Combined drug intoxication

Combined drug intoxication (CDI), also known as multiple drug intake (MDI) or lethal polydrug/polypharmacy intoxication, is an unnatural cause of human death. While it is sometimes reported as a simple "overdose", it is distinct in that it is due to the simultaneous use of multiple drugs, whether the drugs are prescription, over-the-counter, recreational, or some other combination. The reasons for toxicity vary depending on the mixture of drugs.^{[citation needed]}

CDI can occur with numerous drug combinations, including mixtures of over-the-counter (OTC) drugs, legally or illegally obtained prescription drugs, herbal mixtures, and home remedies. Ingestion of alcoholic beverages, in combination with other drugs, increases the risk of CDI.^{[citation needed]}

The CDI/MDI phenomenon seems to be becoming more common in recent years. In December 2007, according to Dr. John Mendelson, a pharmacologist at the California Pacific Medical Center Research Institute, deaths by combined drug intoxication were relatively "rare" ("one in several million"), though they appeared then to be "on the rise".^[1] In July 2008, the Associated Press and CNN reported on a medical study showing that over two decades, from 1983 to 2004, such deaths have soared.^[2] It has also become a prevalent risk for older patients.^[3]

Risk factors

People who engage in polypharmacy and other hypochondriac behaviors are at an elevated risk of death from CDI. Elderly people are at the highest risk of CDI, due to having many age-related health problems requiring many medications combined with age-impaired judgment, leading to confusion in taking medications.^[2][3]

Recent veterans back from war and suffering from Post Traumatic Stress Disorder (PTSD) in combat are at risk of dying from CDI/MDI.^{[citation needed]} Nine Veteran PTSD patients died from CDI/MDI in America in 2007.^{[citation needed]} There are anecdotal reports of veterans dying from combinations of antidepressants, antipsychotics, and tranquilizers used in combination with OTC medicines like diphenhydramine.^{[citation needed]} While still a U.S. senator from Illinois, United States President Barack Obama asked the U.S. Congress to inquire about the safety of these drugs.^{[citation needed]} There is an ongoing investigation of the matter.^[4]

Prevention

In general, the simultaneous use of multiple drugs should be carefully monitored by a qualified individual such as board certified and licensed medical doctor, either an M.D. or D.O.. Close association between prescribing physicians and pharmacies, along with the computerization of prescriptions and patients' medical histories, aim to avoid the occurrence of dangerous drug interactions. Lists of contraindications for a drug are usually provided with it, either in monographs, package inserts (accompanying prescribed medications), or in warning labels (for over-the-counter (OTC) drugs). CDI/MDI might also be avoided by physicians requiring their patients to return any unused prescriptions. Patients should ask their doctors and pharmacists if there are any interactions between the drugs they are taking.

Paracetamol / Acetaminophen deaths

On June 30, 2009 an FDA advisory panel recommended that Vicodin and another painkiller, Percocet, be removed from the market because they have allegedly caused over 400 deaths a year. The problem is with paracetamol overdose and liver damage. These two drugs, in combination with other drugs like Nyquil and Theraflu, can cause death by multiple drug intake and/or drug overdose. Another solution would be to not include Acetaminophen with Vicodin or Percocet.

Celebrity deaths due to CDI (or MDI)

Many celebrities have died from CDI/MDI, including:

• Writer/actor/comedian Freddy Soto from fentanyl, alprazolam and alcohol;
• Pro westling manager Elizabeth Ann Hulette aka Miss Elizabeth from alcohol, temazepam, oxycodone, hydrocodone and anabolic steroids;
• Child actress Anissa Jones from cocaine, PCP, methaqualone and secobarbital;
• Pro wrestler Louie Spicolli from carisoprodol, alcohol, painkillers and lorazepam;
• Hawthorne Heights guitarist Casey Calvert from citalopram, clonazepam and hydrocodone;^[1][5]
• Actor Nick Adams from paraldehyde and promazine;
• Acid rock guitarist Jimi Hendrix from alcohol and barbiturates;
• Singer Elvis Presley had over 10 drugs in his system^{[citation needed]} when he died. (The license of his physician, Dr. George C. Nichopoulos was later suspended and then revoked after press reports from then-ABC News reporter Geraldo Rivera on 20/20.);
• Lester Bangs from diazepam and propoxyphene;
• Deep Purple's Tommy Bolin from alcohol and prescription drugs and illegal drugs in combination;
• David Anthony Kennedy, son of Senator Robert Francis Kennedy, from cocaine, pethidine and thioridazine;
• Singer Johnny O'Keefe from combining several prescription drugs;
• Steve Clark of rock group Def Leppard from combining antidepressants, tranquilizers and alcohol;
• Actor Lani O'Grady of Eight is Enough from hydrocodone and fluoxetine;
• Bridgette Andersen from alcohol and multiple drugs;
• Edie Sedgwick from barbiturates and alcohol;
• Dana Plato from carisoprodol and hydrocodone;
• Actor/comedian Eric Douglas from alcohol, hydrocodone and temazepam;
• Actor Heath Ledger from toxic combination of prescribed drugs;
• Michael Jackson from propofol and two other sedatives;
• Brittany Murphy from multiple prescription drugs;
• The Rev of Avenged Sevenfold from oxycodone, oxymorphone, diazepam, nordiazepam and alcohol.
• Slipknot bassist Paul Gray from morphine and fentanyl
• New York Rangers forward Derek Boogaard from oxycodone and alcohol. ^[6]

Anna Nicole Smith and Daniel Wayne Smith

Main article: Anna Nicole Smith

Further information: Anna Nicole Smith#Death and funeral

In February 2007, five months after her son Daniel Wayne Smith was found dead from CDI with methadone, sertraline, and escitalopram in his system,^[7] Anna Nicole Smith also died from CDI/MDI, an autopsy detecting 11 drugs in her bloodstream. On March 12, 2009 California State authorities under State Attorney General Jerry Brown indicted Smith's legal companion Howard K. Stern and two physicians, Sandeep Kapoor and Khristine Eroshevich, for conspiracy to provide the drugs that led to her death. All three were released on bond. Stern was charged with conspiring to give mind altering drugs to a known drug addict (Smith). Both physicians faced loss of their licenses to practice medicine and may be fined or imprisoned. On October 28, 2010, Stern and Dr. Eroshevich were found guilty, but Kapoor was acquitted. Both convictions are on appeal. ^[8][9]

Heath Ledger

Main article: Heath Ledger

Further information: Heath Ledger#Autopsy and toxicological analysis

Australian actor Heath Ledger was found unconscious and died on January 22, 2008, in his SoHo, New York City, apartment; the toxicology report concluded that the cause of death was "acute intoxication" resulting from "the combined effects of oxycodone, hydrocodone, diazepam, temazepam, alprazolam, and doxylamine" and "that the manner of [his] death" was "accident, resulting from the abuse of prescription medications or combine drug intoxication(CDI)."^[2][10][11]

Speedball deaths

Some controversially think speedball deaths are MDI/CDI when they might simply be drug overdose, which is completely different phenomena. The following list is for speedball CDI/MDI deaths only. Victims must be using cocaine and heroin in combination or amphetamine with demerol. An upper and a downer combination can be called speedball death.

• Layne Staley of Alice in Chains from cocaine and heroin.
• Baseball athlete Ken Caminiti from cocaine and opioid painkillers;
• Actor Trevor Goddard from cocaine, heroin and temazepam;
• Actor/comedian John Belushi from cocaine and heroin 'speedball'
• Stand up comedian Mitch Hedberg, also from 'speedball';
• Actor River Phoenix from heroin, cocaine and methamphetamine;
• Elisa Bridges from heroin, methamphetamine, pethidine and alprazolam;
• Zac Foley of EMF from multiple illegal drugs;
• John Kahn, a Jerry Garcia collaborator and member of the Jerry Garcia Band, from heroin, cocaine and fluoxetine;

CDI-related legal cases

Karen Ann Quinlan

Main article: Karen Ann Quinlan

The Right to Die case of then-comatose Karen Ann Quinlan (March 29, 1954 - June 11, 1985) made legal history in 1975 and 1976, stimulating public scrutiny of ethical and moral implications of her case. In 1975, after drinking gin and tonics at a party and then taking Diazepam, Quinlan collapsed, suffered respiratory failure and irreversible brain damage, and, after being taken to the hospital, lapsed into a persistent vegetative state. After she had been kept alive on a ventilator for several months without improvement, her parents requested that the hospital discontinue such active care and allow her to die. The hospital refused, and the subsequent legal battles made newspaper headlines and set significant precedents. After the New Jersey Supreme Court ruled in her parents' favor, Quinlan spent nine more years comatose in the hospital, before dying from pneumonia in 1985.^[12]

See also

• Poly drug use
• Drug interaction
• Adverse drug reaction
• List of drug-related deaths
• Pharmacovigilance

Notes

1. ^ ^{a b} James Montgomery (2007-06-21). "Hawthorne Heights Guitarist Casey Calvert's Fatal Drug Interaction Was Rare, Experts Say: Number of Accidental-Interaction Deaths Still Remains Relatively Low, Although Such Incidents Are on the Rise". MTV.com. MTV. http://www.mtv.com/news/articles/1577017/20071220/hawthorne_heights.jhtml. Retrieved 2008-08-04. 
2. ^ ^{a b c} "Home deaths from Drug Errors Soar". CNN (cnn.com (Associated Press)). 2008-07-28. http://www.cnn.com/2008/HEALTH/07/28/fatal.drug.errors.ap/. Retrieved 2008-08-04. "Deaths from medication mistakes at home, such as actor Heath Ledger's accidental overdose, rose dramatically during the past two decades, an analysis of U.S. death certificates finds. ... Prescription drug abuse plays a role in the rise in fatalities, but it's unclear how much, researchers said. ... The authors blame soaring home use of prescription painkillers and other potent drugs, which 25 years ago were given mainly inside hospitals. ... 'The amount of medical supervision is going down and the amount of responsibility put on the patient's shoulders is going up,' said lead author David P. Phillips of the University of California, San Diego. ... The findings, based on nearly 50 million U.S. death certificates, are published in Monday's Archives of Internal Medicine. Of those, more than 224,000 involved fatal medication errors, including overdoses and mixing prescription drugs with alcohol or street drugs. ... Deaths from medication mistakes at home increased from 1,132 deaths in 1983 to 12,426 in 2004. Adjusted for population growth, that amounts to an increase of more than 700 percent during that time." ^{[dead link]}
3. ^ ^{a b} Rubin, Rita (2008-12-23). "Mixing Drugs Puts More Older Patients at Risk" (Web). USA Today (Gannett Corporation). http://www.usatoday.com/news/health/2008-12-23-mixing-drugs_N.htm. Retrieved 2008-12-24. 
4. ^ Andrea Billups and Audrey Hudson (2008-11-13). "Dead Veteran's Kin Demand Inquiry: After Death of Son, Dad Takes Cases to Capitol Hill" (Web). The Washington Times (Unification Church via News World Communications). http://washingtontimes.com/news/2008/nov/13/veterans-kin-demands-answers-on-ptsd-drugs/. Retrieved 2008-12-24. 
5. ^ Christina Fuoco-Karasinski (LiveDaily Contributor) (2008-10-09). "Hawthorne Heights Stay Positive After a Rough Year" (Web). LiveDaily. Ticketmaster. http://www.livedaily.com/news/15018.html. Retrieved 2008-12-24. 
6. ^ "Boogaard death from alcohol, oxycodone toxicity". http://eye-on-hockey.blogs.cbssports.com/mcc/blogs/entry/27694626/29446801?ttag=gen10_on_all_fb_na_txt_0001. Retrieved 20-May-2011. 
7. ^ "Doctor: Drug Combo Killed Anna Nicole's Son: 20-year-old Mixed Methadone and Antidepressants, Pathologist Testifies". MSNBC News (msnbc.msn.com (MSNBC)). http://today.msnbc.msn.com/id/22191324/. Retrieved 2008-08-04. 
8. ^ Dan Whitcomb (Los Angeles) (2007-04-06). "Anna Nicole Smith's Doctor in Drug Probe". The Age (Melbourne: theage.com.au (The Age Company Ltd.)). http://www.theage.com.au/news/entertainment/anna-nicole-smiths-doctor-in-drug-probe/2007/04/06/1175366475296.html. Retrieved 2008-08-04. 
9. ^ "The Law: Drugs: Anna Nicole's Son Died From Lethal Drug Combo, Pathologist Says: Star's Son Killed by Combination of Pain Killer, Antidepressants, Pathologist Testifies". ABC News (Associated Press). 2007-12-10. http://abcnews.go.com/TheLaw/Drugs/wireStory?id=3980212. Retrieved 2008-08-04. 
10. ^ Sewell Chan and James Barron (contributing) (2008-02-06). "City Room: Heath Ledger's Death Is Ruled an Accident". The New York Times (cityroom.blogs.nytimes.com). http://cityroom.blogs.nytimes.com/2008/02/06/heath-ledgers-death-is-ruled-an-accident/. Retrieved 2008-02-06. 
11. ^ CNN (2008-02-06). "Ledger's Death Caused by Accidental Overdose" (Web). CNN.com (CNN). http://edition.cnn.com/2008/SHOWBIZ/Movies/02/06/heath.ledger/index.html. Retrieved 2008-02-07. 
12. ^ "Karen Ann Quinlan (Medical patient)" (Web). Who2.com. Who2, LLC. 2008. http://www.who2.com/karenannquinlan.html. Retrieved 2008-12-24. 

External links

• Drug Interactions Checker at Drugs.com: Drug Information Online.
• Drug Interaction Checker at Medscape (registration required).