Combined drug intoxication

Combined drug intoxication

Combined drug intoxication (CDI), also known as multiple drug intake (MDI) or lethal polydrug/polypharmacy intoxication, is an unnatural cause of human death. CDI is often confused with Drug Overdose, but it is a completely different phenomenon. It is distinct in that it is due to the simultaneous use of multiple drugs, whether the drugs are prescription, over-the-counter, recreational, or some other combination. The reasons for toxicity vary depending on the mixture of drugs. Usually, most victims die after using two or more drugs in combination which suppresses breathing and the low blood oxygen level causes brain death. [1]

CDI can occur with numerous drug combinations, including mixtures of over-the-counter (OTC) drugs, legally or illegally obtained prescription drugs, herbal mixtures, and home remedies. Ingestion of alcoholic beverages, in combination with other drugs, increases the risk of CDI.

The CDI/MDI phenomenon seems to be becoming more common in recent years. In December 2007, according to Dr. John Mendelson, a pharmacologist at the California Pacific Medical Center Research Institute, deaths by combined drug intoxication were relatively "rare" ("one in several million"), though they appeared then to be "on the rise".[2] In July 2008, the Associated Press and CNN reported on a medical study showing that over two decades, from 1983 to 2004, such deaths have soared.[3] It has also become a prevalent risk for older patients.[4]


  • Risk factors 1
  • Prevention 2
  • Paracetamol deaths 3
  • Celebrity deaths due to CDI (or MDI) 4
    • Anna Nicole Smith and Daniel Wayne Smith 4.1
    • Heath Ledger 4.2
    • Speedball deaths 4.3
  • CDI-related legal cases 5
    • Karen Ann Quinlan 5.1
  • Michael Jackson 6
  • See also 7
  • Notes 8
  • External links 9

Risk factors

People who engage in polypharmacy and other hypochondriac behaviors are at an elevated risk of death from CDI. Elderly people are at the highest risk of CDI, because of having many age-related health problems requiring many medications combined with age-impaired judgment, leading to confusion in taking medications.[3][4]

Recent veterans back from war and suffering from post traumatic stress disorder (PTSD) in combat are at risk of dying from CDI/MDI. Nine veteran PTSD patients died from CDI/MDI in America in 2007. There are anecdotal reports of veterans dying from combinations of antidepressants, antipsychotics, and tranquilizers used in combination with OTC medicines like diphenhydramine. While still a U.S. senator from Illinois, United States President Barack Obama asked the U.S. Congress to inquire about the safety of these drugs. There is an ongoing investigation of the matter.[5]


In general, the simultaneous use of multiple drugs should be carefully monitored by a qualified individual such as board certified and licensed medical doctor, either an M.D. or D.O.. Close association between prescribing physicians and pharmacies, along with the computerization of prescriptions and patients' medical histories, aim to avoid the occurrence of dangerous drug interactions. Lists of contraindications for a drug are usually provided with it, either in monographs, package inserts (accompanying prescribed medications), or in warning labels (for over-the-counter (OTC) drugs). CDI/MDI might also be avoided by physicians requiring their patients to return any unused prescriptions. Patients should ask their doctors and pharmacists if there are any interactions between the drugs they are taking.

Paracetamol deaths

On June 30, 2009 an FDA advisory panel recommended that Vicodin and another painkiller, Percocet, be removed from the market because they have allegedly caused over 400 deaths a year. The problem is with paracetamol (acetaminophen) overdose and liver damage. These two drugs, in combination with other drugs like Nyquil and Theraflu, can cause death by multiple drug intake and/or drug overdose. Another solution would be to not include paracetamol with Vicodin or Percocet.

Celebrity deaths due to CDI (or MDI)

Many celebrities have died from CDI/MDI, including:

Anna Nicole Smith and Daniel Wayne Smith

In February 2007, five months after her son Daniel Wayne Smith was found dead from CDI with methadone, sertraline, and escitalopram in his system,[8] Anna Nicole Smith also died from CDI/MDI. Her two autopsies detecting more than 11 drugs in her bloodstream, namely chloral hydrate, clonazepam, lorazepam, oxazepam, diazepam, diphenhydramine, topiramate, oseltamivir, ciprofloxacin, methocarbamol, carisoprodol and others. The deaths of Daniel Smith and Anna Nicole Smith were declared as Combined Drug Intoxication.[9][10]

Heath Ledger

Australian actor Heath Ledger was found dead on January 22, 2008, in his SoHo, New York City, apartment; the toxicology report concluded that the cause of death was "acute intoxication" resulting from "the combined effects of oxycodone, hydrocodone, diazepam, temazepam, alprazolam, and doxylamine" and "that the manner of [his] death" was "accident, resulting from the abuse of prescription medications or combine drug intoxication (CDI)."[3][11][12]

Speedball deaths

Some controversially think speedball deaths are MDI/CDI when they might simply be drug overdose, which is a related but, completely different phenomenon. The following list is for speedball CDI/MDI deaths only. Victims must be using cocaine and heroin in combination or amphetamine with demerol. An upper and a downer combination can be called speedball death.

CDI-related legal cases

Karen Ann Quinlan

The Right to Die case of then-comatose Karen Ann Quinlan (March 29, 1954 - June 11, 1985) made legal history in 1975 and 1976, stimulating public scrutiny of ethical and moral implications of her case. In 1975, after drinking gin and tonics at a party and then taking Diazepam, Quinlan collapsed, suffered respiratory failure and irreversible brain damage, and, after being taken to the hospital, lapsed into a persistent vegetative state. After she had been kept alive on a ventilator for several months without improvement, her parents requested that the hospital discontinue such active care and allow her to die. The hospital refused, and the subsequent legal battles made newspaper headlines and set significant precedents. After the New Jersey Supreme Court ruled in her parents' favor, Quinlan spent nine more years comatose in the hospital, before dying from pneumonia in 1985.

Michael Jackson

The CDI/MDI death of Michael Jackson led to the trial of Conrad Murray, whose license was revoked in four states and who was sentenced to serve four years in a California prison, but only served two and one half years. [13][14][15][16][17]

See also


  1. ^ "Combined Drug Intoxication". American Outreach. (2010-3-22).
  2. ^ a b James Montgomery (2007-06-21). "Hawthorne Heights Guitarist Casey Calvert's Fatal Drug Interaction Was Rare, Experts Say: Number of Accidental-Interaction Deaths Still Remains Relatively Low, Although Such Incidents Are on the Rise".  
  3. ^ a b c "Home deaths from Drug Errors Soar".  
  4. ^ a b Rubin, Rita (2008-12-23). "Mixing Drugs Puts More Older Patients at Risk" ( 
  5. ^ Andrea Billups and Audrey Hudson (2008-11-13). "Dead Veteran's Kin Demand Inquiry: After Death of Son, Dad Takes Cases to Capitol Hill" ( 
  6. ^ "Boogaard death from alcohol, oxycodone toxicity". Retrieved 20 May 2011. 
  7. ^ Christina Fuoco-Karasinski (LiveDaily Contributor) (2008-10-09). "Hawthorne Heights Stay Positive After a Rough Year" ( 
  8. ^ "Doctor: Drug Combo Killed Anna Nicole's Son: 20-year-old Mixed Methadone and Antidepressants, Pathologist Testifies".  
  9. ^ Dan Whitcomb (Los Angeles) (2007-04-06). "Anna Nicole Smith's Doctor in Drug Probe".  
  10. ^ "The Law: Drugs: Anna Nicole's Son Died From Lethal Drug Combo, Pathologist Says: Star's Son Killed by Combination of Pain Killer, Antidepressants, Pathologist Testifies".  
  11. ^ Sewell Chan and James Barron (contributing) (2008-02-06). "City Room: Heath Ledger's Death Is Ruled an Accident".  
  12. ^  
  13. ^ "Karen Ann Quinlan (Medical patient)" ( 
  14. ^ Lauren Marmaduke (October 21, 2011). "'"Music’s Top 5 Dubious 'Dr. Feelgoods. Houston Press. 
  15. ^ David Batty (27 June 2009). "In the public eye - feelgood physicians". The Guardian. 
  16. ^ Steven Mikulan (November 16, 2009). "Dr. Feelgoods and Their Celeb Patients: Who Needs Who? (PART 2: Hollywood's history of addicted stars and the doctors who supply them". The Wrap. 
  17. ^ By Steven Mikulan. "Jailing Dr. Feelgood: Prescriptions-on-Demand Gets Riskier (First of 2 Parts:Prosecutors are targeting celeb-friendly docs, but making charges stick is tough". The Wrap. 

External links

  • Drug Interactions Checker at Drug Information Online.
  • Drug Interaction Checker at Medscape (registration required).