The variety of legal and illegal substances available today to anyone with a credit card or a well-stocked home medicine cabinet is wider than it used to be, and in some ways even more dangerous.
The two guys who showed up in a Portland, Oregon emergency room in the summer of 2012 gasping for air and wide-eyed insisted that they had swallowed nothing but one soft drink before one of them collapsed. But the strange color of their skin indicated that this was not the case. About a quarter of an hour after drinking the drink, their lips and skin were painted an alarming blue. Their blood became dark as chocolate.
Finally, one of them confessed: they "strengthened" the drink with a bitter liquid they bought over the Internet. They were going to order 2C-E, an artificial hallucinogen they heard was similar to ecstasy or LSD. What they got instead, from a Chinese chemical company, was aniline, an industrial solvent that split their red blood cells, prevented the supply of oxygen to their body tissues and nearly killed them. No one knew if the confusion between the materials was their fault or the fault of the company that sent the material. "For quite a long time after they got to the emergency room, we didn't know what they ingested, and neither did they," says Zane Horowitz, medical director of the Oregon Poison Center.
Credit: Bartholomew Cook, Trunk Archive
Horowitz and other poisoning experts say the range of legal and illegal substances available today to anyone with a credit card or a well-stocked home medicine cabinet is wider than it used to be, and in some ways even more dangerous. Stupid, bored teenagers who want to have fun are just part of the growing problem. Patients who double the dose of the long-acting narcotic drugs they receive by prescription, or those who mix different drugs with each other or with alcohol, also put themselves in danger. The increasing death rates from the use of drugs and medicines in the US is alarming, as shown by a recent survey conducted by the US Centers for Disease Control and Prevention (CDC). Poisoning accidents displaced road accidents from first place in the list of causes of fatal injury, and 89% of these poisonings result from taking drugs and medicines.
The dimensions of the problem pushed lawmakers, doctors and public health experts in the US to look for solutions. In July 2012, President Barack Obama signed the expansion of the Act to Prevent the Abuse of Artificial Drugs, which outlaws the production, sale and possession of 2C-E and 25 other "boutique" drugs throughout the United States. To curb the misuse of prescription drugs, 49 states in the US approved funding for the establishment of electronic databases in order to identify doctors who overprescribe narcotics and addicts who make "shopping trips" to different doctors to accumulate painkillers or stimulants.
And in the meantime, poisoning experts have some surprising advice for emergency room staff: Rely less on routine blood and urine tests when trying to figure out what substance patients ingested, as those tests can be very misleading. Instead, these medical detectives suggest asking more pointed questions to save more patients.
A new breed of painkillers
Although recently the rate of deaths from the consumption of engineered "boutique" drugs, whose pharmacists play with their chemical composition in a way to stay within the law, is rising, the most common type of drug poisoning is less exotic. In the most recent statistical analysis of all overdose deaths in the US, it was found that more than 40% of them were caused by taking prescription painkillers. Moreover, the strong pain relievers, including oxycodone, hydrocodone, and methadone, are sold in larger quantities today. According to the CDC, sales of these pain relievers increased 300% from 1998 to 2008 as doctors pay more attention to relieving the pain of cancer, surgical and seriously injured patients.
In the last ten years, studies have clearly shown that taking prescription painkillers for a short period of time can reduce suffering without danger. But the abuse of these potentially addictive drugs, whether alone or with other substances, can be fatal. A study published in the Journal of the American Medical Association (JAMA) in 2008 reviewed the problem in West Virginia: 56% of the 275 people who overdosed on prescription painkillers did not have a prescription for the drug that killed them. Others, about 21% of those who overdosed, received a prescription from five or more different doctors in the year before their death, a figure that suggests they went from doctor to doctor to get more pills than one doctor is allowed to prescribe. All-American statistics highlight the danger: legal narcotics kill more people each year than heroin and cocaine combined.
Not only are these drugs more available than before, some of them even stay in the body for a longer time. Patients seeking continuous relief of severe pain throughout the night, for example, will prefer to take high-dose, slow-release pills. But the danger of overdose is greater if they are used incorrectly. Some drug users grind up 60-milligram oxycodone slow-release pills to snort or smoke the powder. When they do, they may inject into their bloodstream at once a large enough amount to cause poisoning.
Even patients who really just want to ease their pain are sometimes harmed by the pills. "Patients come to me and tell me: 'I ran out of pills, so a neighbor gave me his own,'" says Horowitz. "But it turns out that the amount of active substance in the neighbor's pills is much greater."
The increased availability of prescription drugs also makes it easier to take mixed doses - a very dangerous thing. In the same overdose study published at the time in JAMA, it was found that about 80% of the deceased had taken a mixture of drugs, which usually included drugs from the benzodiazepine family (which are usually prescribed to treat anxiety and sleep disorders), and sometimes also drank alcohol at the same time. According to the study, the mixing phenomenon usually implies addiction. In high doses, each of these drugs alone is enough to slow breathing, and combining them together is especially dangerous, says Jane Prosser, a trauma specialist at Weill-Cornell Medical Center in New York City. "This is one of those cases where one plus one equals four."
In older patients, who are more likely to be receiving treatment for several chronic conditions, overdose can be especially difficult to diagnose in the emergency room, says Prosser. "An elderly man, confused, comes to the emergency room and says: 'I feel terrible weakness and dizziness.' So is it because of the cancer he has? The chemotherapy? The painkillers? Or is he suffering from dehydration due to vomiting and diarrhea? Sometimes it's very hard to know."
When the lab is wrong
Although modern chemical analysis techniques can selectively identify drugs, they are too expensive and too time-consuming for emergency treatment, says Mark B. Michick, a poison specialist at John H. Stroger Jr. Hospital in Cook County, Chicago. And the usual array of rapid screening tests designed to detect substances in the blood and urine does not keep up with the changes that have taken place in the habits of abusing drugs and drugs.
"These basic [toxicological] tests were developed for the war on drugs in the workplace in the mid-70s, and they were designed primarily to detect the use of heroin, cocaine and marijuana," Micik says. These tests will not distinguish the almost illegal or completely illegal drugs, such as 2C-E, the number of which is increasing and they are found in all kinds of versions that are slightly different from each other - the handiwork of creative chemists looking to rake in a profit. And even many of the legal drugs, including the anti-anxiety drugs Ativan and Xanax and the pain relievers Methadone and Oxycodone, are not detected in the standard blood tests for drug detection that are done in hospitals. Relying on laboratory tests, says Prosser, can disrupt the diagnosis in such cases and lead to incorrect treatment.
Let's say a meth addict arrives at the emergency room who also swallowed a decent dose of Xanax and is unconscious. The doctor will try to find out why the man is unconscious and will take a urine sample for a test designed to detect narcotic anesthetics. The test will find nothing because it is not designed to detect Xanax or Methadone. The doctor, who is misled by the test results, will not prescribe the patient a drug that dulls the withdrawal symptoms that will appear when the effect of the narcotic drug wears off - and this decision has fateful consequences. "Suddenly he [the patient] starts vomiting because of the "craze" created by the lack of opiates, but he does not wake up, because he took an overdose of benzodiazepines," says Prosser. He can choke to death by inhaling vomit.
It is not certain that improving the tests is the answer, Michik says. When time is pressed, it is better to pay attention to combinations of symptoms that are specific to a certain type of drug or drug, and treat these symptoms without waiting for chemical confirmation of the diagnosis.
Some federal agencies have also begun working on solutions. In July 2012, the US Food and Drug Administration began requiring drug companies to develop educational programs for doctors about the special dangers inherent in prescription drugs. The CDC called for consideration of the development of programs to detect "signs of improper use of controlled prescription drugs" in Medicaid and workers' compensation claims. To help reduce doctor-to-doctor hopping, the CDC says, health services could limit drug funding to one prescription from one doctor and buy at a particular pharmacy per patient.
Michik today tells emergency room doctors that it is a device that they can save more lives if they ask more focused questions than the questions they learned to ask in medical school. "Don't ask: 'Are you using illegal drugs?'" he tells them, "Most of the drugs people use today are legal drugs. Many of the patients take an overdose of drugs prescribed by the doctor."
Instead, Michick says, questions like "Have you ever gotten sick of cough syrup?" or "Have you ever taken pills from a friend or relative?" They will guide you to a more beneficial treatment. "Most [patients] will help you as much as they can," Micik says. "In most cases they had no intention of coming to the emergency room. They don't want to die."
on the notebook
Deborah Franklin lives in San Francisco. She reports and writes about science and medicine in the New York Times, Fortune and Health Magazine and the National Radio Network of the United States (NPR).
