Accidental overdose?

[NSAIDAllergy]

I wanted to get the opinions of SDNers. We have this news item http://www.foxnews.com/story/0,2933,328828,00.html about Heath Ledger's "accidental" overdose of "the combined effects of oxycodone, hydrocodone, diazepam, temazepam, alprazolam and doxylamine".

Three Vicodin instead of two may be "accidental"; taking your Xanax when you thought you grabbed your vitamins may be "accidental". CAN ANYONE OUT THERE TELL ME HOW SOMEONE TAKES THREE BENZOS, TWO NARCS AND AN ANTIHISTAMINE ACCIDENTALLY?????????????

I just notice the threads about how medicine is slipping in prestige and how future physicians have low morale about their profession. Then I see a story like this and I have to, at least for a moment, ask: "Does it make more sense to (at least) imply that doctors and their wacky prescription writing killed this actor rather than (at least) the possibility that this was another Holloywood overdose?

I can understand wanting to spare the Ledger family the pain of the Paparazzi invasion if this were a suicide. (I don't wish anyone that kind of pain.) But can anyone else out there see this as a thinly veiled attack on physicians while spinning this story away from blaming Hollywood and its culture?

Just a thought.

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[pseudoknot]

It's Fox News. I really think that if they were going to blame doctors for this, they'd come out and say it. Subtlety isn't their thing.

And I don't think it had to be a suicide. Some people, especially in that town, just take a lot of pills, and sometimes go too far. Who knows, who cares.

 

[Katydid]

It wouldn't be a stretch to say that there certainly are people who doctor shop, don't tell their various doctors about ALL the medications they are taking, and that this happens more often than anyone would like to think.

Do I think it's a suicide? I think that's a possibility.

Do I think it was an accident? Dude, how the hell would you do that by accident? I've taken a Claritin, mistaking it for a birth control pill (both are small and round, and I wasn't looking at color) before. I took an extra calcium supplement when I thought I was taking a vitamin (same size, shape, and very close in coloration).

But accidentally take three benzos, two narcs, AND an antihistamine? That's a stretch. Really, it is.

And why anyone would bother to take Faux News seriously is beyond me. Just not credible as a news source, IMHO.

 

[ccfccp]

Just because you're abusing prescription drugs doesn't necessarily mean you're suicidal. You can be taking the drugs for fun and then end up overdoing it and throwing yourself into respiratory depression... All conjecture, but I would say taking the pills was on purpose but the overdose was accidental.

Besides, how many times a week do you see this (minus the Heath Ledger part) in the ED?

 

[ThedarnmikeDO]

my theory is that he did a bunch of coke and a day or two later decided he wanted to go to sleep. So he tossed back a bunch of pills that he knows make him sleepy. Doesn't cocaine clear in 24-48 hrs? I"m also curious about the quantity of each medication he took. I think that if we find out he threw back a bottle of each it was def suicide. Otherwise I think he was just trying to come off a coke/amphetamine/pcp binge.

 

[Dr. Dukes]

Didn't the New York City Medical Examiner rule it an accidental overdose? All accusations about the media coming after doctors aside, I don't see why a medical examiner in New York would pull any punches...

 

[doctawife]

There are plenty of people who don't know about 1) synergy or 2) that there are classes of medication. He might well have thought that since each separate drug was safe, they were still safe when taken together. And please, who is thinking straight after taking one or two of the drugs he was on? We're not talking about a rational decision.

 

[Flopotomist]

By accidental, I think they making an assessment of the INTENT of the individual. This becomes important for things like life insurance (intentional overdose may not qualify for a payout whereas accidental would).

An accidental overdose could be distinguished from an intentional overdose via whether there was a note left at the scene, whether the pill bottles were completely emptied, whether there was a recent declaration of intent by the patient etc.

An accidental OD would be relatively easy if you took the "correct" prescribed amount of each of the 6 meds HL was prescribed.

 

[dmitrinyr]

I think the main thing here is the INTENT of Heath Ledger. By them saying that his death was "accidental", that means that he was NOT intending to kill himself but was trying to use the medications for what they were supposed to be used (possibly even in the correct dose) and just didn't realize that there was a synergistic effect once the medications are taken together. Correct me if I'm wrong, but the toxicology report did not mention that any of the concentration of any of these medication was in excess of what would be expected upon taking a normal dose of the medication.

The truth is that regular people (meaning those with no medical or pharmaceutical knowledge) no very little in regards to what medications can be taken with what medications and how many pills one can take of any medication. People often do not read the labels on the bottles, they often forget to tell their doctor that they are taking another medication. Yes, there is a possibility that he was trying to kill himself, but I personally think that that is less likely.

Here's what I think happened: In interviews shortly prior to his death, Ledger mentioned that he had trouble sleeping and there were reports that he had pneumonia at the time of death. So, lets just say he hasn't gotten a lot of sleep the night before and so in the afternoon prior to his massage he wants to take a nap but cannot. So he takes a few sleeping pills. That morning maybe he took the Xanax and Valium that he takes every morning for a possible anxiety disorder that was not made public prior to his death. So at this point he has 3-4 pills in his system. Then for some reason (pain, addiction, etc.) he took 1-2 oxycontin that morning. Then an hour later, he still cannot fall asleep, he then takes another sleeping pill just to do the trick. At this point there is 4-7 pills in his system, yet in the patient's mind or his intention, all the pills were taken for a particular purpose and not with any intent to hurt himself. He then falls asleep and the synergistic effect of the medication slowly leads to decreased respiratory drive..... respiratory distress and then full respiratory failure while he sleeps. Along with the meds, his pneumonia might have slightly contributed to his decreased airway expansion and decreased delivery of oxygen to the lungs. In the end, he died in his sleep.

Now you might think, well all of these events happening together like I mentioned is a bit of a stretch and it's far more likely that he just a whole bunch of pills to kill himself. But I've seen many times that patients go to different doctors and while taking a medication, forget to tell the new doctor of that medication and that doctor prescribes them a medication which if taken together with the first medication can cause severe morbidity and possible mortality to the patient. Pts are often oblivious of the serious effects of taking multiple pills and many times take their narcotics, benzos, and other meds as if they were skittles and then those same patients show up to the ED with an acute intoxication.

Maybe I'm stretching my imagination on this one. Just my 2 cents.

 

[mariolatry]

I'll throw my 2 cents in as a toxicology fellow.

Very difficult to say anything without having access to the medical examiner's tox report. All forensic tox can tell you is that a particular substance was found in the system at a given concentration. Can't tell you a thing about intent. Hell, even the concentrations can be difficult to interpret depending on where the blood is drawn (heart vs. central vein). Also, many drugs exhibit post-mortem re-distribution to complicate matters further.

Obviously, being found dead or unconscious with empty pill bottles is highly suspicious for intentional (but not necessarily suicidal) ingestion. That being said, if he wasn't aware that most of his drugs fell into the benzo and opioid classes, he may very well have had an accidental death due to their additive effects. Most of the benzos, in particular, have prolonged half-lives, so its possible to accumulate a high body burden if you stack the doses to closely.

 

[BADMD]

my theory is that he did a bunch of coke and a day or two later decided he wanted to go to sleep. So he tossed back a bunch of pills that he knows make him sleepy. Doesn't cocaine clear in 24-48 hrs? I"m also curious about the quantity of each medication he took. I think that if we find out he threw back a bottle of each it was def suicide. Otherwise I think he was just trying to come off a coke/amphetamine/pcp binge.

Cocaine clears fairly quickly, however the metabolites take several days to clear. With habitual or heavy use it can take a week or longer to clear the detectable metabolites.

 

[Flopotomist]

my theory is that he did a bunch of coke and a day or two later decided he wanted to go to sleep. So he tossed back a bunch of pills that he knows make him sleepy. Doesn't cocaine clear in 24-48 hrs? I"m also curious about the quantity of each medication he took. I think that if we find out he threw back a bottle of each it was def suicide. Otherwise I think he was just trying to come off a coke/amphetamine/pcp binge.

Holy Conclusion Leaper!

There was no evidence of any cocaine (or any other illicit substance) in his home, or in his system according to the published reports.