Thursday, February 07, 2008
Sad lessons from Heath Ledger's Death
By Miriam Falco
Managing Editor Medical News


Ever since we learned of Heath Ledger's sudden death on January 22, the question of what killed him loomed large (at least in the news media). Just a couple of days after, New York's Police Commissioner Ray Kelly announced that no illegal drugs had been found in Ledger's apartment, but two unnamed law enforcement officials told the Associated Press that six types of prescription drugs were found.

Yesterday the New York City medical examiner released the final autopsy report. Cause of death: a combination of six prescription drugs. Ledger "died as the result of acute intoxication by the combined effects of oxycodone, hydrocodone, diazepam, temazepam, alprazolam, and doxylamine."

A spokesperson for the medical examiner tells us that none of these drugs - two sleep medications, two anti-anxiety drugs and two narcotic painkillers - was taken in excess. Still, the ME ruled this accidental death resulted "from the abuse of prescription medications." And sadly, Ledger is only the latest celebrity to die after mixing prescription meds. Tomorrow is the first anniversary of Anna Nicole Smith's death.

But experts from addiction specialists to pathologists point out that prescription abuse is hardly limited to celebrities. In fact, within an hour of the report's release, two acquaintances told me they had some or all of those drugs in their medicine cabinets, left over from previous prescriptions.

Many people may not realize that mixed together, sleep aids, anti-anxiety drugs, antidepressants and narcotic painkillers can be lethal. In Ledger's case, we're told the combination of drugs probably caused his central nervous system to slow down so much that his heart stopped beating and lungs stopped breathing and he never woke up. It's hard to imagine that any doctor would prescribe all six of these drugs to the same patient, but nowadays it's not difficult to obtain prescriptions from several different doctors. Unless you tell your doctor what other drugs you're taking, it's difficult for him or her to anticipate potential complications.

Some use prescription drugs to get high because they are so widely available, and much easier to get than illegal drugs such as cocaine and heroin. And many parents may not know that among teens, prescription drug abuse ranks ahead of all illegal drugs except for marijuana according to a report by the White House Office of National Drug Control Policy released two days after Ledger's death. The agency noted that, "Teens are abusing prescription drugs because many believe the myth that these drugs provide a 'safe' high." That may be a common misconception among the young and the old. Even though a drug may be prescribed by a physician, taking it in the wrong way or in excess can be deadly.

Concern for prescription drug abuse has led the drug control policy agency to participate in a $30 million ad campaign to raise awareness about the problem. The launch was delayed in light of Ledger's death (the White House didn't want to appear to "opportunistic," according to spokeswoman Dana Perino), but if you watched the Super Bowl, you may have seen the commercial showing a drug dealer complaining that he can't compete with kids getting their drugs for free out of their parents' medicine cabinets.

Many, including Ledger's parents, hope that lessons will be learned from this tragedy. In a statement, the family said, "Heath's accidental death serves as a caution to the hidden dangers of combining prescription medication, even at low dosage."

Were you surprised that too many prescription drugs led to Health Ledger's death? Were you aware of the risks of combining multiple prescription drugs?

Editor's Note: Medical news is a popular but sensitive subject rooted in science. We receive many comments on this blog each day; not all are posted. Our hope is that much will be learned from the sharing of useful information and personal experiences based on the medical and health topics of the blog. We encourage you to focus your comments on those medical and health topics and we appreciate your input. Thank you for your participation.
We must remember that this is still drug abuse, and many, many people responsibly take medications such as the ones Ledger was prescribed. I have been taking anti-anxiety medications for years and they have such a bad reputation because some people choose to abuse them. This is not a problem with prescription drugs, this is a problem with a person who chose to abuse drugs. Aspirin can be deadly if taken in an irresponsible manner. While a young person's death is tragic and we all have our share of issues, please do not place the blame on the medications or condescend your readers by suggesting that we aren't intelligent enough to realize we should not be taking all those medications at once. This is not a matter of a person being ill-informed, it is a matter of a being an addict.
It is tempting to keep commenting on this case as the information comes in. Most op-ed pieces seem to want to use the story now as a "teachable moment", something which goes beyond the history and reputation of the man who was Heath Ledger. Unfortunately, some of the more sensational press exploit the confusion in the minds of some of the public that it was his fictional character with a presumably gay lifestyle that led to his death. One reputable paper conflates his friend, the co-star Jake G. with his ex-girlfriend and mother of his child, when they state that his "ex-beau" will attend his funeral in Perth. Normally, a female lover is not known as a "beau". But this is to keep the sensationalism going and to castigate life upon the wicked stage as the source of the problem. I have seen abuse of prescription drug use in my community too much to imagine it is something practiced just by adolescents, looking for a high, or by those in the drama queen business (in either the legitimate or gay sense). From the bored merchant behind his counter on my street to one of the professors in my law school, to an elderly female relative --- there's plenty of it to go around. And basically the problem is simply that real long-term work on personal problems takes more effort than having a physician fill out a prescription. Heath Ledger was just young enough and I think uneducated enough to be unaware of the risk he was taking. He had an anxiety disorder which cannot necessarily be attributed to recreational drug use. Perhaps it was partly genetic. And he had not yet tamed it. As for the older and more mature people who abuse these drugs - I wonder how many of them unknowingly overdose and die. Surely there are statistics. I would doubt in the ones I know about Ledger's level of ignorance. He was clearly asking for help when he told people he didn't sleep well. He was complaining of his symptoms. Perhaps people considered him too exalted to warn him, too invulnerable.
I work in the pharmaceutical industry. Something, some "kind" of mechanism needs to made to stop people from "double doctoring" or " poly pharmacy" especially when Narcotic and Controlled drugs are concerned. Some kind of "smart card" perhaps, so that even if you are being honest with multiple dr's about what you are getting from others, it will allow PHARMACISTS to check for these potentially lethal interactions.

It has just amazed me since Heath's passing, how many celebrities are entering rehab, probably they are "realizing" they are not young and immune to these problems anymore.
I was not surprised. These celebrities *big sigh* .... well, I'll keep my opinion of celebrities to myself.

I'm afraid that if Britney Spears doesn't get a grip, she is next.
2/07/08

Doctors should find a way to track what other perscriptions a person has. Even if it was supplied by another doctor.

Bri, NC
You make it sound like he was intentionally misusing the drugs, i.e. to get high. It sounds to me like he may have accidentally taken too much without realizing it -- probably because he was so desperate for sleep.
A justification for a centralized computerized patient's medical record. Addiction maintained by using multiple physicians is common among those who can afford it.
My husband gave me two strong pain prescription tablets on my 40th Birthday as I was in pain. I couldnt get out of bed or wake up, it was just like I had just woken up from aneasthetic, so I can understand how such a tragedy could happen. It nearly happened to me!!
i think he would have had some idea of the risks. I have a medicine cabinet that contains, valium, xanax, seroquel(mood stabiliser), zoloft(antidepressant), antihistamines and some pain killers from when i had a tooth pulled. Not all of these are in use anymore and not all were prescribed by the same doctor. I have never been made aware of the risks but feel there is a degree of common sense involved. I love heath leger, i have since i first whatched the aussie cult flick "two hands" but i think he took these in bad judgement and probably had taken the same sort of mix once or twice before and had been fine... taking them again thinking he would be fine again.
i have over the years taken pain medacation ,and i know because that if the doctor has told me to take one
hydrocodone before bedtime that if i take 2 then i am overdoseing and risking slowing down my breathing enough that i could die ,so why is it that it wouldnt click in someones mind that if they take oxycodone, hydrocodone ,at the same time that it could kill them ,just taking those 2 drugs could have killed him ,but trow in the other 4 and your just asking for disaster ,its the same as if your taking something with codeine in it and you drink alcohol ,i know it feels wonderfull to take alot of hydrocodone..vicoden ,i became addicted to it ,and if it was leagal to get it on your own it would have killed me in the long run ,but the doctor took over and got me off of it ,when you take drugs to make you feel good and not for the reason it was given to you and then you mix them with other drugs for the same reason ,your risking death .and i wouldnt say thats and accadent i would say its a choice you know it but you want to get the high .sorry for the mis spelled words ,bob vanbuskirk
Heath's Law should be enacted as fast as lawmakers can get it in play...barring this sort of thing from happening through a national rx pharmact network that can catch these rx's in a cyber 'net' no matter who is prescribing. If someone is filling an RX from several doctors the pharmacy net could block this sort of thing or at least create an opportunity for the pharmacist to counsel the patient on the other drugs they are shown to have been prescribed.
Come on lawmakers...make it happen! Peter Defazio in Oregon can be the pointman.
I think it's really sad about Heath Ledger's untimely death and could easily happen to anyone who is not educated on the interactions of drugs. This should serve as an educational tool for people and not to sit in jedgement of Heath's intention taking these drugs. For all we know he may have taken them over several days, finally was able to sleep and never woke up.
I had a feeling that it probably wasnt too good to mix pills...but have i done it before? YES!, I have done it quite a bit. Whether tylenol and cough medicine or other. You just dont figure it will hurt. There was even one time that I took two kinds of perscription muscle relaxers because my back was all screwed up, and I couldnt move well because of stiffness and swelling. THat I never repeated, I knew it was a mistake the minute i did it. And am very fortunate it didnt stop my heart. But come on people: I know tons of people that either mix pills or dont follow instructions as to when to take them. Its the same thing. Dont act all innocent.
Many people assume that he or people who die from prescription overdose take all these pills together, and that's the reason they die. Unfortunately, this is not the case. Some of these drugs have a long life in your blood system, but they are enough to be toxic. Some of them might have been taken the day before, or even 48 hours.
I think it is very important for the "healthcare professionals" or "pharm" companies to come and worn that even 1 of each of these pills taken together over the course of 48 hours can be deadly.
I think it is interesting that he was taking two types of painkillers. Recently I had a fairly intense surgery done, and the pain in the aftermath was not easy to handle, however, I did not need two different painkillers to combate the pain. I think the amount of drugs in Heath's system seems a little excessive, even if they were individually in small doses.
I believe that not only is it the obligation of any doctor that you visit inquire for a complete list of medications that you are currently on, but if you maintain a (that is one) pharmacist to deal with your medications, than what the doctors may have missed, your personal pharmacist will be able to advise you of lethal combinations.

It is imperative maintain a relationship with one pharmacist who has a record of all the current drugs and dosages that you’re taking. After all, they did spend a lot of time in university, and I'm sure the courses went beyond just counting pills.
I think the doctor(s) that were treating this poor man should be questioned as to why he was on so many different medications and if there was any education given as to how to take and not the meds.
This death could have easily been avoided and a little girl would still have her father. Anna Nicole Smith was different, she abused her pills for a very long time but for someone like Heath and people that are not even celebrities to try to get some help through doctors and prescriptions this is a tragedy.
Doctors seem very willing to prescribe prescribe prescribe.
i don't think it's a question of being an "addict". it's something that can easily happen to anyone and to isolate the problem to a certain group of people is irrational and irrelevant. these drugs that were given (aside from the antihistamine) are considered control drugs, meaning they have the high potential for tolerance. (oxycodone, for instance, is rated a CII drug, the highest control rating given to prescription meds.)unfortunately people taking medications without alerting each of their doctors about their complete prescription history is common. (ive worked in a pharmacy for five years). ultimately i think it's a loophole in the system. i think the US should have a general database that pharmacies and doctors can access to see what patients are taking, esp when doctors need to prescribe medications, and for the pharmacy to check for interactions. it's also partly the prescribing doctor's fault...even though heath mightve gotten it from different doctors they should still inquire if he's on other medications prior to prescribing. but then again maybe the doctors did and lectured him about mixing these drugs...who really knows. but this is a common problem and pharmacists have to point it out to patients all the time not to mix drugs because they're unaware. i think we should stop pegging this as an isolated incident...something that can happen to everybody. once we all get on that plane maybe something can actually be done about it.
I think that every doctor before prescribing medications should know what there patient is taking even if they dont use the same doctor because of situations like this!!They should take the time to call the doctors hello they have nurses that can call!!Its very sad to sit there and have everyone analyze his death because no one knows if he meant to do it or not he is gone and no one can ask him!!So I just say we live this alone and let the family mourne there son!!
Painkillers as far as my experience with them work very well at getting the job done...it seems that Heath may have been suffering from the so called flu he had contracted in london, and simply tried to combat it with more medication. I have know people who may have just a headache and take 4 or 5 tylenol thinkng that if they increase the dosage the pain will dissappear.
In Heaths case it was simply accidental...exhaustion and other factors contributed to his decision i assume to increase the pills before going to bed which resulted in this tradegy... There are many deaths contributed to overdose of the just regular over the counter medications...its just that Heath is a celebrity so the focus is strong and played over and over in the public mind.


Kraig Rasool
Fort Washington
Would we be having the same conversation if the celebrity accidentally fell off the edge of a cliff. Should the givernment do something about people that walk too close to the edges of cliffs? SHould the government set up some kind of tracking system to determine when people are about to walk near the edge of a cliff. Should we question the park rangers as to why they didn't know this person was walking near the edge of a cliff?

Life is full of dangers. Life isn't always fair. Sometimes people die due to accidents or lack of knowledge. Every single one of us will ignorantly do something today that is dangerous. There is not always someone to blame, including the victim. It is impossible to remove all risks of death from the process of life.
People are talking about a U.S. data base of prescriptions thatpatients are taking; I agree, but you've forgotten that Heath appeared to have walking pneumonia when he was in LONDON, when he was also complaining to the film's director that he couldn't sleep and was so exhausted. The 'weird, phycho joker' character he was having to portray no doubt caused phychological unrest (and Heath spoke to the media about how despicable and sick the character was), added to his admitted depression over his split from Michelle and his baby girl. He was in LONDON when he got his first meds. Got home, had the same sleeplessness and anxiety (which totally intensifies without sleep); started working on his third film in a row, and FELL from a moving overhead contraption on the film set (shown in a phone video clip viewed online)just a couple of days before he went home to New York. He probably went to bed in pain wanting to rest his heart and mind, hoping to sleep peacefully, and the meds had accumulated in his system. .....Has anyone ever awakened in the night having a panic attack?? I have. It scares you to death and you don't know what's happening. What did they prescribe for me? Xanax. What sleeping pill did they give me? Ambien. I'm already taking a low dose of Wellbutrin, an antidepressent, because I cry easily over divorce and empty-nest syndrom and lonliness. I'm sensitive to medication so I take 1/2 of a pill! (luckily) Did I get any of the warnings you're talking about from my ONE and ONLY Doctor? No Indeed. Ibuprophin is what I used to take for headaches in the morning if I cried myself to sleep. Did anyone warn me at all? NO! Now, after learning from this tragic young man's death, I won't touch those things, but need to continue with the Wellbutrin. Heath was everything that everyone has praised him for, and his remarkable vulnerability, beauty and talent touched those of us who enjoy the sweetness and warmth of love and friendship depicted in films, maybe because our lives are a little empty and we miss our loved ones. Is that so wrong? It gives us hope that love is alive somewhere. Bless his tender heart, his loving parents who raised him and allowed him to develop into an amazing actor who touched many lives....and his darling baby girl and her mom. Wish for the best for these hurting loved-ones who cherished him.
The comments that Heath Ledger was abusing these drugs because he had so many different types of drugs are very miss guiding. One article stated "that is if a normal person took two Ambien it would knock them out". I consider myself to be "normal" but I have had a prescription for taking two Ambien at night. It had no effect on me. The reason there so many types of each of these types of medicines is because what works for one person may not work for another. As far as being prescribed six different drugs, we are not his doctor and do not know all of the information as to why theses drugs were prescribed together. I have a prescription for welbutrin, xanax, seroquel(mood stabilizer), zoloft(antidepressant), atemazepam, and vicodin. All of these drugs are prescribed by the same doctor and work for me and my medical issues. One thing that seems to be over looked is that he was also sick and exhausted. Both of which can lower your bodies tolerance to medications especially when it comes to slowing down breathing.. Heath's death is very tragic but to try to destroy his memory and reputation is just as tragic. Heath was open about his difficulty with anxiety and lack of sleep. If he was abusing these drugs why would he draw attention to his drug use? Heath's family and friends should not have to defend his reputation. His reputation over the years should be enough to know Heath was not a drug addict to prescription or illegal drugs. There is a lot of talk about abusing these drugs but I have not heard anything about him having had multiple refills for any of these drugs. Unless you know the all of the facts do not make assumptions as to what he was thinking or why he was taking the medications.
One factor that keeps being left out of this story is that, at the time of his death, Mr. Ledger was suffering from pneumonia, no? Having had pneumonia myself, I can tell you that you function very poorly and may not even know how sick you are as your brain isn't getting the normal amount oxygen. Mr. Ledger may very well have simply lost track of what he had taken and when, and that coupled with his already-compromised breathing, had tragic results.

Folks who want to paint him as "an irresponsible drug abuser" may be missing a more useful point, which is that it's very important to be extremely careful when you're on more than one medication, and it's very easy to make dosing mistakes when you're sick.
My condolences to his child and family. How very sad.
The problem in Mr. Ledger's case would not be solved by a national pharmacy register, as he travelled a lot and can get one prescription in one country and other prescriptions in another without coordination. Not knowing Mr. Ledger personally, but knowing how easy it is to have a lack of judgement if you are sleep deprived and ill with something like pneumonia or a severe flu at the same time I do not have an answer.
Maybe Medline can create a simple chart for those who have full medicine cabinets that doesn't involve much reading but just charts interactions that everyone could access from the internet. Something designed for very ill people to read quickly and get the warning. My prayers are with his family and friends.
In the current climate, I think some doctors need to be made more aware of how serious this is. My family doctor (back in Houma, LA) prescribed me 6 mg/day of Klonipin for a severe Anxiety Disorder (this dose has risen to that level after 6 years of use), 2 mg/day of Ativan when I became Tachardic; Flexeril for back problems related to a Car Accident, and Endol (codine cough syrup) for my asmha related cough. My Pharmacist advised me that I did not need to be on 2 benzodiazepines, but did not state it could be fatal. I figured my doctor knew best. Now, I'm in a new city, under another doctor's care, and only on the Klonipin. My prior Dr. was kind and elderly and I am sure meant no harm. Heath's tragic passing was a wake up call because just because you take meds as prescribed, tragedy can happen. I learned from his passing, hopefully others do, too.
My late mother was sadly addicted to prescription medications for almost 20 years. She was a brilliant person. She was what you call a "bookkeeper". She had some health problems beginning in her early thirties and during the course of events she became addicted. My sisters, my husband and I found a clinic that helped us get her "unhooked". However, this did not happen until after she overdosed, which resulted in some brain damage (sad for a smart person)and dependence on seizure medication for the rest of her life. My heart goes out for anyone and family of anyone who must endured this.
I have to say that I got so angry when I read the first comment under this story. "We must remember that this is still drug abuse..."
Now, I am not angry because I claim to know Heath personally, or because I know the situation. I am angry becuase this comment and the ones in the rest of the posting brush off the "teaching moment" here.
I suffer from chronic migraines, and between going to the ER at times, and my regular doctor, and a headache specialist, I try to tell everyone what I am taking, and I hope I am being careful.
But, when this story came out, and then the list of drugs came out, I was shocked to see that I had most of these medications on hand myself, and that sometimes in severe pain and frustration, I have taken an extra pain pill, etc with the onset of a migraine. This happens once every four months or so.
I am not an addict. AND, I was so extremely thankful for the wakeup call I got from this tragedy. I do think probably Heath was trying to solve a temporary sleep or anxiety issue- but either way, it made me realize that even in small doses, I need to be careful. So many of my friends have also commented that this scared them for the same reasons it did me. We sometimes forget that these are strong medications and need to be taken with caution.
A teaching moment, indeed.
The idea of a database to track all prescriptions taken by people is not realistic in any way. People do need to be honest with docs about all meds they take. Many people see different docs because of this great thing we have now called "specialties." It makes it hard for docs to keep track of patients meds when they see several docs. Our medical community has made great strides in the medicines we have now, think back to 50 years ago and what people had to endure and also die from because of lack of these medicines. Every prescription I have been given comes with a very detailed written explanation of what the drug is all about. People need to read these! Do some research for yourself on medications and quit blaming everyone else. It's called taking an active approach to your own health. Heath's condition I am sure was hastened by pheumonia (not good oxygenation to the rest of the body plus lowered immune system) and the mixture of drugs. My question is why was he on the two very potent painkillers. Because of his character he played as an actor? Give me abreak.
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