Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.
Thursday, November 08, 2012
How Not to Die a Tragic Death from a Drug Overdose
Whitney Houston, Michael Jackson, Heath Ledger, Amy Winehouse, Anna Nicole Smith -- I imagine you know what these celebrities all have in common: they've died from accidental overdoses.
In the first 20 years of my career, I can't recall hearing a single story of an accidental overdose resulting in the death of a young person that I knew, a friend knew, or a patient told me about. Maybe I've forgotten them, but if so, it's because they were spaced well apart and there weren't memorable trends. One close friend had a young relative, a substance abuser, overdose and end up in an ICU, but he lived. Somehow, in the past year, I've been hearing more and more stories of tragic deaths of young people, full of life and promise, who partied just a little too hard and stopped their lives in it's tracks. Not suicides, just a little too much of whatever the substances might be.
So young people party. They drink, they smoke weed, and sometimes they pop pills or shoot drugs (though please do note that IV drug use is not considered to be "recreational.") Given that this is the reality of some people's youths, and these stories are heart breaking, let me offer some words of wisdom. It's not just the hardcore addicts who are dying, it's not just the shooters, and often the deaths are caused by medications with legal uses. And the horror of the deaths is not just their tragedy, but the guilt that gets left behind, by the person who left the victim alone, who noticed they seemed off but not enough to call an ambulance, by the person who didn't think much of an unanswered call or text and gets to wonder if they had done something differently, if their friend might have lived. It's all horrible.
Here are my words of wisdom:
Only take one substance.
Don't drink and take drugs. Don't do it even if you've done it 2,413 times and it was fine all those times, Many people who die accidentally have lots of experience with it and have never died before.
Don't mix drugs. Benzodiazepines may be relatively safe, but once you take your Xanax, add a little oxycontin, and have a beer, you may be in for a very long sleep. Xanax/Valium/Ativan/Klonopin (benzos) and Oxycontin/Oxycodone/heroin/methadone/morphine/MS contin/percocet/percodan/darvocet/demoral (opiates) --- these medications have effects that are more than additive and they cause respiratory depression and have unpredictable effects. This combination of xanax/alcohol/pain killers seems to be especially popular and especially lethal. Cocaine and stimulants are also a really bad idea.
If you've had a drug problem, quit using, and have been clean for more then a few days, your body starts to heal, and if you relapse, it will take much less drug to get the same effect, Taking your old dose of medication can be lethal. This is a major reason why death rates are so high soon after prisoners are released from jail -- they hit the streets and take their former dose of drugs -- it's much more than their body can handle after being clean.
Don't drink on an empty stomach. Food slows absorption. The body is made to resist dying from alcohol poisoning -- it's why people throw up, it keeps them from absorbing too much alcohol. You can overwhelm this safety mechanism if you drink too fast.
---Don't do shots. See the above logic. It's hard to kill yourself drinking beer alone, but I've heard of people doing 21 shots on their 21st birthday or drinking an entire bottle of straight vodka as part of a frat initiation. This can kill you. If you must do shots, don't do them on an empty stomach, let a fair amount of time pass between shots, and drink a non-alcoholic drink in between to slow the process down.
----If you must drink heavily, do it with friends and stay with each other, don't lose your drunk friends. Don't leave someone who has passed out alone, roll them on their side so that if they vomit they don't aspirate it (aspirate = breathing your puke into your lungs, a common reason people die after heavy drinking or overdosing). If someone can not be aroused after drinking, call an ambulance! It's better to be embarrassed than to be dead. Remember, you don't have to be an alcoholic to die of alcohol poisoning.
-----Don't drink and drive. There is a cab driver out there who needs your business.
-----Don't drink and go on the roof.
-----Don't drink and walk on railroad tracks.
If you take prescription drugs for medical reasons, don't increase the dose without checking with your doctor first. If you're not sure if it's safe to combine prescription drugs, ask your doctor or call a pharmacist (any pharmacist, look for a 24 hour pharmacy and call and ask to talk with the pharmacist.)
And probably the best advice: don't abuse drugs or alcohol.
If you take prescription pain killers, sedatives, or stimulants, know where they are, and know that someone else can't access them. These medications aren't meant to be shared.
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Huh. You' think I'dve known some of these meds don't go together but after my second knee replacement, i was on oxycontin, percocet, and I think from my psychiatrist, clonazepam (but she'd spaced the fact that I was having/had had surgeries, even tho i was using a cane, in obvious pain and such, and had told her. I wonder if this is why my grip on reality went bye-bye the week after the second surgery . . . hello, Spock, when are you coming over for lunch? Oh, and Cornelius & Zira, my favorite talking simians, are coming over tomorrow . . . thought they were real. It's sorta funny now but sorta not (i had to spend some time alone every day during tat week, and I coulda really done some damage so soon after surgery if I did anything I thought was real but wasn't)
I sorta knew meds like this were bad w/alcohol already. I just don't want to get any ideas (but yeah I knew they were bad w/alcohol, good thing I don't drink)
It does not surprise me that deaths due to drug overdose are on the rise during the same period of exponential increase in wide use of psychiatric medications, even when general use of recreational drugs, especially among young people, was decreasing.
If I had to propose a hypothesis, I would propose that both directed and non-indicated use of many psychiatric medications are riskier than is commonly believe, and when used together and with other substances, have increased toxic effects.
And you are comparing deaths of Houston, Jackson, Ledger, Winehouse, and Smith to dangers of run-of-the-mill youth partying? These celebrities were severely troubled (Jackson had a live-in drug dispenser!) and had long histories of addiction, trauma, abuse, and/or distress.If anything, I think that in their search for some relief found psychiatric medications, found that it was not enough, and still used other drugs to try to feel better (or even mitigate adverse effects of meds), leading to increased addiction and danger. Mixing the drugs effect how your body responds to the drugs individually and people cannot gauge safe use (or get messed up too fast due to the mix of psychoactive substances that they cannot determine safe use anyway).
I do think many psychiatric drugs need to dispensed and prescribed with more care, and with better understanding of people's drug use, erring on the side of the most cautious and monitored, or not at all.
Great post, I needed to read this. Just had my hip operated on and realizing that I am enjoying the pain medicine more than I should be. (and I happen to enjoy a glass of wine or two) Self awareness and your words of wisdom shall be my guide.
Also in the "don't mix drugs" category- Don't mix MAOIs with illegal drugs. It's almost always a bad idea. I'd hope that most people taking MAOIs would know this already... but there it is.
Don't mix MAOI's with anything. If nardil + cheese can kill you, it goes without saying that nardil and cocaine are a really bad idea.
Sarebear, so glad you lived. But the talking simians thing does sound entertaining.
I remember when I was young, my parents were really against meds. We took cold medicine and some prescription meds. This rubbed off on my brother and me, and we never wanted to take even headache medicine as we got into our teen years. Friends would offer, but we would just say we preferred to fight our headaches naturally. Maybe our culture is changing? Taking prescription and illegal drugs is more socially acceptable? I know my brother is now much more liberal about meds and he sometimes uses stimulants. I will continue to be paranoid and ditch any future benzo and stimulant meds. However, if I ever am in severe pain, I might go for a pain killer.
I not judging anyone else's experience in any way by saying this.
Me, I was so anxious/nervous about the potential for addiction from post-surgical pain meds, that I'd test, once or twice a week, skipping a dose and seeing if there was any "craving" for it, beyond wanting the pain dealt with.
This was after the second surgery, when I had percocet and oxycontin; the first surgery lortabs and oxycontin were enough, but the pain was worse the second time. I'd had some experience with Lortabs and had experienced a time when, being so desperate to stop the pain I had in the months following childbirth, that there was one day I took six of them (spread out somewhat, two at a time, they told me I could take two at a time but I didn't know how many in 24 hrs).
I ended up feeling . . . well it was beyond handling the pain, I started feeling good in a wierd way I'd never felt. So I figured that was a clue and backed off.
So, I was more well I wouldn't say comfortable with the Lortabs, but I knew what the danger signs were (I don't think the being desperate to solve the pain was a problem, I was in almost constant pain from childbirth-level pain, that who wouldn't be desperate after months of that getting worse and worse to be out of it; I didn't have any craving for the drug specifically).
I suppose the same danger signs may have applied to Percocet, but signs I'd never been on that before, I wanted to make sure. So 6 or 7 hours of extra post-surgical pain once or twice a week for awhile to give me peace of mind on that account, wasn't too much for me. Maybe I was just paranoid. Still, I'd had some notion I'd heard that getting addicted to pain meds like that after surgery, was a higher percentage than I was comfortable with . . .
If I'm ever prescribed an MAOI, I'll have to refuse it, because it interacts with so many things (fuzzy idea, but I see so many warnings on cold medicines and other things) that I'd be too likely to use it or keep it as a method to die. There's something else I'd mention but I don't want to give anyone any ideas.
I'm not saying people not raised with a thing like the LDS Word of Wisdom (no coffee, tea (well, caffeinated, is some interpretation, and many don't drink caffeinated soft drinks either), recreational drugs, alcohol, eat meat sparingly and good amounts of grains, stuff like taht) are more likely to abuse drugs, but I'm saying for me that being raised with this firm set of rules (well, some stretch it and interpret parts differently to suit them, as is human nature) maked me really sensitive to this stuff.
I was "bad" when I turned 21 and let my boss take me out to a bar and I had two fuzzy navels. Got in trouble w/my clergy for that (cause yeah I told. Some people might laugh at me feeling guilty for such mild? alcoholic drinks, but for me it was a well it wasn't good). Oh yeah and I felt guilty for once having a bananas foster flambee thing and the flames made me feel so nervous i blew it out before the alcohol was burned off, and I thought the whole thing tasted like Nyquil . . .
So you are advocating "safe" use of illegal and dangerous drugs?!??? That is, obviously you're not, but your post certainly is. I don't think you thought twice before posting it to the very public internet.
I'm not advocating ANY use of illegal drugs, but the truth is that many many kids under the age of 21 tell me they drink, many people smoke weed, Maybe I've met 2 college students who have not tried someone else's stimulants, and I'm hear a rumor out there that a few people in Baltimore might actually be shooting drugs....so it's like distributing condoms at a student health center. If you're doing it anyway, and my writing on a blog to say "don't" is not going to change your mind about this (and it's not) then maybe someone will read it and try to avoid the behaviors that may result in death, permanent brain injury, or death. Or people on meds who might not have thought about what might not mix. I thought perhaps parents who know their college kids are binge drinking might pass this along to them. I'm not condoning illegal drug use, but I am a realist and we need to do something different (and I don't know what that is) to halt this horrible trend of young people dying. It might help a lot to tighten up the ease with which people are able to obtain narcotics legally.
Nope, but I've never smoked weed or done drugs or taken anyone else's stimulant. Your post said to me - it's not that bad. A medical doctor said just take these precautions and go have a good time. So you've converted at least one once upon a time non-drug-or-alcohol-user....
A very fine line you're treading. Very fine.
Doing those things are not likely to kill you, but they may addict you and make your life less than pleasant, just in case you didn't know that.
And they are illegal. Unless you live in Colorado or Washington, where you may now legally enjoy your weed. Taking someone elses' stimulant may not kill you but it's still a felony, and for children, it's recommended that an EKG be done prior to taking them.
When people are dying -- and lots of them are -- an 'abstain or die' stance makes no sense.
Oh, Dinah. It's nice to always be right, isn't it.
making life unpleasant isn't a particularly strong deterrent for most people when it comes to alcohol and drugs.
Hearing an MD say something I always thought was medically terrible is really just unpleasant is as good as a go ahead. I'd offer to take your post into my high school students on Tuesday and get their opinion, but I really don't want them getting the message you're sending, whether you want to think so or not -- that drugs and alcohol have just unpleasant effects.
Take responsibility for your words.
It really isn't about being right, I posted this not to condone illegal or dangerous behavior, but because these stories are so sad and tragic and it's so hard to sit with the pain of the survivors, that I wondered if I might put something out there that might prevent deaths. I hope that no one else reads this and decides, like you, that they should now try drugs or alcohol because they are benign. If my post really encouraged you to actually do something dangerous that you would not have done, then I am very sorry. I hope you didn't actually smoke weed because of my post.
I certainly could understand why you would not want to show this post to your students. But if you do decide that would be a reasonable thing to do, I would be very interested in hearing how they feel about exposure to warnings that are given which acknowledge that they might be behaving in ways that show poor judgement. Do free condoms tell them it's okay to have sex? People worry that asking teens if they are suicidal will give them the idea to do it. What do they think?
I tell people not to do dangerous, harmful things all the time. When it comes to issues related to either addictions or to the social pressures of being a cool teen, my advice just doesn't seem to hold much weight.
If you discuss this with them, please let me know their thoughts.
I like the post, it acknowledges behaviors that people do engage in, and gives some ideas of how to reduce risk of serious consequences for self and others. Giving information about possible consequences, and ways to avoid them, seems reasonable to me. The abstinence programming doesnt work for everyone. In American culture, coming of age into adulthood and belonging in a social group are often linked with uses of substances and behavior practices that have some risk involved. The post is not saying there are NO risks, or that EVERYONE engages in these behaviors, or that EVERYONE will be unlucky.
I thought about this for a while today. I also shared it with several colleagues. The consensus was unanimous. There is no safe, responsible or comprehensible way to share this with teens, young adults, and probably many actual adults, either. Dinah, your very first line is "Only use one substance." So when teens or college kids drink themselves to death (literally)..... Unless you're talking about pot or a drink then, I'm sorry, your very first line has invalidated all the rest. I'm sure you didn't mean drink yourself to death or do a ton of heroin, but you did not specify what you meant. "Only use one substance...." That is a profoundly irresponsible and dangerous sentiment, certainly for teens, and I suspect for some older people as well.
Condoms give teens a safe way to have sex. Your post did not, even though I'm sure you were well intentioned, give a safe way to drink alcohol or use drugs. As I said several times, your very first line, "use only one substance" invalidates the rest.
It may be that you are just out of touch with a population that is not adult and willingly entering treatment to get help, or a population like some of your readers who are happy to jump on every word you say and provide long anecdotes about why and how they agree. I don't know. All I know is that this post was dangerous and alarming -- although I do know that was not your intention. I would strongly suggest adding a disclaimer. Unless, of course, you really do feel that using one non-specified substance is perfectly fine. Of course, I include heroin, coke, vodka - all the stuff that is common out there.
Honestly L, I felt like this was a public service. Amy Winehouse was on Librium for alcohol withdrawal when she relapsed and drank herself to death. The Librium surely contributed to her death. I wonder if she thought mixing substances could be that dangerous...A lot of alcoholics take benzos when they are trying to get sober. I wonder how many are warned of what the consequences could be if they relapse while ingesting these drugs. Obviously, no one wants alcoholics to relapse, but relapse happens and they should be warned of the consequences of mixing drugs.
Heath's drugs were all prescription right? And Brittany Murphy? I heard her pneumonia was caused by prescription drug use. Did they know their prescriptions could be that dangerous?
I love your article.
Harm reduction works much more than "abstinence" - it just would not work for active substance users and teens trying to be cool.
I have patients coming into my clinic and ask for BDZs all the time (some drinks everyday). I often got annoyed and refused their requests straight ahead (and they got angry). Next time I'll tell them about Michael Jackson.
L needs to be more in touch with what teens already know and do. For goodness sakes, many of my daughter's friends already drink way too much caffeine- how many monsters or 5 hour energy does the average over-achiever slam? And yes, at some point there will be parties and there will be alcohol. When the 4Loko thing hit, I pulled an article off the internet and told my daughter (12 or 13 at the time) that she should be aware, and make sure her friends are aware that mixing any type of stimulant with a depressant is flat out unsafe.
Perhaps because we have family members with major mental illness, she already knows that psychosis is not just "unpleasant." Frankly, if you can't educate teens about these tough topics, maybe you aren't relating to them and as well as you think.
So yes, people should only use one substance, if at all, and then, be aware that some substances are a lot more dangerous on their own than others. Kids are already aware of this- they just don't fully understand or appreciate the actual danger, or because they are young they think either it doesn't matter or won't happen to them.
And seriously, Dinah, you left out caffeine, and some of the other stimulants that are sold as energy boosters- there is an add that was running in the back of a Sunday insert about an ephedrine like supplement? the title was something like, "get it quick before the FDA bans this." I have had kids having palpitations because they don't eat properly and drink a boatload of legal stimulants before a game. They really don't understand the toxicology and biology.
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