What We Can Learn from Heath Ledger's Death: Don't Mix Downs!!!

Although "just say no" is certainly the safest position to take on recreational drug use, the vast majority of humans ignore this advice. Some use alcohol, nicotine or caffeine; others take prescription medicines in ways other than as prescribed; others use illegal drugs like marijuana, cocaine and heroin. Add that all up and a significant majority of the population is "under the influence" at any given time.

Consequently, we owe it to ourselves to understand the risks involved with using these drugs. To avoid the kind of accidental overdose that seems to have killed Heath Ledger, we need to understand several important facts.

First, if I could only impart one lesson about reducing overdose risk, it would be this: Don't Mix Drugs-- but Especially, Don't Mix Downs. That is, don't take "depressant" drugs-- drugs that make you calm or sleepy, not depressed!!!-- in combination with each other. This category includes sleeping pills. These include benzodiazepines like Xanax, Valium and Clonopin--chemical names for this class of drugs tend to end in -zepam. So, valium is diazepam, etc.

The category also includes benzodiazepine-like drugs such as Ambien and Sonata as well as drugs like barbiturates which are rarely prescribed these days.
Another category of depressant drugs is opioids: These include heroin, Oxycontin, Vicodin, codeine and similar painkillers. Antihistamines like Sominex and Unisom are also depressants.

The most commonly used depressant drug is alcohol, however. Mixing drugs across these categories is the riskiest type of drug use there is, especially if some of them are injected. The overwhelming majority of overdose deaths result from mixtures of depressants: for example, most of the "Oxycontin" deaths that have been reported recently are more accurately described as Oxycontin-plus-alcohol-and/or-benzodiazepine.

About 75% of all overdose deaths involve drug combinations: the most deadly combinations seem to involve opioids plus other depressants. According to the federal Drug Abuse Warning Network, more overdose deaths are caused by opioid mixtures than by any other single drug or combination of drugs [PDF].

Cocaine use is reported in a significant minority of overdose deaths: however, because cocaine counteracts some of the sedating effects of depressants, it may actually reduce overdose risk [PDF] from opioids. Nonetheless, cocaine/depressant combinations--especially intravenously-- are still highly risky.

Heath Ledger appears to have been one of the less-common cases in which a mixture of benzodiazepines, benzodiazepine-like drugs and antihistamines was fatal.

His case may also be an example of the second key fact I'd love to impart in sane risk-reduction education: if you have been addicted, and then quit, the dose you can tolerate after detox is far lower than the dose you could tolerate before.

This means you can literally overdose on an amount of drugs that previously would not even have been enough to get you high.

While relapsing is obviously not advised, if someone insists on doing it, he should be aware of this fact and be very cautious about doses taken. There are actually addicts who go into detox deliberately seeking this effect: they know their habits will be a lot cheaper, at least at first, after a period of abstinence.

Failing to take tolerance into account can be deadly, however: a large percentage of overdoses occur amongst recently detoxed addicts.

Obviously, we'd prefer no one to ever overdose and no one to ever relapse: but since relapse is a frequent occurrence in addiction, I'm sure everyone who knew and loved Heath Ledger--and all of his fans--would prefer that he had known these facts, if, indeed, his death was not a deliberate suicide.

I'll post soon about how to save lives in the crucial time following an overdose

Comments

[mattersometimes]

Thanks so much Maia. This is such important information. Wow--I never knew this was such a dangerous combination. Very sobering news indeed on the heals of such a tragedy. Loss oft-times brings with it deep reflection and review, a search for pearls of wisdom to pass on--and I see your post couched in this spirit.

Yes: no-one should die of ignorance, and your commitment to getting critical information out is inspiring. I so appreciate how compassionate and pragmatic you are in your approach which appreciates that (for better or worse) most don't "just say no".

Please keep up the good work--and mis-spellings are allowed, for goodness sake--it's the facts that matter most--and explaining the facts in a way that inspires, informs and empowers--which indeed you do so well.

[Maia Szalavitz - Huffpost Blogger]

One clarification regarding the cocaine thing: this is in no way an endorsement of cocaine, nor am I suggesting it is impossible to overdose on cocaine. Simply that the risk of death seems to be highest amongst people who mix depressants.

The research I cited was looking only at people who were mixing opioids or other depressants and cocaine: not at people who were using cocaine alone or opioids or other depressants alone.

It is certainly possible to overdose on cocaine and the riskiest way to take cocaine in terms of overdose is injection.

The way to eliminate risk from drugs entirely is not to take them. Short of that, if you avoid injecting, avoid "powders" (ie, cocaine and heroin), avoid methamphetamine, avoid other opioids (ie Oxycontin etc.), never mix downs and never use anything daily except alcohol in moderation when you are over 40, your risks of addiction and other drug-related harm are dramatically lower.

[Counselor]

I think that while there is important information in this blog, there are at least two problems with it: 1) We do not yet know why Ledger died so it is premature to speculate; and 2) You are exaggerating a little. While I am not a doctor, I do know that it is simply not true that "all" downs are dangerous if mixed together in prescribed amounts. I do not want to be irrespnsible since I am not a doctor and can only talk from my own experience and that of friends, but I know that Xanax is very very frequently prescribed with Ambien or Sonata as they treat 2 different conditions--anxiety and insomnia. I myself have taken Xanax and Sonata together (in relatively low prescribed doses) for years with no ill effects. I have, in the past, also taken Xanax and Ambien together for a long period. Indeed, Xanax is a relatively safe drug for most people and that is why it is likely the most prescribed "benzo". Many people (although I am not advocating this) have a drink and a Xanax or Ambien at bedtime with no ill effects. Admittedly, large doses of any drugs can be dangerous, particularly if mixed together or mixed with alcohol, but in low prescribed amounts (under a doctor's care) the drugs I have named are not, to my knowledge, all that harmful. OF COURSE DRUGS SHOULD ONLY BE TAKEN UNDER A DOCTOR'S CARE AND I AM NOT A DOCTOR. I am certainly not advocating overmedicating or excessive drug use, but as a scientist you should be accurate. I am happy to hear your (or a physician's) response to this post.

[Maia Szalavitz - Huffpost Blogger]

Note: This post never claimed that overdose was definitively the cause of Heath Ledger's death: I very clearly said "seemed to be" because so far the actual cause is unknown. But whatever it turns out to be, this offers an opportunity to educate people on the riskiest forms of drug use.

To the person who claims that all drug use is risky except marijuana: read the top of the post. I'm talking about reducing risk for those who are already using other drugs.

And look at the statistics: something like 80% of opioid overdoses involve multiple drugs. So, clearly, avoiding mixing reduces risk. I am a former addict whose life was saved by this kind of advice-- does it work 100%? No, but it reduces the odds.

Finally, to the person who said that the cocaine study was inconclusive and didn't generalize because of differing use patterns in the US and UK, well, no. The study compared whether users of cocaine plus opioids were more likely to die compared to users of opioids plus benzodiazepines or other opioids.

The cocaine users had an overdose risk of .16 or .26. Because this is below one, it means that their risk of overdose was actually lower than the average risk for people who used opioids without cocaine.

And the benzo/opioid users increased their risk by a factor of 3.5 if they were heroin users and by a whopping 10 if they were methadone users. So cocaine use actually seems to reduce risk: again, it's certainly not recommended and injecting seems to increase risk (most of these seem to have been crack smokers) but common sense suggests that a stimulant, by keeping you awake, is going to avoid you 'forgetting' to breathe, which is what kills in opioid overdoses.

Bottom line: if you have this information, you have a chance of reducing your risk if you are using dangerous drugs. If you don't have it, you have no chance to do so because you are ignorant of what's most dangerous. no one should die of ignorance.

[Guitarsandmore]

Maia,

Your message is the one that needs to get out to a whole new generation of kids that weren't around in the sixties. We had to watch Hendrix, Joplin, and Morrison, drop over dead before some of us thought, " hmmm, maybe there should be some pause for concern about all of this better living through chemistry horseshit."

The one message that should get out to everyone is don't mix anything with anything.

Don't drink, but if you are going to drink don't take any pills with it.

John Bullushi died taking a mixture of something.

You can't mix drugs and if you can't sleep then just stay awake and call in sick the next day.

Chamomile tea is usually a safe bet if you can't sleep.

Doctors and pharmacists too often prescribe multiple medications that do not play well together. Check the internet for drug interactions. Read the little paper that comes with your prescription. Ask the pharmacist for the additional pages.

[PattiNYC]

I love the HuffPost, but sometimes I really question the appropriateness of some of the content of the blogs posted.......like this one.

Any discussion of mixing prescription drugs is one worth having - but to put the words "accidental overdose" and "Heath Ledger" in the same sentence is irresponsible and highly opportunistic - no matter how it "seems".

The cause of Heath Ledger's death hasn't been determined yet.

[Jaze]

As a senior medical examiner in a major US city, I'd like to follow up a bit on Ms. Szalavitz' piece.

The advice not to mix depressants is solid, and can never be repeated enough.

However, what I see as a tacit endorsement of cocaine as possibly protective in opiate intoxication seems irresponsible. The British study Ms. Szalavitz cites is inconclusive, and likely reflects different patterns of usage - inside the study groups compared, in England, and even regionally.

I trained in forensics in Miami at the end of the 1980s. Almost all of the recreational drug deaths I saw there - and I saw many - were cocaine deaths. It wasn't until I moved up to the North East the next year that I began to see heroin deaths. I visited the Miami office this year, and my former colleagues told me the drug deaths there are still cocaine-pr­edominant, with inroads being made by prescription drug misuse.

In New York City, many - possibly the majority - of the drug deaths are deaths where the user has used cocaine and heroin. That pattern is very different from that seen in the Sheffield study cited, largely, I suspect, because of differences in cocaine availability in the UK.

I'm sure Ms. Szalavitz isn't trying to recommend doing cocaine with heroin to make the experience safer, but I don't doubt that there are people who will see the statements she made as encouraging that approach. I'd just like to point out that the morgues are full of people for whom that mixture didn't work out.

[willa]

Excuse me. And HOW exactly do you know that Heath Ledger died of an accidental overdose?

It is stories like this that perpetuate lies through innuendo. Because too many people are too stupid to know the difference. Shame on you. You know better.

[MDTERP]

Re cocaine being in the minority among OD deaths.Maybe because you don't have to "OD" on it. There is NO SAFE DOSE! Whatever is considered a "touch" of cocaine can kill you from an intracerebral hemorrhage or MI ("heart attack"). Better yet, you can end up a bed-bound, drooling idiot who needs his/her diaper changed when the stroke isn't fatal. Won't even go into the fools who come in amazed that they can't breath after they inhale that crap into their lungs. And let's not talk about how it's drugs in combo that are not safe. So if you take your oxycontin alone it does not depress your respiratory drive? Nice try. Perhaps it is the fact that people who are abusing drugs are more likely to use them in combo- looking for that unattainable comfort- and they end up dying. If they only have one class available, they manage to OD on that too. It is irresponsible to say that it is "safer" to stick to one form of "recreation". All of these drugs, except for marijuana, will kill. And this is not even addressing allergic reactions and anaphylaxis. Stick to comedy or whatever your day job is.

[shanghaislim]

Thanks. Great Post. We knew many of these things but it always is a sobering reminder at times like these.

[GoodwithWood]

Um. The cause of death has not been determined. This whole post is inappropriate.

[jfor]

Marijuana has never killed anyone. Marijuana is not addictive. Marijuana helps with insomnia, helps with high blood pressure, helps with stress, helps with glaucoma. Marijuana is a natural substance. Marijuana will never be legal,

Big Pharma will not allow this amazing plant to be legal, because big pharma cannot make any money off of marijuana. Marijuana cannot be patented.

Marijuana does not cause anal leakage like many of the the drugs pushed everyday on TV.

Grow up America.

Alcohol and Tobacco have what Marijuana doesnt...... Lobbyists.