Careful Mixing Medicines

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This month in the Crozet Annals of Medicine I am pleased to feature a submission by one of the many excellent practitioners in the Crozet area. Dr. Catherine Casey MD practices at Western Albemarle Family Medicine across the street from the new Harris Teeter on Rt. 250. She is also an assistant professor at U.Va. and spends part of each week teaching there.

In the last few months, the world has been riveted by stories of Michael Jackson’s death, as well as the death of “Oxy-Clean” pitchman Billy Mays. Once the initial shock wore off, details emerged suggesting that both were taking large amounts of prescription medicines. Did these medicines play a role in their deaths? How could this have happened?

Doctors and pharmacists have a term for taking many medicines at once, “polypharmacy.” Some medicines can be taken together, some should never be taken together, and some can be taken together only very carefully. The medicines found in Michael Jackson’s system fall into this last category. Propofol (a milky-white injectable medicine) and benzodiazepines are often used together to help put people to sleep for surgery. However, because these medicines amplify each other’s effects, they should be given together only under close supervision by an anesthesiologist in an operating room.

The medicines found in Billy Mays’ system—oxycodone, hydrocodone, tramadol, and yes, benzodiazepines—are sometimes prescribed for back pain. However, they are normally prescribed only one (or maybe two) at a time. Like the medicines Michael Jackson was taking, these medicines, if taken together at high doses, can cause so much sleepiness that breathing stops.

High-profile cases such as these, as well as the death of the actor Heath Ledger, have made the general public more aware of the risk of overdosing on prescription medicines. Many of these same medicines that have the side effect of sleepiness—usually pain, anxiety, or sleep medicines— can also be addictive. Addiction is a disease of the brain which causes someone to crave and use a substance despite negative consequences. This leaves doctors with a conundrum: how do we treat people’s pain, anxiety, or insomnia while not creating or feeding an addiction?

In my own practice, I have learned to think of addiction as a disease, sort of like high blood pressure or diabetes. It’s something that I screen for by asking questions about how people use their medicines, their family history, and by looking carefully at the patterns of their medicine use. I also perform urine drug screens regularly, and keep in touch with pharmacies to make sure patients aren’t getting medicines from other doctors that could cause bad interactions. Most importantly, I try to have open, honest conversations with my patients about the risks of taking these medicines, and seek help from pain and addiction specialists if needed.

Let your doctor or pharmacist know ALL the medicines you are taking, so that they can check for drug interactions, and always ask your doctor before changing how you take medicines. Keep in mind that even over-the-counter medicines, vitamins, and herbal supplements can have dangerous interactions when taken with prescription medicines, and with one another. Also, if you suspect that you or a family member might be developing an addiction to a prescription medicine, let your doctor know. More and more, doctors are recognizing addiction as a real disease, with new treatments becoming available all the time. Polypharmacy, abuse, and addiction to prescription medicines are all preventable causes of death, if caught in time.

Catherine Casey MD