This is such an awful situation and I certainly am sorry for your loss.
What exactly made them claim it was heroin? Was it a morphine metabolite autopsy finding along with acetylcodeine and noscapine in the system? The combination of the three indicates that it indeed was heroin, in this case probably processed by an NGO such as the Mexican or Colombian cartels or the Taliban or someone else, and not pharmaceutical narcotics like Sevredol, MS-Contin, Percodan, Tylenol With Codeine Nº 4 or other paracetamol with codeine, Synalgos DC, and the like, and also not diamorphine, which is pharmaceutical heroin, which is used in several countries because it is 1.8 to 2.7 times stronger than morphine and extremely water-soluble so they can give it in very small shots. Morphine metabolites and noscapine without acetylcodeine points to a form of whole opium, which could be anything from poppy seed tea to the Big O itself.
If she was supplementing a prescription with putative Xanax sourced on the street, which is the kind of thing that legitimate pain patients with legitimate narcotic prescriptions including the late Prince and many others have been forced into doing because of the malfeasance of the government threatening doctors into cutting back or cutting off patients because of the propaganda concerning the fake opioid cri$i$ to line the pockets of rehab owners and go on whatever Satanic power trip makes them think that tormenting people in pain is something they should do, then the reverse could have happened as well. Since benzodiazepines help the same things which can be making pain much worse, narcotics and benzodiazepines overlap clinically, and therefore politically in this case. The Bolshevik government arseholes, to cite just one thing, use the same prescription monitoring databases (also a windfall for the people who demanded them most -- stockholders of companies involved -- why the hell is that not insider trading?) to terrorise doctors about benzodiazepine prescriptions, and it has actually been the benzodiazepines that I first and most frequently heard about pharmacists using the databases to plan their strategy to extort political and more fun favours from doctors and nurses, demand bribes from patients, and work with pharmacy examiners and US attorney's office personnel to collect fees for ratting out people and blackmailing potential candidates for office and journalists.
The usual ingredients of counterfeit pills, or the ones that make the news because they kill people or nonplus folks at crime labs and hospitals, have tended to be fentanyl, other similar narcotics closely related to it, other synthetic opioids which are available for scientific research but have not been made into pharmaceuticals because they have unfavourable properties for that purpose, and other chemicals which are not even opioids -- they could be benzodiazepines, barbiturates or other active drugs not currently used as pharmaceuticals, stimulants, antihistamines, muscle relaxants, veterinary drugs, quinine, Similac, Ex-Lax, mannitol, lactose, confectioner's sugar, ivermectin, jock itch powder, ground up Imodium, vitamin pills, Sudafed, Midol, and other such things, "bath salts" (MPDV and the like) and everything else under the sun . . . of course it is not the best customer service for the people behind this, so there is more to it as I pointed to elsewhere . . .
Since this was a case of alprazolam and heroin being mixed, and there are the issues with mixing the two categories which are known to the medical profession, and here is why people should not do so without extreme caution and diligence:
Depending on the dose, it is anything from forgetfulness to lethal outcomes. The CDC and European Medicines Agency both issued warnings about these mixtures of drugs, as raising the risk of a number of dangerous things for patients, especially the enhanced risk of accidents like falls, in 2010. There are certainly falls which are anything but trivial, by people of all ages, and they can be fatal, of course.
There are legitimate medical uses for mixing the two categories of drugs, and it can be done, almost exclusively at low doses especially of the benzodiazepine, but great caution is needed, and fortunately there are also alternatives.
One has to keep a close eye on their reactions to any benzodiazepine-narcotic combination, as there are a number of problems which can occur, and are not always obvious to the patient that they may be likely, and the matter of confusion and anterograde amnesia aggravates it. At least during induction and adjustment to the combined regimen, having another person watch and be able to assist the patient is important.
Preventing the possibility that the combination will cause the patient to forget what medications were taken then take more is critically important as this is a common mode of dangerous mixed benzodiazepine overdose. Mixed overdoses are almost invariably what kill people with respect to benzodiazepine related overdoses.
The relative low toxicity and the safety of benzodiazepines when used therapeutically by themselves becomes irrelevant when they are mixed with depressant drugs in particular, with other types of depressants like alcohol, barbiturates, carbamates like carisoprodol, meprobamate, and methocarbamol, and other less common ones like non-barbiturate sedative-hypnotics. Mixing multiple benzodiazepines will have additive effects of course -- the canonical benzodiazepine side effects of memory impairment and some impact on co-ordination and movement will be the ones to manifest most clearly, of course.
Anything which slows down the central nervous system can have this kind of general interaction with a benzodiazepine, so it is important to consider anything, including antihistamines, first-generation anti-depressants, muscle relaxants, anticholinergics and so forth also being used at the same time. This also provides opportunities for changing to a less risky drug combination -- if a patient on narcotics also needs something for sleep at bedtime, an antihistamine like hydroxyzine or diphenhydramine can be considered, and these have known interactions with narcotics -- which are generally as potentiators and do such things as broaden the analgesic effect of the narcotic, so they could be a lot better than the benzodiazepine anyways.
Narcotic-benzodiazepine mixtures have legitimate clinical uses and at low doses are safe. Higher doses particularly exacerbate accident risk, with falls being a particular concern; falls are a problem in older patients ipso facto but this enhanced fall risk affects all ages. The fact that there are many narcotics which can cause nausea and vomiting brings into play the possibility that a person who is passed on and laying on their back who vomits could aspirate vomit.
Narcotics, benzodiazepines, and alcohol mixed are very possibly lethal and there is suppression of breathing, circulatory collapse, or vomit aspiration which are direct causes of fatality whilst accidents contribute greatly to injuries and fatalities from mixed benzodiazepine intoxication.
At moderate doses and some low doses of narcotics plus benzodiazepines, the risk of falls in people of all ages begins to climb. Other accidents around the home or office, and driving and heavy machinery of course remain a potential serious problem . . . the patient may overestimate the degree to which they have acclimated to the effects and acquired partial tolerance to the effect. as is common with narcotics. For example, the drowsiness effect of narcotics is the one to which tolerance is acquired most quickly by most people, and it can be reduced to a level where it is quite manageable within a week, even for patients being started on strong narcotics, and most patients on narcotics are cleared by their doctor to drive an automobile and operate machinery after such adjustment has taken place. This seems to be the case to some extent with all drugs which cause drowsiness, including benzodiazepines.
The concomitant use of narcotics, benzodiazepines (often for a tangentially-related issue like insomnia) and carisoprodol is in fact medically legitimate, used successfully, and has been as long as benzodiazepines have been used as carisoprodol is slightly older. This protocol, does, however, markedly enhance the risk of falls and other potential problems so monitoring by the patients themselves, and by caregivers is important. Narcotic-carisoprodol mixtures also have some added risk of falls, but they are also legitimate and especially have use when a smaller narcotic dose is wished to be used to combat moderately severe or worse pain, hydrocodone and dihydrocodeine being very common agents used with carisoprodol with codeine, nicocodeine, and others of the type as well -- carisoprodol can also make tramadol work for a patient when otherwise it would not be at all effective for pain. Carisoprodol can also be used conservatively with stronger narcotics, and carisoprodol is a prodrug of meprobamate, so the two can be interchanged. The same cautions apply.
These are generally low doses of the carisoprodol and benzodiazepines, one or both of the depressants being prn or ad libitum rather than round the clock and every single day, though this can be different depending on the case. The carisoprodol and/or benzodiazepine is often at bedtime, and low doses of these drugs in combination are used for ambulatory patients, whilst moderate doses are used for homebound, bedridden, or those in assisted-living situations.
