Who is Prescribing Sedatives to Celebrities?

February 20, 2012 in Medicine, Misc by RangelMD

The late – love-song-gospelizer – Whitney Houston is now suspected (by the press) to have possibly died from a lethal combination of alcohol plus various prescription drugs including alprazolam (Xanax) while in her Hollywood hotel bathtub. Mrs. Houston joins a surprisingly long list of celebrities who have died of accidental overdoses involving benzodiazipine sedatives such as alprazolam. What’s the deal with this common prescription sedative?

Usually, alprazolam is prescribed as a short term treatment of acute anxiety disorders. It is classified in the US as a controlled substance with significant abuse and addictive potential. It’s popularity may be due in part because it is widely considered to be relatively mild and safe by many patients and their physicians. But, in fact, alprazolam can be much more toxic than even other prescription sedatives.

However, unintentional overdose with alprazolam alone is unusual (it was responsible for less than a quarter of ER visits  for benzodiazepine toxicity in the US for 2008). What is much more common is unintentional overdoses that involve other prescription medication and/or alcohol. It’s unclear why but it may be that patients are unaware of or tend to minimize the risks of combining different controlled medications that could suppress breathing. Or they don’t realize that alcohol can suppress breathing, be difficult to dose (because you are already intoxicated), and have an additive effect when combined with benzodiazepines.

What I want to know is . . . . who is the physician . . . .  being aware of Mrs. Houston’s very well publicized problems with substance abuse, including cocaine and alcohol . . that he or she felt compelled to write her a prescription for alprazolam or other sedatives which she then reportedly filled at a local pharmacy? It would have been understandable if the late Mrs Houston had diverted another person’s medications for her own use or acquired sedatives over the internet or in another country or illegally on the “street” but from all accounts she was actually legally prescribed these medications by an American physician!

Strictly speaking, a history of alcohol or other type of substance abuse is not a legal or medical contraindication to prescribing controlled medications for a medically valid reason. But, there has to be a good degree of due diligence and caution on the part of the prescribing physician in these cases.  Drug testing can be done on potential candidates for therapy with sedatives and a detailed and complete history of the patient’s prior problems with substance about should be performed in order to allow the physician to get the best possible idea of the patient’s tendencies and potential for abuse. Treatments for pain, anxiety, and insomnia should start with non-controlled medications and drugs with the lowest potential for harm and abuse before stepping up to more powerful alternatives. In the very least, small amounts of potentially harmful medications should be prescribed in a “trial” treatment period to be used sparingly and only as a last resort.

But this approach is often an idealistic fantasy when confronted with the reality of real-world medical practice. Patients can be demanding and incredibly impatient and the physician has only 15 minutes (often less) to gather as much information as possible and develop a complex treatment plan. Too frequently this process gets degraded into the best plan for getting the patient in and out of the office in the shortest amount of time and this often includes a month’s supply of the desired medication and a cursory warning of the risks.

But even without these time constraints, the fact that the patient is a major celebrity can have significant and deleterious effects on clinical decision making. This was clearly seen when Dr. Murry felt compelled to discard sound medical judgement when he delivered a powerful anesthetic to Michael Jackson to treat insomnia. Maybe this is what happened in the case of Mrs. Houston? How can you say “no” to a famous patient?  The temptation to give in to the needs of a super-famous client might have been too much for the local MD.

Still . . . . . this justifies nothing.

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