An autopsy conducted on boisterous television pitchman Billy Mays revealed a mix of drugs in his system, including cocaine and several painkillers—hydrocodone, oxycodone, and tramadol. Is there a valid medical reason for taking three medications that do the same thing?
Yes. A doctor might prescribe one medication to treat chronic, baseline pain and another one for a more acute pain that the first drug couldn’t prevent. In unusual circumstances, a third medication might be used to treat another “breakthrough” pain that differs in intensity, duration, or location from earlier symptoms. In these cases, all the drugs could be from the same family of painkilling medications—like those found in the Mays autopsy. Still, taking three such similar medications over a long period is dangerous and unusual.
The presence of cocaine in Mays’ system suggests that he might have been abusing the painkillers. A specialist with experience in dosing heavy-duty analgesics might prescribe this opioid cocktail, but doing so would raise a significant risk of side effects such as nausea, vomiting, constipation, unstable blood pressure, sleepiness, and long-term dependence. And an overdose could quickly lead to respiratory suppression and death (especially since Mays was also taking anti-anxiety medications, which also suppress breathing.) Any responsible doctor who would offer these medications in combination would be testing Mays’ urine regularly to ensure that he was taking the drugs as prescribed. Through these tests, he would have found out that Mays was also taking cocaine. Federal law prohibits doctors from prescribing opioids to patients with uncontrolled substance-abuse problems.
Other sorts of multidrug cocktails are quite common in pain management. Most of the time, the painkillers are not from the same family. Patients often take several medications that work in different ways to improve clinical impact without increasing the likelihood or intensity of side effects. So your doctor might prescribe an opioid like oxycodone—which works by binding to pain-reducing receptors in the brain and spinal cord—in combination with aspirin or ibuprofen—which work by reducing inflammation. Pain medications are also prescribed along with drugs that are not technically painkillers themselves but that enhance the effects of opioids. These are called “adjutants,” and include antidepressant and anticonvulsive medications. (Tramadol itself takes advantage of this synergy. It has two mechanisms, operating as both an opioid and a mild antidepressant.)
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Explainer thanks Scott M. Fishman of the American Academy of Pain Medicine.
