Online Program

SSRI/SNRIs and Opiate/Opioid poly pharmacy toxicity deaths in Cowlitz County in Washington State 2010-2013

Sunday, November 1, 2015

Patrick Gallaher, R.Ph., BS, BPharm, MBA, MPH, Kaiser Permanente, Kelso, WA
Susan Cheng, PhD, MPH, Master of Public Health Department, Benedictine University, Lisle, IL

Objective: To analyze and compare poly pharmacy drug toxicity toxicology reports from 2010-2013.

Background: Poly pharmacy toxicity death rates are rising. Deaths are assigned poly pharmacy toxicity when the autopsy is inconclusive but drugs are present in the serum. The author discovered a concerning group with SSRI/SNRI presence and non-lethal Opiate/Opioid serum levels.

Methods: Retrospective review of cases where poly pharmacy toxicity was the cause and manner of death. A review of 1,336 coroner case files for toxicology reports and subsequent serum level patterns was conducted.  A comparison to the presence of different classes of drugs in relation to Opiate/Opioid presence and penetration into the toxic range was then examined.

 Results: Of the 1,336 coroner case files reviewed, we identified 34 cases that met the study criteria between 2010 and 2013. Three groups were separated based on serum penetration of Opiates/Opioids into the toxic range; all individuals were positive for Opiates/Opioids. Group one included both Sedatives/Respiratory depressant drugs and SSRIs/SNRIs (9 cases, 26%), Group two included only Sedatives/Respiratory depressant drugs (5 cases, 15%), and Group three included only SSRIs/SNRIs (5 cases, 15%). Groups one and two presented drug toxicity with Opiate/Opioid serum penetrations well into the toxic range. Group three presented Opiate/Opioid serum penetration generally below the toxic range. The remaining 15 cases were eliminated due to illegal substance presence.

 Conclusions: Drug poisoning is increasing at a concerning rate. Decedent serum concentrations of prescription drugs in the toxic range present a logical explanation for death.  Exclusive SSRI/SNRI and Opiate/Opioid deaths presented a concerning lack of Opiate/Opioid penetration into the toxic range. These findings may indicate a new SSRI/SNRI ADR risk in the long-term opiate treated pain patient. A proposed mechanism is lethal syncope due to 5-HT and Opiate activity on the vascular system compounded with opiate exposure accelerated vascular aging.

Learning Areas:

Other professions or practice related to public health
Public health or related research

Learning Objectives:
Define Poly Pharmacy Toxicity and how it differs from other manners and causes of death. Discuss the process of determining serum toxicity levels of offending agents contributing to an overdose. Describe a concerning relationship between SSRI/SNRI serum presence, generally non-lethal levels of opiate or opioids in the blood stream and death.

Keyword(s): Physicians, Pharmacists

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am a pharmacist in Washington State with 20 years of experience in multiple venues of pharmacy practice. I currently work with my county Coroner’s office advising on drug overdose and toxicity deaths. My academic work in pharmacy and public health has provided opportunities to research preventable drug deaths. Additionally, I guest lecture at the University of Washington School of Pharmacy and work with Washington State legislators to create State Pharmacy and Public Health Policy.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.