Drug Deaths By State

Is Coumadin the Most Dangerous Drug in America?

Common drug most likely to land seniors in the hospital.

High-risk drugs for seniors aren’t the ones you might think. Take warfarin, trade name Coumadin. Millions of seniors do. For people with certain kinds of heart trouble, or who have had a stroke, Coumadin works against the blood’s tendency to clot, and saves lives. In cases of accidental overdose, however, it causes uncontrolled bleeding, and is the likeliest drug to put people over 65 in the emergency room. To further complicate matters, Warfarin interacts with a number of common medications, such as antibiotics, in ways that alter the blood’s clotting ability.

A team of researchers from the Centers for Disease Control and Prevention (CDC) and Emory University studied almost 100,000 emergency hospitalizations due to adverse drug events between 2007 and 2009. The results, published in the New England Journal of Medicine, showed that nearly two-thirds of such hospitalizations were due to hemorrhages caused by unintentional overdoses, and that warfarin was the leading culprit, accounting for about one third of the admissions and costing “hundreds of millions of dollars annually.” Prescription painkillers and sedatives, generally considered to be a major hazard for seniors, account for a mere fraction of hospital admissions—about 1.2%.

Accidental overdoses of insulin products came in second, followed closely by anti-coagulant drugs like Plavix and aspirin. The study makes clear that the main danger for seniors is hemorrhages and other forms of uncontrolled bleeding. In addition, insulin overdose can cause fainting and seizures, and it is not uncommon for those over 65 to be taking drugs for both diabetes and heart disease at the same time.

Half of those hospitalized for drug emergencies were over the age of 80, according to the study, which says that drug-related hospitalizations can only grow as the population ages. 40% of Americans over the age of 65 take five to nine medications, the study revealed.

Clearly, doctors can cut down on admissions and save money by more closely monitoring medications in older patients. But the sad fact is that physicians don’t do a very good job of keeping track of all the medications older patients may be taking. Michael R. Cohen of the Institute for Safe Medication Practices told the Wall Street Journal that pharmacists needed to step into the information gap: “When you get a prescription filled, you’re handed a patient education sheet that’s a printout from the computer,” he said. “It’s very difficult to read, so it generally ends up in the trash.”

Photo Credit: http://www.doctortipster.com

Today is Overdose Awareness Day

Annual global day of action coordinated by Red Cross.

According to the most recent figures from the Centers for Disease Control and Prevention (CDC),  more than 26,000 Americans die needlessly, pointlessly, from accidental drug overdoses.  For example, in San Francisco, there were more drug-related accidental deaths in 2007 than there were deaths by automobile crash. These days, oxycodone is  our leading killer, followed by cocaine and heroin.

The Harm Reduction Coalition notes the success of the DOPE project (Drug Overdose Prevention and Education) in San Francisco. DOPE is a community group composed of members trained to recognize and respond to drug overdoses. In San Francisco, one person dies every other day from a preventable drug overdose death.

"Overdose Awareness Day is a time for us to remember the thousands of lives lost to accidental drug overdose every year and to restate our commitment to effective strategies to reduce overdose deaths in our community," said DOPE Project Director Eliza Wheeler.  "This year, we would like to publically thank the courageous people who have successfully revived their friends, family members and partners using naloxone."

Over at Injecting Advice, they have gathered together twitter hashtag posts about Overdose Awareness Day:

“Today (31st August) is International Overdose Awareness day and all around the world there are services (and individuals) working hard to raise awareness of the main course of death for people who use drugs. As you'd expect a lot of these people are now using social media like twitter, so I've decided to collect together the mentions of the official 'hashtag' for overdose awareness day.”

In addition, www.injectingadvice.com offers a downloadable OD Awareness Workshop. 

Mixing up the Medicine: What Alcohol Doesn’t Go With

Drug/Drink interactions are no joke. 

--Mixing alcohol with certain antibiotics, like Furozone and Flagyl, can lead to headache, nausea, vomiting, and even convulsions.

--Chronic alcohol consumption increases the risk of liver damage from surgical anesthetics like Ethrane and Fluothane.

--Alcohol decreases the effectiveness of Inderal, a common medication used to control blood pressure.

--Continued high levels of alcohol activate the enzymes that metabolize Tylenol and other forms of acetaminophen into compounds that can impair the functions of the liver.  In older persons, the combination markedly increases the risk of gastric bleeding.

Get your exercise, eat your vegetables—and don’t mix alcohol with a list of common medications about as long as your arm. Unfortunate but true. But let’s face it—people cut corners on this matter all the time. People like to drink.  With 70 percent of the adult population consuming alcohol at least occasionally, and more than 10 percent consuming it on a daily basis, the 14 billion prescriptions doctors write annually, accounting for more than 2,800 prescription drugs (plus another 2,000 over-the-counter medications) means that the “concurrent use” of booze and pills is inevitable (figures from NIAAA).

But it’s my job to be the wet blanket, and soldier on, and present my readers with a list of common drugs, which, if any of my readers are taking them regularly, means they should not be getting their drink on.

What is actually going on when alcohol and prescription drugs interact? The amount of drug that reaches its site of action is known as its availability. Alcohol can have a direct effect on a drug’s availability and hence its effectiveness. Alcohol in acute doses—a drink now and then, or a few drinks over several hours—can increase a drug’s availability by competing for the same set of enzymes of metabolization. This increases the chances of harmful side effects. Alcohol in chronic doses—long-term heavy drinking—can have the opposite effect, decreasing a drug’s availability and effectiveness by activating metabolizing enzymes, even in the absence of alcohol.

I have edited the list to eliminate low-risk, trivial, or commonly understood interactions. Most people, for example, know that drinking seriously on top of prescription sedatives, opiates and other painkillers, or anti-anxiety medications like Xanax and Valium, is universally understood to be a risky venture. That particular combination is how lots of people stop breathing, permanently.

Having glossed those categories, we move on to a blizzard of other restrictions for daily drinkers, some very serious, some less so. They have been culled from the University of Rochester’s excellent University Health Service site,  and from publications available at the website for the National Institute on Alcohol Abuse and Alcoholism (NIAAA). An extensive list of references can be found at NIAAA’s Alcohol Alert.

--Other antibiotics  that may be responsible for adverse effects, according to the NIAAA, includes Acrodantin, Flagyl, Grisactin, Nizoral, Nydrazid, Seromycin, and Tindamax (all trade names).

--Cardiovascular medication that can cause possible problems if combined regularly with alcohol include Coumadin and Nitroglycerin which may become less effective, while blood pressure meds like Catapres, Lopressor, Accupril, and several others may lead to dizziness and fainting.  The NIAAA also notes potential reductions in the therapeutic effects of reserpine, methyldopa, hydralizine, and guanethidine.

--Allergies/cold medications react with alcohol in the usual way—increased drowsiness, and possible dizziness, particularly in the elderly. Drugs containing diphenhydramine, like Benadryl, or chlorpheniramine, like Tylenol Cold and Flu, can prove substantially more sedating with alcohol.

--The anti-ulcer medications Tagamet and Zantac “increase the availability of a low dose of alcohol under some circumstances.”

--Thorazine, a common antipsychotic, can lead to “fatal breathing difficulties” when combined with alcohol, according to the NIAAA.

--The anti-seizure drug Dilantin may not control epileptic seizures as effectively in chronic drinkers.

There are others, too many to list here. But if you are a chronic drinker—and you know who you are—don’t be so quick to dismiss the variously-worded DO NOT MIX WITH ALCOHOL warnings if you find them on your pill bottles.

Photo Credit:  http://www.doitnow.org/

The Perils of Fair-Weather Cocaine

The higher the temp, the higher the death rate.

As spring approaches, cocaine users might take note of further evidence of a connection between high ambient air temperatures and accidental overdoses.

A study published recently in the journal Addiction used mortality data from the Office of the Chief Medical Examiner in New York City from 1990 to 2006 to determine the frequency of cocaine-related overdoses (itself an enterprise fraught with uncertainty and argument over listed causes of death).  The researchers cross-referenced the mortality data with temperature records from the National Oceanic and Atmospheric Association (NOAA).  

As reported in Addiction Journal, “accidental overdose deaths that were wholly or partly attributable to cocaine use rose significantly as the weekly ambient temperature passed 24 degrees Celsius [75 degrees F].”

Previous research, the authors write, had indicated that significantly higher temperatures—in the high 80s F--were required before cocaine mortality rates showed an increase. The researchers said they did not detect a corresponding rise in other types of drug overdoses during days over 75 degrees.

What is the mechanism connecting temperature to cocaine overdose? Cocaine intoxication raises core body temperature. Overheated cocaine users risk overdosing on smaller doses of the drug because their bodies are already under the strain of mild hyperthermia, or increased body temperature.

Specifically, the researchers from the University of Michigan and elsewhere found that above 75 degrees, there were 0.25 more drug overdoses per 1,000,000 residents per week for every two-degree rise in temperature, according to Addiction Journal. Applied to New York City, these numbers suggest and additional two cocaine deaths per week for every two degrees increase in average temperature over 75.

Lead author Dr. Amy Bohnert of the University of Michigan Medical School said in a press release that cocaine users are already “at a high risk of negative health outcomes and need public health attention, particularly when the weather is warm.”  During the study period, New York City had average weekly temperatures in the >24 C range roughly seven weeks per year.

The idea is quite plausible, given that ambient air temperature can affect many other metabolic processes.  Earlier investigations led to the discovery of a fairly well established diurnal AND seasonal variation for measurements of blood pressure. Researchers at Emory University data-mined 2 million  electronic records of participating patients and discovered that the odds of having high blood pressure were lowest during the morning, and generally increased throughout the day. Seasonally, high blood pressure occurred more often in winter, and was at its lowest in the summer. 

Graphics Credit: http://flatbushgardener.blogspot.com/

Bohnert, A., Prescott, M., Vlahov, D., Tardiff, K., & Galea, S. (2010). Ambient temperature and risk of death from accidental drug overdose in New York City, 1990-2006 Addiction DOI: 10.1111/j.1360-0443.2009.02887.x