Of OxyContin and Alcohol

I was boredly scrolling through my Twitter feed this afternoon when this caught my eye:

The part about not mixing OxyContin and alcohol is absolutely right.  The part about how people with head injuries should never use it?  Not quite.  First of all, there’s a difference between an acute head injury and a concussion five months ago.  But I’m getting ahead of myself.  This was next:

What’s that link?  Why, it’s the oh-so-reputable Canoe.ca drug fact sheet!  And here’s what the renowned world experts at Canoe.ca had to say that apparently caught Steve’s eye:

Oxycodone should not be taken by anyone who:

– blah blah blah

– has a head injury

– blah blah blah

And then I think he stopped reading.  Yes, Derek Boogaard sustained a concussion on December 9th of last year.  No, the mix of taking oxycodone after having had a concussion five months ago didn’t cause his death.  What caused his death was a mixture of oxycodone and alcohol.

What is OxyContin?

OxyContin is the trade name for oxycodone, which is a synthetic opiate.

What are opiates?

You’ll often hear the terms opiate and opioid used interchangeably.  Technically opiates are natural derivatives of a certain type of poppy, and opioids are the class of drug that binds the opioid receptors in the body.  So opioids as a whole include the opiates (morphine, opium) and the synthetic and semi-synthetic derivatives (oxycodone, fentanyl, methadone, heroin).

What do they do?

Opioids bind to the opioid receptors, which are found in the nervous and GI systems.  These drugs are used for pain relief, cough suppression, diarrhea, sedation and to ease withdrawal from other drugs in the same class.

What’s the big deal?

Opioids have a lot of side effects – sedation, constipation, itching, etc.  Unfortunately, they also have a nasty habit of causing respiratory depression in larger doses or extremely potent forms.  Also unfortunately, someone who has been using opioids for a long time will establish a tolerance, meaning they require higher and higher doses to achieve the same effects.

Where do head injuries fit into this?

In Derek Boogaard’s case, they don’t.  He had a concussion five months ago – he was not dealing with an acute head injury.  The reason “head injured” people shouldn’t have opioids has to do with intracranial pressure (ICP), the potential for respiratory depression with these drugs, and the nasty connection between the two.  The reason I have “head injured” in quotes?  Because we’re talking about people with acute injuries.  Those are the people that will have increased ICP.  Remember there’s a finite amount of space in your head.  If your brain is injured it swells, and since there’s not much of anywhere to go, you get an increase in the pressure inside your skull.

Now remember back to middle school science.  When you breathe, you exchange carbon dioxide for oxygen.  So if you’re taking opioids to the point that you’ve depressed your respiratory drive, you won’t be exchanging gases adequately and you’ll have increased levels of carbon dioxide.

Still with me?

We’re moving on to bigger and badasser science.  Carbon dioxide causes vasodilation in the cerebral vasculature.  Put simply – too much CO2 causes the blood vessels in your brain to dilate.  If you’re head injured and already have or are at risk for increased ICP, the last thing you need is increased CO2.  You’ll have bigger vessels, which means more blood, which means more space occupied, which means even higher pressure.  You’ll be making a bad situation worse and risking your brain trying to find a pressure release, which involves trying to squeeze its way out of the bottom of your skull.  That’s called herniation, and that’s generally deadly.


– Head injury = increased pressure in your head (from bleeding or swelling).

– Lots of opioids = respiratory depression (shallow/slow breathing, or no breathing).

– Respiratory depression = too much CO2

– Too much CO2 = more pressure in your head.

– Not good.

The Boogaard connection

Derek Boogaard’s cause of death was said to be a mixture of alcohol and oxycodone.  There’s not a huge amount of research on the pharmacology/pathophysiology of mixing alcohol and opioids, but they’re both depressant medications and together they’re dangerous.  Some studies suggest that alcohol alters opioid metabolism, resulting in an effectively higher serum concentration, and thus greater effects.  Common sense suggests that if you take two substances that can knock you out, one of which can make you stop breathing, that you’ve got all the ingredients for a terrible outcome.

From a paramedic’s perspective:

Over the years I’ve seen a lot of overdoses that resulted in death.  Most of them were opioid overdoses, and very, very few of them were on purpose.  Heroin addicts with the needle still in their arm,  college kids that got hammered and took too many pills, chronic pain patients with a huge opioid tolerance that fell asleep and never woke up.  People on the street, people in million dollar houses, and people just like you and me.

Before we start judging Derek, we need to stop and realize just how easy (and common) this situation is.  We know he was trying to get help.  We also know from his family’s statement that he’d been dealing with pain for a very long time.  The suggestion that taking oxycodone five months after his concussion was what caused his death minimizes his struggle, and isn’t scientifically based in reality.

Derek Boogaard’s family has asked that donations be made to Defending The Blue Line, a Minnesota charity that helps military kids stay involved in hockey with equipment donations, camps, and grants to cover fees.  Donations may be made online or by mail:

Defending the Blue Line,

c/o Boogaard’s Booguardians Memorial Fund,

1206 N. Frontage Road Suite B, Hastings, MN 55033.

My heart aches for the Boogaard family.  All the best to them.

– Jo