Reports of recreational codeine cough syrup use have increased in Houston and in the State of Texas. Occasional and polydrug users increasingly have consumed codeine cough syrup (with or without alcohol or other drugs) over the past 3 years, accounting for a $40 increase in the price of an eight-ounce bottle on the underground economy. In Houston, such cough syrup is usually called “lean” with other terms including, AC/DC, barr, down, Karo, and nods. Reported side effects include a drowsy relaxed high, fatigue, loss of coordination, constipation, and urinary retention. With an increase in news stories regarding cough syrup abuse and reports of deaths from codeine overdoses, the need to explore this emerging trend was clear. A literature search of scientific journals and news media, interviews with community authorities, and guided interviews with 25 adults who reported using codeine cough syrup in the 30 days preceding their interviews were conducted. From this study, it appeared that “lean” syrup use had grown in response to the poor quality of illegal drugs and relative ease of its procurement without fear of arrest. Most of the procurement involved the abuse of Medicaid or private health insurance benefits, or the diversion of syrup from hospital dispensaries, pharmacies, and distributors. All individuals interviewed reported enjoying the peaceful euphoria provided by codeine. Although the side effects have minimal health risks, overdose deaths have occurred. Syrup use was shown not to be limited to a specific sociodemographic group or to Houston. The study demonstrated that the procurement and misuse of prescription cough syrup requires prevention, treatment, and social welfare precautions to improve the problem. Tables and references