If you’re here reading The Fix, you already know that substances of abuse can make a mess of people's lives. There are dozens of chemicals that can render you friendless, jobless and despondent—if not outright kill you—all by themselves. That makes mixing them together a bit like throwing a Molotov cocktail at your own body. Too much of drug A may cause liver failure, say. Add a little of drug B and it might happen two hours sooner. Toss in drug C, and maybe you’ll stop breathing before your liver even gets involved.
Because every person reacts slightly differently, there’s virtually no way to determine which drug combination is most likely to land you, personally, in a body bag. But that doesn’t mean some pairings aren't deadlier than others. Some—like the painkiller/anti-anxiety drug/sleeping pill cocktail that killed Heath Ledger, and has been soaring in drug use stats—terrify even medical professionals.
Based on SAMHSA's Drug Abuse Warning Network (DAWN) report—and the opinions of Dr. Joseph Lee, medical director of Hazelden’s youth continuum, and Dr. Cynthia Lewis-Younger, managing/medical director at the Florida Poison Information Center - Tampa—here are some of the very worst offenders:
•Alcohol and benzos
Benzodiazepines were involved in over a fifth of drug- and alcohol-related hospital visits in 2009, according to the DAWN report—and you can bet that respiratory failure was a factor in most cases. The likelihood of this pairing happening in a party setting is an added danger; fellow revelers might be inclined to let the guy who overdid it sleep it off while they carry on having fun. That’s a really bad move, says Dr. Lewis-Younger: “We have a cultural mantra, I guess, in this country about letting people sleep it off. I cannot tell you how many tragedies that I have heard of in my duties that happened because of it.”
•Alcohol and prescription painkillers
Even though this combo causes slightly fewer hospital visits than mixing drinks with benzos—15% of visits involving alcohol and drugs, versus 21% that involve anxiety drugs—it may be growing in popularity. The number of emergency room trips due to fentanyl, hydrocodone, hydromorphone, morphine, and oxycodone doubled between 2004 and 2009. And if that trend continues, more problems caused by mixing them with alcohol can’t be far behind. What’s worse, this particular combination, like alcohol and benzos, tends to be common among young women (think: Hollywood starlets) who indulge at parties and concerts—and alcohol has stronger effects on women than on men.
•Cocaine and opiates
Ah, the dreaded speedball. In the ’80s and ’90s—when this combination felled John Belushi, Chris Farley and River Phoenix—this might have topped the combo list. Don’t get too comfortable though; any drop in prominence is mainly due to the increased popularity of prescription pills. The speedball remains just as dangerous as ever. “So many different things—seizures, heart attacks, strokes, unregulated body temperature—can happen when you take drugs that stimulate you, like cocaine," says Dr. Lee. "And then, on the other side you have the respiratory depression. If you have a combination of the two, it can make it harder for you to recognize the impact of one chemical.”
•Cocaine and ecstasy
Just like combining two depressants, combining two stimulants can exacerbate the effects of both. Though you’ll hardly fall asleep and stop breathing on this drug cocktail, you might well stop breathing in another way. Ecstasy on its own can damage the cardiovascular system and cause problems with body temperature regulation, and cocaine can do the same. If you're dancing at a hot sweaty club or a summer music festival while taking both, you’re pretty much asking to overheat or have a stroke. What’s more, these two drugs frequently come cut; you really have no idea what you’re getting. As Dr. Lewis-Younger puts it, “Combining any unknown with any other unknown? It’s like Russian roulette.”
Both of the Above
•Alcohol and cocaine
Not only is this particular combination likely to land you in the hospital—taking these two drugs in tandem results in almost one third of ER visits involving alcohol and drugs—it’s also extremely bad for you in the long term. “When you take cocaine and the alcohol together for a long time, there’s a combination chemical called cocaethylene that is formed that is very toxic," says Dr. Lee. "It can really damage your liver and heart and other organs.” How bad is it? While it wasn’t one of the official causes of singer Whitney Houston’s death, it was present in her system, according to the autopsy report—and heart disease exacerbated by years of cocaine use was a contributing factor in her drowning.
•Benzodiazepines, narcotic painkillers and sleeping pills
Combining any central nervous system depressant—think OxyContin, Xanax, alcohol or heroin—with any other is a recipe for disaster. Their additive effects suppress breathing, and you might not notice. “Your brain has a reward system that tells you if you’re getting high, and then it has a system that controls your breathing that’s located in the brainstem, and the two centers do not necessarily talk to each other,” says Dr. Lee. “Trying to gauge how much you use based on how you feel is going to be deadly.” So why these three? In addition to the extremely addictive properties of benzos, sleeping pills and painkillers, this medley is particularly nasty because of its sheer prevalence: a 2010 study found that hospitalizations in the US for poisoning by these three drug types increased by 65% from 1999 to 2006.
•Multiple prescription painkillers
Another in the multiple-depressant category, this one is again due to likelihood of respiratory failure and the high incidence of addiction. “Narcotics used for pain are not very effective after about six weeks," says Dr. Lewis-Younger. "We see people adding drugs all the time, or increasing the amounts they’re taking over what’s been prescribed.” Also, the perception that all pills prescribed by a doctor are safe can give users a false sense of security. Very false, it turns out: while cocaine was the leading cause of unintentional overdoses as recently as 1999, it has since been left far behind by prescription opioids. In fact, in 2007, opioids were involved in more overdose deaths than cocaine and heroin combined.
•Tylenol 3 and over-the-counter Tylenol
Tylenol doesn’t sound so scary—heck, doctors give it to babies—but it contains acetaminophen, which can be extremely toxic to the liver in high doses. That’s bad to take with any drug, but if you mix it with an addictive opioid—like Tylenol 3 with codeine—your liver is going to take a beating. According to a 2005 study from the University of Washington Medical Center in Seattle, 38% of people who developed acute liver failure because of accidentally ingesting too much had taken more than one kind of pill—and 63% had taken a pill that contained both acetaminophen and an opioid. You can't be too careful.