine (central nervous system depressant) that is not marketed in Canada.

“Anyone who consumes this product could be exposed to an unpredictable and toxic mixture,” the warning states, adding that consuming the liquid could result in overdose or death.

The Montreal alert comes after Laval Public Health issued a notice in November 2023 about a suspected overdose death linked to a similar product.

“Our investigation revealed that a purple liquid containing a mixture of methonitazene, clonazolam and an antihistamine was consumed,” Laval Public Health said at the time, explaining that “Lean” is a “drug consumed in liquid form, often by young adults. It usually contains codeine syrup mixed with a soft drink and may be sold in a cough syrup bottle.”

It added that this was the first time methonitazene, a synthetic opioid that is part of the nitazene family, was detected in purple liquid form in Quebec.

“Some nitazenes are estimated to be several times more toxic than fentanyl,” Laval Public Health warned. “This substance poses an increased risk of respiratory arrest and death. Nitazenes are not detected by fentanyl detection strips.”

Additionally, officials point out that clonazolam is not approved for medical use and can cause drowsiness and increase the risk of intoxication if consumed with other nervous system depressants.

Naloxone remains one of the most effective ways to temporarily reverse an opioid overdose.

Preventing fatal overdoses

Public Health officials advise anyone wanting to take the substance to lower their dosage and avoid using it alone — you can use the National Overdose Response Service (NORS) (1 888 688 6677) as a contact, if needed.

Additional options include:

• Drug-checking services.
• Staying with someone who has consumed, and encouraging regular stimulation.
• Have enough naloxone available, know how to use it and do not hesitate (there is no danger to unnecessarily administering naloxone).
• When using with other people, don’t do so at the same time.
• Avoid using multiple substances at the same time.
• Call 911 in case of overdose.

Signs of overdose include:

• Difficulty breathing, snoring, or not breathing at all.
• Little or no response to noise and pain; unconsciousness.
• Cyanosis (blue lips and fingernails) and miosis (constricted or pinpoint pupils).

“These symptoms are likely to progress to cardiopulmonary arrest,” explains Montreal Public Health.

In the event of an overdose, call 911 immediately and administer naloxone if it is on hand.