Illicit drugs are often associated with death by overdose. But, did you know that every day, more people die due to overdosing on legal, prescription painkillers than they do from heroin and cocaine overdose combined? Deaths due to the most common drugs—both prescription and over-the-counter—are a preventable and disquieting occurrence in healthcare.
Here are five common, legal drugs that can also be highly lethal.
It’s scary to think that a remarkably deadly type of drug can be purchased ad libitum over the counter. Nonsteroidal anti-inflammatory drugs (NSAIDs) may account for an estimated 11% of drug-related hospitalizations—all of which are preventable. Physicians prescribe these drugs for both acute and chronic pain.
An estimated 70% of people aged 65 years and older use NSAIDs at least once a week. Furthermore, half of these people take seven or more doses a week.
When compared with acetaminophen, both traditional NSAIDs like aspirin—which interferes with cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2)—along with selective second-generation cyclooxygenase- 2 (COX-2) inhibitors like celecoxib offer greater analgesia. Nevertheless, NSAIDs increase the risk of gastrointestinal bleeding, cardiovascular disease, and kidney damage.
High-risk patients include elderly patients who have:
Results from a study by researchers in Scotland suggested that in one-third of cases, prescriptions of NSAIDs or anticoagulants—another deadly common drug—could be switched to a safer alternative.
If an NSAID must be used, consider naproxen combined with a proton-pump inhibitor (PPI). Keep in mind that adding a PPI only decreases the risk of GI bleed and not the risk of cardiovascular disease or kidney damage. Moreover, when prescribing NSAIDs, dole out the smallest effective dosages, or consider a topical NSAID, if applicable.
No surprise that bleeding is the main adverse drug reaction from anticoagulant use.
“Anticoagulation requires a careful balance between thrombotic and hemorrhagic risks and is easily influenced by a multitude of factors, such as patient age, co-morbidities, concomitant medications and, for warfarin especially, diet and pharmacogenetics,” according to the National Action Plan for Adverse Drug Event Prevention. “Bleeding rates associated with anticoagulants vary depending on the types of anticoagulant agents, dosing strategies, prophylactic versus therapeutic indications, durations of therapy, and patient populations.”
With warfarin therapy, bleeding risk is 15% to 20% per year, with life-threatening bleeds occurring in 1% to 3% of cases. The risk of bleed while on warfarin is five times that when off the drug.
Newer oral anticoagulants, including dabigatran and rivaroxaban, result in decreased bleeding risk compared with warfarin, but further research is required.
When it comes to treating pain and fever, acetaminophen is used more than any other drug in the world. But many people fail to realize just how deadly an overdose of acetaminophen can be, with dose-related hepatocellular necrosis resulting in about 500 US deaths per year. Furthermore, acetaminophen is responsible for 100,000 calls to US Poison Control, 50,000 ED visits, and 10,000 hospitalizations per year.
When paired with opioids, no other prescription drug comes close to causing as many cases of acute liver failure. Nevertheless, acetaminophen is unregulated in both the United States and Europe for the treatment of pain.
“What is needed is a new paradigm: development of a totally safe congener of acetaminophen that would provide effective analgesia with no risk of toxicity,” wrote liver expert William Lee, MD, in the Journal of Hepatology. “APAP [acetaminophen] has a central CNS effect that is presumed related to the benzene ring structure, and although classed as [an NSAID], it does not share ulcerogenic or cardiac toxicity with other NSAID compounds. Other benzene ring structures should be explored.”
Dosing insulin is tricky. Overdose leads to severe hypoglycemia, which results in seizures, coma, and death. Insufficient dosing can lead to hyperglycemia and ketoacidosis. Both inside and outside the hospital, errors in the preparation and administration are both common and preventable.
“When preparing and dispensing insulin, a tuberculin syringe is sometimes used instead of an insulin syringe, leading to overdose. Other errors arise from confusion created by similar packaging between different insulin products or between insulin and other drugs, such as heparin. Sometimes patients receive insulin intended for another patient. A risk of viral contamination exists when the same injection pen is used for several patients,” according to the editors at Prescrire International.
“In practice,” they added, “many of these errors, which expose diabetic patients to sometimes serious blood glucose fluctuations, can be prevented by involving patients in the details of their treatment, by making use of their experience in managing their diabetes, and by implementing certain preventive measures.”
In 2017, 68% of the more than 70,000 American deaths due to drug overdose involved either prescription or illicit opioids.
Regardless of the opioid epidemic, opioids still have a place in treatment. Consequently, the CDC developed guidance regarding opioid prescription for chronic pain. This guidance covers when to initiate or continue opioids; opioid selection, dosage, duration, follow-up, and discontinuation; and harm/risk assessments.