The Medications
Medscape: Speaking about benzodiazepines and oxycodone, can one of you comment on which specific medications are most concerning here, and how the overall medication profile has changed over the years? In the past illicit substances, such as heroin and cocaine, were the culprit, but how has this changed over the years?
Figure 5. Unintentional drug overdose deaths by major type of drug, United States, 1999-2006.
From Centers for Disease Control and Prevention.[2]
Dr. Paulozzi: It's difficult to identify the riskiest medications. We know from the mortality data that the drugs seen most commonly in overdoses are methadone, oxycodone, and hydrocodone. This may really reflect the fact that these are -- at least in the case of oxycodone and hydrocodone -- medications prescribed in the largest numbers (Figure 5).
In the ED data from DAWN,[14] if you look at the benzodiazepine category, far and away the most common benzodiazepine seen in nonmedical use visits is alprazolam.
Dr. Weisler: Alprazolam is the most prescribed benzodiazepine as well. If you have 45 million prescriptions in the Verispan 2008 generic drug data, which was higher than any other benzodiazepine, this may be a factor in alprazolam's ranking. Clinicians should assume that the risk for unintentional poisoning death is very real for other benzodiazepine anxiolytics and alprazolam. Death counts for compounds, such as fentanyl, which comes in a patch form and lollipop form, can be very high as well because its potency is up to 80-100 times that of morphine.
A lot of the people who are dying aren't even patients. They will just borrow painkillers and other medications from a friend or be given them at a party. Some will also buy them from a friend or relative or a fellow student, or dealer. They don't really get any instruction about how to use these powerful medications appropriately, and they may say, "Well, I'm not feeling anything right now. I'll go ahead and take an extra one, or add them together." Len, what's your experience been looking at this over the last decade as these medications have become more prevalent?
Dr. Paulozzi: I agree with you that there is a general sense among people using the drugs that because they are prescription drugs, they are safer than illicit drugs. Generally, people are using prescription drugs without injecting them as opposed to heroin, for example. Also, there is a general sense that this is a safe product: It doesn't carry an infectious disease; it's certified by the US Food and Drug Administration (FDA). There also seems to be a sense with prescription and over-the-counter drugs that if 1 pill works, 2 might work better; people self-prescribe, modify their doses, and share their medications with friends. If it worked for you, you give it to a friend and suggest that they try it. There is a lot of evidence that this is happening with all kinds of drugs, not just the controlled substances.
Dr. Weisler: Alcohol is often part of this deadly recipe as well. The people who are dying, as well as those using the opiates or benzodiazepines, are frequently drinking at the same time -- and often too much. Alcohol use really increases the chance of errors. I know that we are primarily talking about unintentional poisoning, but let's touch on suicide.
In 2007 there were roughly 35,000 suicides in the country. Moreover, in the 2003 Office of Applied Study (OAS) branch of the Substance Abuse and Mental Health Services Administration study,[15] there were 348,830 suicide attempts by individuals 18 years and older who ended up in the ED in the United States. In 2004, an estimated 106,079 ED visits were the result of drug-related suicide attempts by persons 18 years or older, which in many cases included opiates and benzodiazepines.[14] In another study using the National Violent Death Reporting System, it was revealed that among those tested for substances in 16 states, one third of those who died by suicide were positive for alcohol at the time of death; nearly one fifth had evidence of opiates, including heroin and prescription pain killers. For women, poisoning was the most common method of suicide, at 40.3%.[16] We know that frequently people who die by suicide have only thought about it for a fairly short period of time. In fact, one recent study out of Austria showed that about 47% of the participants had thought about suicide for less than 10 minutes before they made an attempt.[17]
If you're drinking and perhaps taking a benzodiazepine drug and/or an opioid at the same time, your chance of being impulsive most likely increases. Not only is the risk higher for unintentional overdoses, but the risk for suicide is also likely to be higher. Another study[13] by the Office of Applied Studies in Substance Abuse and Mental Health Services Administration (SAMHSA) in 2006 clearly highlighted the increased risk for suicidality in people who abused illicit drugs in the last month, with the risk for suicide increasing from 8.9% to 19% for a suicide attempt in the past year. Binge alcohol drinking in the past month also increased the risk for a past-year suicide attempt from 9.1% to 13.7%.
Len, how does the coroner decide whether death was a suicide or an unintentional drug overdose?
Dr. Paulozzi: Coroners and medical examiners are obliged by law in every state to investigate deaths that have a suspicion of trauma or clear evidence of trauma, such as a poisoning death. They do autopsies in a majority of cases. They should be doing toxicology when there's a suspicion of a drug- or chemical-related death. They do a scene investigation (they or their staff does); they do interviews; and they try to get the medical history and even the prescription records from the state prescription drug monitoring program on the cases that they investigate.
They look at issues, such as history of mental illness, history of suicidal ideation, suicide notes, and then try to put it all together and make the best judgment that they can of whether this represented a suicide or not. Admittedly it's a difficult situation with a person who has a history of depression, for example, but no expressed suicidal ideation, along with a history of substance abuse. It's very hard to know whether a given overdose was an error when they were using drugs, or deliberate. Therefore, there are a few thousand deaths every year in the United States where they simply can't decide whether it's a suicide or an unintentional overdose, and they put them in the undetermined intent category.
Dr. Weisler: What's really important to me as a clinician is I know that if I can treat the underlying mood, anxiety, or psychotic disorder -- and try to address the drug or alcohol abuse or dependence as well -- that I'm hopefully going to be able to reduce the risk for both suicide and unintentional drug poisoning deaths. You can't prevent every episode of illness or every death, but we can prevent many deaths. To highlight the magnitude of the problem again, in 1 week there roughly are as many people dying from suicide in the United States as all allied casualties in both the Iraq and Afghanistan wars in a whole year.
In 2008 in North Carolina, for example, there were also 1016 people who died from unintentional drug poisonings and 1160 by suicide. In the same timeframe, there were tragically 322 deaths of Allied troops in the war in Iraq and 295 in the war in Afghanistan (icasualties.org), so it's a major public health problem, both in terms of suicide and unintentional poisonings in the United States and elsewhere, when over 3.5 times as many people died in North Carolina in that year than the yearly allied casualties in both wars. Nationally, we lose as many people from unintentional drug poisonings and suicides every 3-4 days as we did in both the Iraq and Afghanistan wars in all of 2008 or 2009. Of course, all of us would ideally like to see 0 deaths from any of these causes.
As clinicians, we are looking for depression, bipolar disorder, psychotic disorders, and anxiety disorders that can sometimes help us uncover this self-medication as well. Ashwin, do you want to say something about this?
Dr. Patkar: Yes. I think if a clinician is treating someone with either a substance abuse or a mental health disorder, they've got to assess for both. That is the reality. The data show that half the patients with mental illness also have substance abuse and vice versa; sometimes it's even higher. Even if a primary care doctor is going to see a patient with mental health or substance abuse problems, he/she is going to have assess for both and provide treatment for both conditions. If you have coordinated care that addresses mental health and substance abuse problems at the same time, I think the prognosis is much likely to be better than trying to treat either condition separately. Incorporating participation in Alcoholics Anonymous and Narcotics Anonymous or similar approaches into treatment programs can also be very helpful.
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Cite this: Unintentional Drug Poisoning Deaths: A National Epidemic - Medscape - Jun 28, 2010.
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