Combined Drug Intoxication

Combined drug intoxication (CDI), or multiple drug intake (MDI), is a cause of death by drug overdose from poly drug use, often implicated in polysubstance dependence.

The CDI/MDI phenomenon seems to be becoming more common in recent years. In December 2007, according to Dr. John Mendelson, a pharmacologist at the California Pacific Medical Center Research Institute, deaths by combined drug intoxication were relatively "rare" ("one in several million"), though they appeared then to be "on the rise". In July 2008, the Associated Press and CNN reported on a medical study showing that over two decades, from 1983 to 2004, such deaths have soared. It has also become a prevalent risk for older patients.

Risk factors

People who engage in polypharmacy and other hypochondriac behaviors are at an elevated risk of death from CDI. Other dangers of combining drugs include "brain damage, heart problems, seizures, stomach bleeding, liver damage/ liver failure, heatstroke, coma, suppressed breathing, and respiratory failure", along with many other complications. Disorders like depression and anxiety can also stem from polydrug use. Elderly people are at the highest risk of CDI, because of having many age-related health problems requiring many medications combined with age-impaired judgment, leading to confusion in taking medications. Elderly patients are often prescribed more than one drug within the same drug class, and doctors may treat the side effects of prescribed drugs with even more drugs, which can overwhelm the patient.

Prevention

In general, the simultaneous use of multiple drugs should be carefully monitored by a qualified individual such as board certified and licensed medical doctor, either an MD or DO. Close association between prescribing physicians and pharmacies, along with the computerization of prescriptions and patients' medical histories, aim to avoid the occurrence of dangerous drug interactions. Lists of contraindications for a drug are usually provided with it, either in monographs, package inserts (accompanying prescribed medications), or in warning labels (for OTC drugs). CDI/MDI might also be avoided by physicians requiring their patients to return any unused prescriptions. Patients should ask their doctors and pharmacists if there are any interactions between the drugs they are taking.

Common combinations

Acetaminophen/paracetamol deaths

On June 30, 2009, an FDA advisory panel recommended that Vicodin and another painkiller, Percocet, be removed from the market because they have allegedly caused over 400 deaths a year. The problem is with paracetamol (acetaminophen/Tylenol for example) overdose and liver damage. These two drugs, in combination with other drugs like Nyquil and Theraflu, can cause death by multiple drug intake and/or drug overdose.

Alcohol

Alcohol can exacerbate the symptoms and may directly contribute to increased severity of symptoms. The reasons for toxicity vary depending on the mixture of drugs. Usually, most victims die after using two or more drugs in combination that suppress breathing, and the low blood oxygen level causes brain death.

Celebrity deaths because of CDI/MDI

Many celebrities have died from CDI/MDI, including:

• Nick Adams, actor, from paraldehyde and promazine
• Bridgette Andersen, actress, from alcohol and multiple drugs
• Lester Bangs, music journalist, from diazepam and propoxyphene
• Ol' Dirty Bastard, rapper of the Wu-Tang Clan, from cocaine and tramadol
• John Belushi, actor, from cocaine and heroin
• Tommy Bolin, guitarist for Deep Purple, from alcohol, heroin, cocaine and barbiturates
• Derek Boogaard, New York Rangers forward, from oxycodone and alcohol
• Casey Calvert, guitarist for Hawthorne Heights, from citalopram, clonazepam and hydrocodone
• Truman Capote, author, from multiple drug intoxication complicated with liver cancer and phlebitis
• Steve Clark, of rock group Def Leppard, from combining antidepressants, tranquilizers and alcohol
• Eric Douglas, actor/comedian, from alcohol, hydrocodone and temazepam
• Paul Gray, Slipknot bassist, from morphine and fentanyl
• Curt Hennig, professional wrestler, cocaine overdose
• Jimi Hendrix, guitarist, from alcohol and barbiturates
• Whitney Houston, singer, from alcohol, alprazolam, diphenhydramine, cocaine, and cyclobenzaprine
• Elizabeth Ann Hulette aka Miss Elizabeth, pro wrestling manager, from alcohol, temazepam, oxycodone, hydrocodone and anabolic steroids
• Michael Jackson, singer, from the IV anesthetic propofol and other sedatives
• Anissa Jones, child actress, from cocaine, phencyclidine, methaqualone and secobarbital
• Janis Joplin, singer, from heroin and alcohol; the heroin was not properly mixed for use and was too potent
• David Anthony Kennedy, son of Senator Robert Francis Kennedy, from cocaine, pethidine and thioridazine
• Rodney King, from alcohol, and cocaine
• Heath Ledger, actor, from toxic combination of oxycodone, hydrocodone, diazepam, temazepam, alprazolam and doxylamine
• Cory Monteith, actor, from heroin and alcohol
• Lani O'Grady, actress known from Eight is Enough, from hydrocodone and fluoxetine
• Johnny O'Keefe, singer, from a combination of several prescription drugs
• Chris Penn. actor, from valium, morphine, marijuana and an elevated level of codeine
• Dana Plato, actress, from carisoprodol and hydrocodone; suicide
• The Rev of Avenged Sevenfold, from oxycodone, oxymorphone, diazepam, nordazepam and alcohol
• Edie Sedgwick, actress, from barbiturates and alcohol
• Freddy Soto, writer/actor/comedian, from fentanyl, alprazolam and alcohol
• Louie Spicolli, pro wrestler, from carisoprodol, alcohol, painkillers and lorazepam
• Layne Staley, lead singer of Alice in Chains, from heroin and cocaine; specifically a combination called a speedball (drug).
• Philip Seymour Hoffman, actor, from heroin, cocaine, benzodiazepines and amphetamine

Anna Nicole Smith and Daniel Wayne Smith

In February 2007, five months after her son Daniel Wayne Smith was found dead from CDI with methadone, sertraline, and escitalopram in his system, Anna Nicole Smith also died from CDI/MDI. Her two autopsies detected more than 11 drugs in her bloodstream, including chloral hydrate, clonazepam, lorazepam, oxazepam, diazepam, diphenhydramine, topiramate, oseltamivir, ciprofloxacin, methocarbamol, carisoprodol and others. The deaths of Daniel Smith and Anna Nicole Smith were declared as Combined Drug Intoxication.

Heath Ledger

Australian actor Heath Ledger was found dead on January 22, 2008, in his SoHo, New York City, apartment; the toxicology report concluded that the cause of death was "acute intoxication" resulting from "the combined effects of oxycodone, hydrocodone, diazepam, temazepam, alprazolam, and doxylamine" and "that the manner of [his] death" was "accident, resulting from the abuse of prescription medications or combined drug intoxication (CDI)."

Speedball deaths

Some speedball deaths that are diagnosed as MDI/CDI might simply be drug overdose, which is a related but completely different phenomenon. The following list is for speedball CDI/MDI deaths only. Any combination of uppers and downers can be called a speedball death.

• John Belushi, actor/comedian, from cocaine and heroin 'speedball'
• Elisa Bridges, actress, from heroin, methamphetamine, pethidine and alprazolam
• Ken Caminiti, baseball athlete, from cocaine and opioid painkillers
• Chris Farley, actor/comedian, from cocaine and heroin 'speedball'
• Zac Foley, bass player for EMF, from multiple illegal drugs
• Trevor Goddard, actor, from cocaine, heroin and temazepam
• Mitch Hedberg, stand-up comedian, also from 'speedball'
• Philip Seymour Hoffman, Oscar-winning actor, from heroin, cocaine and amphetamines
• John Kahn, a Jerry Garcia collaborator and member of the Jerry Garcia Band, from heroin, cocaine and fluoxetine
• Chris "Mac Daddy" Kelly of Kris Kross, from cocaine and heroin
• Brent Mydland, keyboardist for The Grateful Dead, from cocaine and heroin
• River Phoenix, actor, from heroin and cocaine
• Layne Staley of Alice in Chains, from cocaine and heroin
• Scott Weiland of Stone Temple Pilots/Velvet Revolver from cocaine, Methylenedioxyamphetamine (MDA), alcohol, buprenorphine, and alprazolam

CDI-related legal cases

Karen Ann Quinlan

The right-to-die case of then-comatose Karen Ann Quinlan (March 29, 1954 – June 11, 1985) made legal history in 1975 and 1976, stimulating public scrutiny of ethical and moral implications of her case. In 1975, after drinking gin and tonics at a party and then taking diazepam, Quinlan collapsed, suffered respiratory failure and irreversible brain damage, and, after being taken to the hospital, lapsed into a persistent vegetative state. After she had been kept alive on a ventilator for several months without improvement, her parents requested that the hospital discontinue such active care and allow her to die. The hospital refused, and the subsequent legal battles made newspaper headlines and set significant precedents. After the New Jersey Supreme Court ruled in her parents' favor, Quinlan spent nine more years comatose in the hospital, before dying from pneumonia in 1985.

Michael Jackson

The CDI/MDI death of Michael Jackson led to the trial of Conrad Murray, whose license was revoked in four states and who was sentenced to serve four years in a California prison.

See also