Losing sleep

The official verdict has been rendered: Heath Ledger died from an overdose of prescription medications. The Globe and Mail reports that Ledger died "as the result of acute intoxication by the combined effects of oxycodone, hydrocodone, diazepam, temazepam, alprazolam and doxylamine”. If Mr. Ledger was receiving all of those medications legitimately from one physician and one pharmacy, some questions need to be asked. If, however, he was obtaining these medications "on the street" as is often the case with prescription drug abuse, then it only serves to add heft to the warnings of the medical community against illicit use of these medications.

I too often see multiple benzodiazepines (BZDs), a drug class of which diazepam, temazepam, and alprazolam are members, prescribed by physicians. There is no good reason to do this and is exceedingly dangerous. BZDs are safe if used properly but very dangerous when used in combination with excessive alcohol, other sedating drugs (like those mentioned above), each other, or illicit substances. The fact that Mr. Ledger was on THREE is very unfortunate. As well, he was on two very potent opioid painkillers (morphine-like drugs), hydrocodone and oxycodone. Using two different formulations of one opioid is common in chronic pain, but using these two drugs together, given their addictive and potentially dangerous properties, suggests they were being used non-therapeutically, which is increasingly common. These combined with three BZDs is a cocktail incompatible with life.

But how does one get addicted to sleep and pain medications? The causes of the ever increasing abuse of prescription painkillers and sleep aids is multi-factorial. However, the pharmaceutical industry is partially to blame. As it is in their best financial interests, they work very hard to market pharmacotherapy as the best option for treatment of insomnia. They go further to inflate the prevalence of insomnia, a tactic brilliantly documented in Selling Sickness: How the World's Biggest Pharmaceutical Companies are Turning Us All Into Patients.

The fear and frenzy the Ledger story caused amidst the sleep aid using public led to many calls to the American Academy of Sleep Medicine. Thankfully, they used this as an opportunity to reiterate their guidelines on the treatment of insomnia, which include warnings against combining these medications and advice to use behavioral treatments in some cases to treat insomnia. (As a side note, insomnia in and of itself is rare; insomnia is most often a symptom of some underlying condition so treatment with sleep aids should be short lived while the underlying cause is addressed).

Unfortunately, such balanced statements cannot possibly compete against the juggernaut that is pharmaceutical marketing. If you need evidence as to this, check out PharmedOut and PerxInfo. PharmedOut has links to videos of drug reps discussing their sneaky tactics as well as links to objective drug information. PerxInfo is a site created by the US state attorneys general. The money for the program comes from Pfizer, but not in the form you'd think. They paid a $430 million USD settlement after the US Food and Drug Administration charged them with promoting their drug Neurontin for unapproved uses. This happens more than you might think.

The New York Times reported last week that Eli Lilly is considering settling with federal prosecutors by paying a $1 billion fine. That's almost a third of their annual profit, so what could they have done to deserve this? Turns out company documents show that they were actively promoting their blockbuster antipsychotic Zyprexa for unapproved uses from 2000-2003.

Not in Canada you say? Biovail, a Canadian pharmaceutical company, revealed it is being investigated by a US grand jury for improper marketing of its drug Cardizem LA. They were paying doctors in the US $1000 if they prescribed the drug. Even doctor's office managers got $150.

What about companies pushing sleep meds and painkillers? In July 2007, PurduePharma, makers of Oxycontin (oxycodone, which Ledger was taking), one of the most addictive painkillers on the market and an extremely popular street drug, was fined over $600m by US courts. This was for misleading physicians and the public about the addictive nature of the drug, even going so far as to claim that it was barely addicting at all, and certainly no more than other painkillers, which is a load.

And finally we get to the National Sleep Foundation. This organization aims to "educate" the public on the prevalence of sleep problems and their consequences. The .org domain would lead one to believe that the NSF is a benevolent charitable organization, as would the calls for donations. Bruno Maddox reports in Discover magazine that while the NSF does receive funding from individual donations, the majority actually comes from pharmaceutical companies, which would explain why one of their stated objectives is "educating" healthcare professionals. In the 2007 fiscal year, the NSF received $2.4m in funding. Of that, at least $1.6m came from pharmaceutical companies, most or all of which manufacturer medications used for sleep. Of course, this money is then used not only to "educate" but to give research grants under the guise of a benign foundation. And we all know that research grants from pharmaceutical companies have no bearing on research results.

Which all goes to show, in my long winded manner, that you should always assess the risks of any medication, seek out OBJECTIVE information, and NEVER, EVER use prescription medications that were not prescribed to you by a licensed healthcare practitioner. Just because they are marketed pharmaceuticals, doesn't mean they are safe to get off the street. Oh, and next time your doctor wants to try you on "the latest greatest thing" he heard about from his drug rep, politely decline his offer and stick with what is working.