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June 10, 2007

Lethal liniment overdose?

How is it possible to die of excessive topical wintergreen exposure? Was this risk known to the medical community prior to the untimely death of a New York teen? Or is this a previously unknown phenomenon?

NEW YORK -- The sudden death of a Staten Island high school track star was caused by the accidental overuse of over-the-counter remedies routinely used by millions of Americans to treat sore muscles and joints, the city medical examiner ruled after a two-month probe.

Arielle Newman, 17, a cross-country runner, died April 3 after her body absorbed lethal levels of methyl salicylate, a wintergreen-scented ingredient found in sore muscle treatment products like Bengay, Icy Hot and Tiger Balm.

In addition to spreading the muscle cream on her legs between track meets, Newman was using adhesive pads containing the anti-inflammatory, plus an unspecified third product with the chemical, said Ellen Borakove, spokeswoman for the medical examiner.

"There were multiple products, used to great excess, and that's how she ended up with high levels," Borakove said. The products were used and the chemical absorbed over time, rather than from a single instance of overuse, she said. [AP]

I hope this tragedy raises awareness about the potential risks of these common OTC products when used in excess.

As several commenters have pointed out, below, the dose makes the poison.

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Comments

I was just as surprised as you when I first read this story, Lindsay. I've heard of people severely injuring themselves from using these products when weight training, i.e., the cream sufficiently masked the pain of injured muscles and/or tendons to where a person trained so hard that they tore muscles and/or tendons during work outs. However, I've never heard of anything like this.

Is there a doctor in the house? Please explain this phenomenon in a relatively educated layman's terms. And is there anything else in my medicine cabinet I should be scared of? Besides the usual suspects, that is. Which is probably EVERYTHING, I suppose.

We shouldn't forget the 'unspecified third product' which may well have been an analgesic containing salicylate (such as Aspirin). Thousand of annual deaths in the UK are caused by over the counter remedies such as Ibuprofen and Aspirin, although these tend to be from chronic over-use.

Actually, oil of wintergreen is an extremely potent source of the salicilate ion, the pharmaceutically active component of asprin. It's very uncommon to find it sold as an extract in a grocery store or elsewhere because the potential for overdose is fairly high. I could give you the asprin equivalency by weight but that would require scouring through some old class notes. You could probably find more info on Wikipedia or via Google. Anyway, rather than question the safety of the product, perhaps the public should be concerned with the labeling of the product or why people can't follow directions. I'm not trying to take anything away from what was a tragic occourance, but improper use of Rx and OTC products is all too common. Even one tragic case per year is one too many.

As Mike Power notes, there are aspirin overdoses every year (in the U.S. too). I'm actually (and pleasantly) surprised this hasn't happened sooner.

Note: methyl-salicylate is chemically related to acteyl-salicylate (which is aspirin).

In college, they taught me that everything is toxic in too great a dosage. You can misuse anything. Hell, everyone knows the narcotic effects of cold medicine, Nutmeg, and morning glory seeds, and yes, some types of mints. I don't know if this kid was using this stuff as a performance enhancer or as to get high, but either way it's more important to keep people from overdosing on stuff like that than to pretend kids don't know it'll get you stoned. People need to be taught that "over the counter" doesn't mean "completely harmless".

Salicylates are well-known to be a frequent cause of toxicity and are on the classic list of ingested toxins that medical students have to memorize (the mnemonic is MUDPILES—the S is for salicylates)

As far as toxicity from topical application goes, apparently there are a few case reports in the literature:

Salicylism from topical salicylates: a review of the literature

And the risk of this has been demonstrated in the laboratory:

Serum concentrations of salicylic acid following topically applied salicylate derivatives

As soullite points out, anything is lethal given a high enough dosage. Consider that water intoxication is a known phenomenon, for example.

Whenever I read a story like this, I think about how awful it must be to know that someone you love died from a stupid and completely preventable cause.

Regarding labeling and reading directions, I think one of the problems is that all OTC drugs come with so many fine print warnings that it's hard to sort out the really important. People do have a cavalier idea about OTC drugs, assuming that they're safe even at many times the recommended dose.

Overuse of salicylates such as aspirin can dangerously thin your blood. Yes, doctors frequently recommend one aspirin per day for heart health. The key word here is "one." Also, asthmatics should avoid aspirin as it's a known trigger.

Personally, I have to avoid salicylates as best I can as they interfere with the most effective medication I take for a currently incurable chronic illness. From this I have learned that salicylates are found in high concentrations in the leaves and often the fruit of every damn think that grows. Your herbal shampoo and for that matter almost every other shampoo has salicylates in it. Your moisturizer, shaving cream, dish soap, hand soap, bar soap, Pepto Bismul, vitamins, makeup, etc. has salicylates in 'em. Even foods like yogurt, avaocados, apples and others have a high concentration too. I can't walk on grass barefoot and must wear gloves when gardening or cooking with herbs. With practice I've been able to get by pretty well.

My point isn't poor, poor pitiful me. It's that salicylates are everywhere in our everyday life. If, as an athlete likely would, this young woman was eating a healthy diet chock full of veggies and fruits plus taking a lot of showers, using moisturizers, makeup, etc., and overdoing it with Ben Gay and Tiger Balm, I can understand how such an unlikely thing could possibly happen.

Regardless, this is so very tragic. My heart goes out to Ms. Newman's family.

AF

FYI, Aspirin i.e. Salicylic acid is derived from willow bark and can also be isolated from the herb meadowsweet.

AF

as one of Arielle's closest friends, I can vouch for the fact that I never saw her use it more than at a track meet, which is once a week, and only before races. she was just a little petite, sensitive girl. but she was strong and muscular and a powerhouse at that.

so this proves it was a freak accident. you do not just lather that stuff on like lotion every day. granted I didnt watch her moves every day, but i did see her, and i know people who use it a lot more than she did.

please keep your prayers with her family!

Natalie, I'm very sorry for your loss.

We live toxic lifestyles. We die by them as well. I'm gonna go take a chlorine and fluoride shower -- I do so every day.

Hey, Nat -- I posted the toxic lifestyle comment before reading the other comments (including yours.) Didn't mean that post in a cold or twisted way, it just looks bad right under yours and LB's. It's a tragedy. Hang in there.

Nathalie,

Again my deepest, sincerest sympathies to those who knew and loved Arielle.

One of the things I've learned from my illness is that while we as a species share so much, there is also much that is specific to each of us as individuals. Our metabolisms, allergies, sensitivities, diets, habits, regimens, etc., are why seemingly similar folks can have such a wide range of reactions (or not at all) to OTC preparations, drugs and what have you.

We all could stand to be much more mindful of what we put in and on our bodies. Even so that cannot prevent such a rare occurrence.

AF


"Aspirin i.e. Salicylic acid is derived from willow bark"

It came from willow bark when Galen suggested its use to the Roman Emperor Marcus Aurelius and it came from willow bark when the bankrupt John Bayer first began to produce it in Germany. However, since 1897, it has been synthetically created. No willow trees are involved in modern production.

An overdose? Or an allergy? Or a poisoning?

If it's an overdose, then the manufacturers aren't liable.

Wasn't there another death last year when another track and field athlete died from wrapping herself in plastic wrap after applying ointment?

Skin needs to breathe.

This reminds me of the discussion the public recently had about children's medicines that doubled ingredients - so parents were double-dosing their kids unwittingly with, I think, acetaminophen. We do indeed live toxic lifestyles.

If the "unspecified third product" was a chemical vehicle to promote absorption (eg DMSO, etc), I can imagine quite a flood of the essential oils and analgesics finding their way into this unfortunate person... It's a reminder (as someone pointed out) that "over-the-counter" doesn't mean "non-toxic"-- and that herbal remedies are to be pursued with caution (as the old herbal proverb "if you don't know, go slow" suggests)... ^..^

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