Deadly Combinations

Read This First

Most people who die from a dangerous drug combination never knew they were taking one. The painkiller, the sleeping tablet, the cold remedy, the herbal capsule and the drinks were each fine on their own. Together, they stopped someone breathing in their sleep. This book exists so that doesn't happen in your house.

Who this book is for

• Anyone who takes more than one thing: prescriptions from different doctors, painkillers and cold remedies from the chemist, herbs and supplements, alcohol, party drugs or gym drugs.
• Anyone looking after a parent's or partner's pillbox.
• Anyone who has ever thought, "It's from a pharmacy, so it must be fine with my other tablets."

What this book will and won't do

It will show you the combinations most likely to stop your breathing, damage your liver, crash your blood pressure, upset your heart rhythm, make you bleed or make your contraception fail. It will tell you what going wrong looks like, when to get emergency help, and the exact questions to ask a pharmacist or doctor. It ends with one simple system to keep your household safe: the One-List System.

It won't tell you to start, stop or change any medicine on your own. Stopping some medicines suddenly is dangerous in itself. It won't give you doses or "safe" combinations for anything. And it is general health information, not medical advice. It can't replace an assessment by someone who knows your health and can see everything you take.

Danger now?

If someone can't be woken, is breathing slowly, noisily or not at all, has blue or grey lips, has chest pain or has fainted, is very hot, rigid and confused, is vomiting blood, or has taken more paracetamol than the pack allows (even if they feel fine):

Call your emergency number now. In Kenya, 999, 112 or 911 . In the UK, 999. In the US, 911. If you're not sure, call anyway.

The full list of emergency signs is on the Go Now card at the back of this book. Find it now and take a photo of it on your phone.

How to read it

Chapters 1 and 2 are the foundation: how dangerous mixes happen in ordinary homes, and the four patterns behind almost all of them. Read those first.

Chapters 3 to 10 each cover one family of dangerous combinations: breathing, hidden double doses, the heart, serotonin, blood thinners, contraception, herbal products and party mixes. Jump to the ones that match your house.

Chapter 11 is for anyone caring for an older relative. Chapter 12 and the back pages give you the One-List System and the Go Now card.

The stories in this book

Where we describe a real person, the details come from a public record: a coroner's report, a regulator's notice or a published medical case report, and we cite it. Where we describe an everyday scene to illustrate a point, it is a composite. Some stories are composites; names and details are changed. A composite never carries a statistic, a named real clinic or a quote from a real person.

About this book

This book is educational. It is not medical advice, and it is not a substitute for a clinician who knows your history. If you have warning signs now, use the Go Now card or call your local emergency number. For everything else, take the questions in this book to a doctor, nurse or pharmacist.

Before you start

Find the Go Now card at the back. Save a photo of it on your phone, and send it to one person you live with.

How Mixing Happens

It's late. Your back has been bad all week and now a cold is coming on. You open the bathroom cabinet. There's the painkiller the GP gave you, a flu sachet you picked up at the chemist, the sleeping tablet your sister handed you "for a bad night", and the glass of wine you brought upstairs.

You've taken every one of those before. Not one of them has ever hurt you. So you take what you need, you go to bed, and you don't give it a second thought.

That is how most dangerous mixes happen. Not at a party, not on purpose, not with anything exotic. In a bathroom, with things a doctor or a pharmacy gave you, each of them safe on its own.

Sound familiar?

• You've seen two different doctors this year, and neither asked what the other one prescribed.
• You've bought something at the chemist and nobody asked what else you take.
• You've never mentioned the herbal tea, the supplements or the drinking to a doctor, because it didn't seem like "medicine".
• You've taken a leftover pill from an old prescription, or one a family member gave you.
• You've had a drink "on top of" a medicine, because the warning on the pack didn't seem to mean you.
• You couldn't name the active ingredient in half the medicines in your house.

If you ticked even one, this book is for you. Every one of those habits is a route by which two harmless things end up in your body at the same time. Most of the time nothing happens. Sometimes the combination slows your breathing in your sleep, quietly overloads your liver, or makes a prescription stop working. Nobody planned it. Nobody noticed. That's the danger.

The One Thing

Nobody else is holding your whole list. Each doctor, the chemist and the herbalist sees one piece of what you take. The only person who sees all of it is you. So the only person who can stop a dangerous mix, most of the time, is you, or someone holding your list.

A man with several prescribers

Kenneth Daly was 51 and lived in London. He'd had chronic pain in his lower back and legs since an accident in 2000, along with nerve damage, a degenerative spine, heart disease and anxiety. The pain affected his whole life. The coroner's report on his death, published in 2019, lists what he was prescribed: strong opioid painkillers, pregabalin for nerve pain, an antidepressant, an antipsychotic, and two benzodiazepines, diazepam and temazepam.

His GP referred him to a pain specialist, with the aim of cutting down his opioids. In July 2018 the specialist decided he should stop his fentanyl patches and switch to morphine, with co-codamol (codeine plus paracetamol) for bad days. The specialist's view, given later in evidence, was that no other opioids should be taken alongside these. That advice went to the GP in a letter. But the coroner found the letter's wording about his other painkillers "less clear", and the GP practice went on issuing dihydrocodeine and tramadol, two more opioids, at lower amounts than before .

On 4 December 2018, Mr Daly was found dead at home. Toxicology found ten different medicines in his blood. The report also says he had taken more than the prescribed amount of several of them. The toxicologist explained that morphine, dihydrocodeine and codeine belong to the same class and their effects add together, that the main danger of that class is suppressed breathing, and that pregabalin, diazepam and temazepam all make that effect stronger.

The coroner's concerns are the part to read twice. Mr Daly was copied into the specialist's letter, but, in the coroner's words, "he was not given any written advice regarding the risks of using multiple opioid medications in combination".