Brittany Murphy's medications and their interactions

A note of follow up:  According to TMZ, a variety of medications were found in Brittany Murphy’s apartment under her name and under the name of her husband and mother.  Of course it is possible that the medications actually belonged to her husband and to her mother– but as you read in my last post, I am not surprised that opiates were included on the list.  THe medication list:

Brittany Murphy used dangerous medication combinations
Was her death related to dangerous medication combinations?

1.  Topamax.  Topamax is an anticonvulsant that is also used to treat migraine headaches, and sometimes prescribed as a mild ‘mood stabilizer’–  say for someone who has symptoms of bipolar disorder but who instead has borderline personality or just ‘mood swings’ that don’t quite qualify as full blown bipolar disorder.  The medication is favored by some patients, particularly women with eating disorders, because unlike more effective mood stabilizers like Depakote (valproic acid), Topamax (generic name topiramate) causes weight loss instead of weight gain.  It has the nickname ‘dopamax’ because it can reduce cognitive function to a mild extent.
2.  Methylprednisolone.  This is a steroid anti-inflammatory medication, and I have no idea why she may have been taking it, if she was at all.  It is used to treat severe asthma, rheumatoid arthritis, and a wide range of autoimmune or allergic disorders.  It will create a brief euphoria in some people, and can also cause depression, mania, and even psychosis in others.  It tends to cause significant weight gain if taken for a long period of time.
3.  Fluoxetine.  Also known as Prozac, the well-known SSRI used to treat depression and anxiety (and to a lesser extent mood symptoms and irritability related to ‘periods’ in women).  Tends to decrease appetite slightly;  there is an ‘internet fad diet’ called ‘phen-pro’ which is a combination of phentermine (one of the phen-fen drugs from the heart-damaging diet of a few years ago) with fluoxetine.  Fluoxetine and other SSRIs are generally safe medications, but fluoxetine in particular can reduce the liver’s ability to metabolize some other medications, making the other medications more potent.
4.  Klonopin.   AKA clonazepam, a long-acting benzodiazepine (meds in the Valium or Xanax family).  These medications almost always start out small and become big problems in people with addictive tendencies, as I write here in my psychiatry blog.  They are great for short-term anxiety– say for a couple weeks for a death in the family.  But the person quickly becomes tolerant to the medication and then needs to take it to feel ‘normal’, eventually needing it all the time.  Benzos turn managable anxiety into an ‘anxiety disorder’.  They are also potent respiratory depressants when combined with opiates, and are often half of the equation in the case of overdoses.  They work at brain receptors that are also affected by alcohol, making them essentially ‘brandy in pill form.’  Do yourself a favor, and just say ‘no’ to benzos.  One last thing– the way that they block ‘anxiety’ is through their action as ‘amnestics’– they block the formation of memories.  A drug called ‘versed’ is widely used for dental work or colonoscopies to block memory;  that is what clonazepam and alprazolam (Xanax) do.  You can’t worry about what you cannot remember!
5.  Carbamazepine.  Also known as Tegretol, this medication is an anticonvulsant similar to Topamax but one that is potent enough to actually work for bipolar disorder and seizure disorders.  It is also prescribed for some chronic pain conditions, including a very painful facial condition called trigeminal neuralgia.   Not particularly dangerous with opiates except for effects at the liver where it also blocks or increases the metabolism of other medications in an unpredictable fashion.  It can have other uncommon but serious side effects on blood components.
6.  Ativan.  Also known as lorazepam, this is another benzodiazepine.  Works just like clonazepam but with a shorter duration of action– the half-life of lorazepam is about 12 hours and the half-life of clonazepam is 2-3 times longer.  Again, a lousy, addictive medication that is a disaster in people with addictions.
7.  Vicoprofen.  Ibuprofen combined with the opiate hydrocodone, which is a moderate-strength narcotic.  People who take opiates long term become used to them, and have to keep taking them to avoid withdrawal– as all readers here probably know!
8.  Propranolol.  This is an old, cheap medication used to treat a number of things.  It is a ‘beta blocker’, meaning it blocks the actions of adrenaline at ‘beta receptors’ at the heart and other brain regions.  It used to be used commonly for high blood pressure, but now many better medications are available.  It is used to prevent migraines, and to block the feeling of adrenaline in a person’s body– so it will be used in prisons as a non-narcotic medication to treat panic attacks or anxiety.  It is commonly used by musicians, politicians, and public speakers to help them feel calm during presentations or public appearances.  For example it will stop that ‘rush’ in a person’s chest, stop the hands from shaking, stop the heart from racing or pounding, and reduce the husky voice some people get when nervous.
9. Biaxin.  An antibiotic also known as Clarithromycin, used to treat a wide range of bacterial infections including acne, sinus infections, bladder infections… again, an old medication with many better modern substitutes.  The use of the medication is limited by the fact that similar to many of the other medications in this list, it interacts with many other medications, making the other medications more or less potent than intended.  The medication can also cause potentially fatal heart arrhythmias, particulary in combination with STEROIDS, such as the methylprednisolone on the list.
10.  Hydrocodone.  Not needing much explanation for readers of this web site, hydrocodone is a moderate-strength opiate narcotic.  It is a component of the Vicoprofen described above.  Like all opiates, it initially works very well to relieve pain.  Some people, though, find that it ‘fits’ very well;  it makes them feel whole, loved, happy, content, warm… at least for a little while.  It works just like heroin, but has a lower potency so more hydrocodone is required– but if enough is taken the same effects will occur.  The person becomes tolerant to hydrocodone fairly quickly, resulting in withdrawal if the medication is discontinued.
All in all, the medications, if they were all taken by Brittany Murphy, would be consistent with someone being treated for migraine headaches, anxiety or panic, and a mood disorder.  Just guessing, of course… and this would NOT  be the ideal way to treat these conditions.  For example, opiates are lousy ways to treat headaches, especially long-term, probably causing far more headaches than they get rid of.  Propranolol is a relatively harmless med for anxiety (providing the person doesn’t have asthma, which propranolol would aggravate).  If the carbemazepine, fluoxetine, and topamax were being used for a mood disorder like bipolar or a personality disorder like borderline personality, then taking the steroid methylprednisolone would be a risky thing to do, as steroids can cause pretty severe mood effects.
These medications have a number of dangeroud interactions, besides the addictive dangers of several of them both alone and in combination.  For those interested in a more detailed list of the dangerous interactions, I have prepared a list of the med/ med interactions in pdf format using the interactions checker provided by epocrates.
Suboxone Talk Zone

Another one?

I have no idea what killed Brittany Murphy.  The press are reporting that she had a ‘heart attack’ at age 32, not fully understanding the difference between a ‘heart attack’– which typically refers to a heart that stops functioning because of an inadequate suppy of oxygen, usually from coronary artery blockage– vs. ‘cardiac arrest’, a garden-variety term used by coroners who must cite a cause of death without an autopsy, reliable history, or lab results.  We ALL die of cardiac arrest in the end.  Opiate addicts usually suffer respiratory failure, either because of a reduced drive to breathe secondary to the effects of opiates at the brainstem, or because of a ‘blocked airway’ caused by stomach contents gettting into the throat and/or trachea.  The respiratory failure ultimately leads to too little oxygen at the heart, causing the heart to either stop beating or to go into an erratic beating pattern called ‘V-Tach’ or ‘V-Fib’, eventually failing to keep blood flowing to the rest of the body– particularly the brain.

Britttany Murphy with USO, July 2009
Britttany Murphy with USO, July 2009

Reports of Brittany’s death have mentioned that ‘prescription medications’ were found at the scene.  The phrase ‘prescription medications’ is usually code for ‘pain pills.’  And since the death rate for opiate addicts is so high, I am going out on a limb in a BIG way.  I am not trying to make a prediction– only to eventually make a point about opiate addiction, admitting that I may be making the point prematurely.
Britttany Murphy was rumored to have an eating disorder and an addiction to cocaine.  I don’t mean to impugn her character, and hopefully anyone who reads my blog understands that addiction is a disease that NOBODY asks for or deserves.  My concept of addiction would include an eating disorder, by the way.  I am sure that readers have a hard time understanding where I draw lines of responsibility;  I often write from a stance requiring ‘personal responsibility,’ so where do I get off, you ask, painting Brittany Murphy as a victim?  My answer is that it is possible to be everything at once.  We are all responsible for maintaining the behavior necessary to keep ourselves alive.  But there are times when we fail– all of us.  And most people who ‘fail’ and as a result become addicted to drugs face penalties constantly from that point forward– very rapidy getting to a point where we have been punished enough.  IF Brittany Murphy died from complications related to addiction, her death would be on top of the many evenings of misery she already endured– waking up early shaking with chills, running to the bathroom with diarrhea, missing parties at the last minute because of being too sick to go, and the demoralization that comes from looking in the mirror each morning and seeing that pathetic, failure of a person looking back.  Sometimes we look at celebrities and picture the moments when flashes are going off and the person is mugging for the cameras.  But from the moment this morning when I heard that Britttany Murphy had died, I felt (again, perhaps incorrectly) as if I know her very well.  I know how she felt each morning.  I know the relief she felt when certain people ‘came through’ for her.  I know how she felt about having a double personality– that all of her fans thought she was this great person, and deep inside she felt like a liar for keeping her secret from them.  I know how she felt when things looked hopeless– when she thought there was no possible way to escape.  I know how she felt when she was alone with the bathroom door closed and locked, wishing that things would just end without ever taking another step outside that safe little space.

If I am wrong, I am sorry– and I am thinking about someone else who is one of thousands of people who think exactly alike about a few deeply-personal things.  If I am right, I’m sorry that the long list got a little longer with the name of someone so obviously special.