Ingestions of Hydrocodone, Carisoprodol, and Alprazolam in Combination Reported to Texas Poison Centers
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Journal of Addictive Diseases, 30:110–115, 2011
Copyright c Taylor & Francis Group, LLC
ISSN: 1055-0887 print / 1545-0848 online
DOI: 10.1080/10550887.2011.554778
Ingestions of Hydrocodone, Carisoprodol, and Alprazolam
in Combination Reported to Texas Poison Centers
Mathias B. Forrester, BS
ABSTRACT. The combination of hydrocodone, carisoprodol, and alprazolam is subject to abuse.
Ingestions of this drug combination reported to Texas poison centers during 1998–2009 were identified
(totaling 1,295 cases) and the distribution of ingestions by selected factors was determined. The number
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of cases increased from 0 in 1998 to 200 in 2007, and then decreased to 132 in 2009. The counties in
eastern and southeastern Texas accounted for 80.9% of the cases. Of the patients, 57.3% were women
and 94.6% were age 20 or older. Suspected attempted suicide accounted for 59.3% of the cases and
intentional misuse or abuse for 27.3%.
KEYWORDS. Alprazolam, carisoprodol, hydrocodone, poison center
INTRODUCTION known by the brand name Soma (Meda Pharma-
ceuticals, Inc., Somerset, NJ). Alprazolam is a
Abuse of prescription drugs is increasing in prescription anti-anxiety medication known by
the United States. Rates of overdose deaths the brand name Xanax (Pfizer, Inc., New York,
involving prescription drugs increased during NY).5,6 Taking these three drugs in combina-
1999–2006.1 Emergency department visits in- tion is not usually medically justified.6 When
volving the nonmedical use of opioid analgesics taken together, these medications may give users
increased during 2004–2008.2 There has also a feeling of euphoria similar to heroin.5,7 As a
been an increase in prescription drug abuse result, this prescription drug combination, which
among adolescents.3,4 may be referred to by such slang terms as “Hous-
Hydrocodone is a prescription narcotic pain ton Cocktail,” “Holy Trinity,” or “Trio,” is sub-
reliever sold alone or in combination with other ject to abuse and has resulted in deaths.5−7
medications known by the brand names Vi- All three of these medications are often dis-
codin (Abbot Laboratories, North Chicago, IL), pensed at pain management clinics, some of
Lorcet (Forest Pharmaceuticals, St. Louis, MO), which have dubious prescribing practices.5 The
Lortab (Mallinckrodt Inc., Hobart, NY), and city of Houston, Texas, has been reported to
Norco (Watson Pharmaceuticals, Corona, CA). have become a national sales hub and regional
Carisoprodol is a prescription muscle relaxant distribution center for the drug combination.6,7
Mathias B. Forrester is affiliated with the Texas Department of State Health Services, Austin, TX.
Address correspondence to: Mathias B. Forrester, BS, Environmental Epidemiology and Disease Reg-
istries Section, Texas Department of State Health Services, 1100 W 49th Street, Austin, TX 78756 (E-mail:
mathias.forrester@dshs.state.tx.us).
Funding for this research was provided by a contract with the Commission on State Emergency Commu-
nications in Texas. The author would like to thank the staff of the six poison control centers of the Texas
Poison Center Network (Central Texas Poison Center, North Texas Poison Center, Texas Panhandle Poison
Center, South Texas Poison Center, Southeast Texas Poison Center, West Texas Regional Poison Center) who
collected the data.Mathias B. Forrester 111
According to the Texas Department of Public site, final medical outcome, and most commonly
Safety Prescription Program, more than 144,000 reported adverse clinical effects were evaluated
prescriptions for the drug combination were dis- for total cases and those cases not involving
pensed in Texas in 2009, 70% of which came coingestants.
from Harris County, where Houston is located.6 The caller county is the county from which
Review of the literature failed to find pub- the call originated. If the call originated from
lished data on ingestions of this drug combi- a health care facility, then the caller county
nation. The intent of this investigation was to was recorded as the county where the health
describe the pattern of ingestions of this drug care facility was located and not necessarily
combination reported to Texas poison centers. where the patient resided. Texas poison center
agents often do not collect information on the
patient’s residence if it differs from the caller’s
METHOD location.
The final medical outcome is assigned by the
This retrospective study used data from agent managing the case and is based on the
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the Texas Poison Center Network (TPCN), a known or expected adverse clinical effects. Med-
statewide poison center system comprised of ical outcome is classified according to the fol-
six poison centers that service the entire state. lowing criteria: no effect (no symptoms due to
Texas poison centers receive calls from the pub- exposure), minor effect (some minimally trou-
lic, health care providers, and law enforcement blesome symptoms), moderate effect (more pro-
on how to manage potentially adverse exposures nounced, prolonged symptoms), major effect
and for information requests. These calls cover a (symptoms that are life threatening or cause sig-
variety of substances, such as medications, illicit nificant disability or disfigurement), and death.
drugs, home and industrial chemicals, plants, an- A portion of exposures cannot be followed to a
imals, and food. All of the Texas poison centers final medical outcome because of resource con-
use a single electronic database to collect demo- straints or the inability to find subsequent infor-
graphic and clinical information in a consistent mation on the patient.
manner. The data field definitions and allowable The Texas Department of State Health Ser-
variables are defined by the American Associa- vices institutional review board considers this
tion of Poison Control Centers. investigation exempt from ethical review.
Cases were all ingestions reported to
the TPCN during 1998–2009 that included
hydrocodone, carisoprodol, and alprazolam.
Multiple-drug formulations that included the TABLE 1. Number of Ingestions of Hy-
medications of interest were eligible for in- drocodone, Carisoprodol, and Alprazolam in
clusion. For example, Vicodin contains ac- Combination Reported to the Texas Poison
etaminophen in addition to hydrocodone and Center Network During 1998–2009
would be eligible for the study. Ingestions in-
volving just one or two of the medications Year Number
of interest were excluded from the investiga-
1998 0
tion; an ingestion must involve all three of the 1999 0
medications. 2000 47
The distribution of cases was calculated for 2001 70
year, caller county, patient gender and age, cir- 2002 76
2003 105
cumstances of or reason for the ingestion, expo- 2004 160
sure site, presence of coingestants, management 2005 168
site, final medical outcome, and most commonly 2006 187
reported adverse clinical effects. Because the 2007 200
2008 150
presence of coingestants might affect the man- 2009 132
agement and outcome of a patient, management112 JOURNAL OF ADDICTIVE DISEASES
FIGURE 1. Ingestions of hydrocodone, carisoprodol, and alprazolam in combination reported to
the Texas Poison Center Network during 1998–2009 by caller county.
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Number of cases
60-434
38-59
15-37 Houston
(Harris County)
6-14
1-5
0
RESULTS The distribution of cases by patient gender
was 742 (57.3%) female, 548 (42.3%) male, and
A total of 1,295 ingestions of the drug com- 5 (0.4%) unknown. Sixty-three (4.9%) of the
bination were reported to the TPCN during patients were aged 0 to 19, 1,225 (94.6%) were
1998–2009. This represented 3.9% of the 33,365 age 20 and older, and 7 (0.5%) were of unknown
hydrocodone, 9.3% of the 13,946 carisoprodol, age. Of those adult patients with a known age, the
and 4.7% of the 27,598 alprazolam ingestions mean age was 37 years (range: 20 to 79 years).
reported to the TPCN during this time period. The distribution of ingestions by the circum-
Table 1 presents the annual number of inges- stances of the ingestion were 768 (59.3%) sus-
tions. No ingestions were reported in 1998 or pected attempted suicide, 354 (27.3%) inten-
1999. The number of ingestions increased each tional misuse or abuse, and 173 (13.4%) other
year during 2000–2007 then decreased during and unknown circumstances. The exposure site
the following 2 years. was 1,171 (90.4%) in the patient’s own resi-
The caller county was known in 1,289 of the dence, 38 (2.9%) in a public area, 15 (1.2%)
ingestions. Figure 1 shows the number of cases in another residence, 4 (0.3%) in the work-
by caller county. Harris County accounted for place, 4 (0.3%) in a health care facility, 3
434 (33.7%) of the cases. Texas Public Health (0.2%) in a restaurant or food service facility,
Regions 5 and 6, the counties in eastern and 2 (0.2%) in a school, 13 (1.0%) in an unspec-
southeastern Texas, accounted for 1,043 (80.9%) ified other site, and 45 (3.5%) in an unknown
of the cases. site.Mathias B. Forrester 113
Substances other than products containing DISCUSSION
hydrocodone, carisoprodol, or alprazolam were
reported in 484 (37.4%) ingestions. The most This investigation examined the pattern of
frequently reported other substances were alco- ingestions of a combination of hydrocodone,
hol (n = 118), diazepam (n = 35), cocaine (n = carisoprodol, and alprazolam reported to Texas
33), zolpidem (n = 29), quetiapine (n = 25), poison centers. There is little published infor-
oxycodone (n = 21), marijuana (n = 20), and mation on the demographics and outcome of
trazodone (n = 20). ingestions of this drug combination. Abuse of
Table 2 contains the distribution of cases by this drug combination appears to be a particular
management site, final medical outcome, and problem in Texas.
most frequently reported adverse clinical effects. Reporting of exposures to the TPCN is gener-
The majority of patients was already at or en ally voluntary. However, in 1999 the 76th Texas
route to a health care facility when the poison Legislature passed Texas Health and Safety
center was contacted. A small number of patients Code 161.042, which requires physicians to
were managed on site (e.g., at home). Few pa- report overdoses of controlled substances in
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tients were known or expected to have no effects. Penalty Group 1 of the Texas Controlled Sub-
The most commonly reported adverse clinical stances Act to the Texas Department of State
effects affected the neurological, cardiovascu- Health Services. It was decided that this re-
lar, and respiratory systems. The distribution of porting would occur via the TPCN. Accord-
cases with and without coingestants was similar. ing to Texas Health and Safety Code 481.102,
TABLE 2. Ingestions of Hydrocodone, Carisoprodol, and Alprazolam in Combination Reported to
the Texas Poison Center Network During 1998–2009 by Selected Variables
All Cases Cases Without Other Coingestants
Variable Number % Number %
Management site
Already at/en route to health care facility 1,213 93.7 767 94.6
Referred to health care facility 68 5.3 40 4.9
On site 12 0.9 3 0.4
Unknown 2 0.2 1 0.1
Final medical outcome
No effect 109 8.4 68 8.4
Minor effect 550 42.5 355 43.8
Moderate effect 313 24.2 188 23.2
Major effect 146 11.3 84 10.4
Death 9 0.7 8 1.0
Not followed - minimal effects expected 20 1.5 14 1.7
Not followed - potentially toxic 144 11.1 93 11.5
Unrelated effect 4 0.3 1 0.1
Most common reported clinical effects
Drowsiness 845 65.3 531 65.5
Slurred speech 271 20.9 169 20.8
Tachycardia 179 13.8 98 12.1
Coma 168 13.0 97 12.0
Respiratory depression 113 8.7 69 8.5
Confusion 111 8.6 67 8.3
Agitation 79 6.1 39 4.8
Hypotension 70 5.4 43 5.3
Hypertension 66 5.1 31 3.8
Ataxia 58 4.5 31 3.8
Total 1,295 811114 JOURNAL OF ADDICTIVE DISEASES
hydrocodone is in Penalty Group 1, although health care facilities, which are primarily likely
carisoprodol and alprazolam are not. It is not to see ingestions when the patient is experiencing
known how thoroughly physicians comply with some adverse effect to the drug combinations.
Texas Health and Safety Code 161.042. Varia- Exposures to the illicit drugs cocaine, heroin,
tions in compliance might bias the results of the and marijuana that were reported to Texas poi-
study. son centers exhibit a similar pattern with re-
No ingestions of the drug combination were spect to management site and final medical
reported to TPCN prior to 2000. Afterward, the outcome.8
number of reported ingestions increased each The most frequently reported adverse clinical
year through 2007 then decreased in 2008 and effects were neurological (drowsiness, slurred
2009. One potential explanation for the recent speech, coma, confusion, agitation, ataxia), car-
decline is that a new Texas monitoring require- diovascular (tachycardia, hypotension, hyper-
ment went into effect in 2008. According to tension), and respiratory (respiratory depres-
this requirement, pharmacies now reported all sion). These particular clinical effects have been
prescriptions that physicians wrote for these reported with the individual drugs in the combi-
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controlled substances. Investigators used these nation, with some of the same effects reported
records to examine pain management clinics to with more than one of the medications.9
identify individuals who were writing large num- Ingestions of hydrocodone, carisoprodol, and
bers of prescriptions for the drug combination, alprazolam in combination reported to Texas
and prosecutions of physicians occurred.5 poison centers have been increasing until the
Eighty-one percent of the ingestions were re- past few years. The majority of ingestions were
ported in eastern and southeast Texas, and the reported from eastern and southeastern Texas,
county with the highest number of ingestions with the highest number of ingestions reported
was Harris County, where Houston is located. from Harris County. Most of the patients were
This is consistent with reports that Houston has female, adult, and managed at a health care fa-
become a national sales hub and regional distri- cility and their use of the combination of drugs
bution center for the drug combination.6,7 This resulted in some sort of adverse clinical effects,
suggests that TPCN data may be useful for track- particularly neurological, cardiovascular, or res-
ing where prescription drug abuse is occurring piratory.
in the state.
Eighty-seven percent of the ingestions were
reported to have occurred as a result of suspected
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