December 2008

ACUTE COMBINED POISONING DEATH

Image: Prescription pills and pill bottles

Death Investigation at the Ada County Coroner's office includes many cases whose cause of death is Acute Combined Poisoning. The following information will give you some insight as to the reason we are seeing an increase every year concerning combined poisoning.

PRESCRIPTION MEDICATIONS

Drugs called "opioids" are frequently prescribed to relieve pain, but if abused they can kill. Over the past 15 years, sales of opioid pain killers, including oxycodone, hydrocodone, methadone and fentanyl, have increased, and deaths from these drugs have increased in parallel. In 2002, over 16,000 people died in the USA as a result of drug overdoses, with most deaths related to opioids, heroin, and cocaine. Opioids surpassed both cocaine and heroin in extent of involvement in these drug overdoses between 1999 and 2002. The situation appears to be accelerating. Between 1979 and 1990 the rate of deaths attributed to unintentional drug poisoning increased by an average of 5.3% each year. Between 1990 and 2002, the rate increased by 18.1% per year. The contribution played by opioids is also increasing. Between 1999 and 2002 the number of overdose death certificates that mention poisoning by opioid pain killers went up by 91.2%. While the pain killer category showed the greatest increase, death certificates pointing a finger of blame at heroin and cocaine also increased by 12.4% and 22.8% respectively.

OVER-THE-COUNTER MEDICATIONS

Just because you can buy many medicines without a prescription doesn't mean they're entirely safe. Over-the-counter drugs can kill you. One of those over-the-counter drugs is Acetaminophen. Acetaminophen belongs to a class of drugs called analgesics (pain relievers) and antipyretics (fever reducers). Acetaminophen relieves pain by elevating the pain threshold. It reduces fever through its action on the heat-regulating center of the brain.

Acetaminophen overdose causes more than 450 deaths due to acute liver failure each year in the United States and this number appears to be on the rise. In 2001, the U.S. Acute Liver Failure (ALF) Study found acetaminophen responsible for 39 percent of cases. In 2003, the number had risen to 49 percent. Studies show that more than 50 percent of the country's cases of acute liver failure are related to acetaminophen. While acetaminophen overdose is a fairly common way to attempt suicide, most suicidal patients receive medical care within four hours and can be protected by the acetaminophen antidote.

The fact that an overdose of acetaminophen can result in liver toxicity, liver failure, and even death has been known for some time. Patients with overdoses of acetaminophen should seek emergency care immediately. Early treatment with acetylcysteine (Mucomist) can prevent liver damage or death. The signs and symptoms of liver toxicity may not become apparent for 2-3 days after a toxic overdose. People who ingest large quantities of the drug over several days - usually to relieve pain and often in conjunction with other narcotics - are typically not aware of the potential harm and only seek treatment after symptoms of toxicity have appeared and their prognosis is poor. These unintentional cases constitute roughly half of all cases that develop liver failure and 30 percent of all these cases are fatal.

ALCOHOL OVERDOSE/POISONING

Alcohol Bottles

Death from alcohol overdose can occur through several physiological mechanisms. When the concentration of alcohol in the brain becomes high enough to depress the brain areas responsible for the control of consciousness and respiration, for example, the drinker lapses into a coma, stops breathing, and dies within minutes. As a central nervous system depressant, alcohol can kill just as easily as barbiturates, heroin or other depressants, because when organs that are necessary for life support fail, so does the patient. Even superficial examination of the term in-toxic-ation, should alert the consumer that alcohol is a toxin, and can be toxic (deadly). The consumption of even small quantities of non-beverage types of alcohol, such as methanol or rubbing alcohol, can be fatal.

In many cases, overindulgence will produce an early symptom of toxicity from alcohol: nausea and vomiting. Most people stop drinking after such a reaction. Although tolerance to alcohol can significantly increase the threshold for this effect, the threshold for a fatal overdose does not increase in proportion to other behavioral effects of this drug.

Contrary to street wisdom, mixing drinks generally does not make you sick. However, people who mix drinks may be consuming more alcohol because they are sampling different kinds, which will increase their blood alcohol concentration. Drinking games, sweet tasting alcoholic drinks, or novelties such as Jell-O shots can be deceptive in terms of gauging alcohol consumption. Being caught up in the excitement, or having a significant delay between the consumption of a large quantity of alcohol and the eventual effect, can be dangerous. If blood alcohol concentrations increase very rapidly or reach high concentrations, specialized cells in the brain detect this change and send signals to the stomach to violently contract. This is the brain's way of trying to save itself! Removing unabsorbed alcohol from the stomach through a vomit reflex will prevent blood alcohol levels from increasing further.

Although vomiting is certainly helpful in many overdose situations, it can also be fatal. As a depressant, high blood alcohol concentrations will produce depression, even coma. The drinker will no longer be able to maintain consciousness. If someone is in a deep sleep from the depressant effects of alcohol and vomits reflexively, he may asphyxiate on his own vomit and be too intoxicated to know or respond effectively.