My turn—the Heath Ledger thing

Since the release of Heath Ledger’s autopsy report this week, there has been a ton of press returning to the his tragic story. I say “tragic story” not for the drama, but because it is a tragedy that can happen quite easily to any family. The blogosphere has been buzzing with the social and scientific implications of his pharmacologic mishap. Not that anyone asked, but I’d like to shine an internist’s light on this for a moment. Drug overdoses are very common, depending on how you define an “event”. Completed suicides from drug overdoses probably represent somewhere around 5000-6000 deaths per year in the U.S. There are far more ODs than that, however, and the data is nearly impossible to collect. As an internist, I see inappropriate use of narcotics (both accidental and intentional) all the time. Here’s some of my observations…

Any overdose is a complex combination of patient, drug, and situation. Some people take a large dose of drugs with the intention of dying. Some just wish to feel less physical or psychic pain. Some are trying to get high and overshoot. Some people take medications as prescribed, but can have an unexpected reaction. And sometimes drugs are prescribed inappropriately.

The one thing in common with all overdoses is that they are usually preventable. Obviously, if someone really wants to get high or to kill themselves, they will find a way. For the others, there’s a lot that can be done.

Electronic prescribing systems automatically check for drug interactions while you prescribe. They can also maintain a list of other medications a patient takes. The technology exists to link databases to keep track of prescriptions from multiple doctors. In my state, I have access to a database of narcotic prescriptions, so that I can see if a patient is “doctor shopping” or otherwise obtaining prescriptions by guile.

But universal e-prescribing is probably a few years away, and various cultural and legal impediments exist to linking databases.

As is recommended, I go over every medication with every patient at every visit (at least, that’s my goal, and I come close). I make sure to have them tell me if they are getting meds from anyone else, and, if they are on any narcotics or sedatives, I check the state’s database from time to time to look for abuse.

In the case of someone like Heath Ledger, no one will ever know what his intentions were, but everything points to someone who was using medications inappropriately, with disastrous results. This can happen to you. For example, many sleeping pills impair memory. If you take one, and still can’t sleep, you might forget what you’ve taken, and then grab another one or two. Maybe you had a glass of wine at dinner, too. Oh, and your knee hurts, isn’t there some Vicodin left in the cabinet from last year? Suddenly, a simple desire to relax, sleep, and be comfortable turns into a life-threatening overdose.

It’s up to patients to know what they are taking and why, and it’s up to physicians to be careful how they prescribe. Legder’s death is unique to him, but the situation isn’t.