Stimulant Response

Yesterday Broward County, Florida, Medical Examiner Joshua Perper released a toxicology report showing that Baltimore Orioles pitcher Steve Bechler had "significant amounts of ephedrine" in his system when he collapsed and died of heatstroke in February. Bechler had been taking a dietary supplement containing the herbal stimulant ephedra, which the Food and Drug Administration has indicated it may ban for safety reasons.

"It is my professional opinion that the toxicity of ephedra played a significant role in the death of Mr. Bechler," Perper said, "although it's impossible to define mathematically the contribution of each one of the factors in his unfortunate death due to heatstroke."

Here are some of the other factors: Bechler was overweight, had high blood pressure and abnormal liver function, and was excerising hard in hot, humid Florida weather to which he was not acclimated. "I am not saying [ephedra] was the triggering factor," Pepper said, "because I cannot identify the triggering factor. You have here a constellation of factors working together."

But if ephedra was not the "triggering factor," Bechler would still be dead even if he hadn't consumed the herbal stimulant. And even if ephedra played a role in his death, this is not the sort of case from which you can judge its safety in ordinary use. On that question, the governmment's numbers indicate that ephedra is safer than over-the-counter drugs such as Benadryl, Tylenol, and aspirin.

Yet Perper insists ephedra should be available only by prescription. Could that position have influenced his judgment about Bechler's death?

Comments

[Neb Okla]

My concern with Ephedra and other *natural* chemical substances is that people seem to believe that it can't hurt them.

A co-worker of mine was peddling Natural Trim in the office so I read the bottle. It says "not to be taken for more than 6 months". She was on her second straight year of it.

Should it be banned? Probably not.

Should it be regulated? I can't answer that - but I routinely see it being misused. Of course, I see cough syrup and Tylenol being misused too - and they are regulated.

Ultimately, I'd prefer that people take pharmaceuticals more seriously. Should I force this upon them? I think not.

[Brian]

"Perper, who stated _immediately after the autopsy_ that he believed ephedra played a role..."

"Perper said Belcher's weight at autopsy was about 320 pounds...
The team doctor said he did not think Belcher weighed more than 250 pounds..."

OK, so we have an ME that 1) Stated prior to the tox screen results that he "believed" ephedra was involved; and 2) has at least one discrepancy in his measurements on the order of about 70 lbs.

His bias here is obvious...he made up his mind how he was going to interpret the tox screen results before he even saw them. Not exactly objective work.

I work in a lab for a living. Every day we make measurements, and we understand that with every measurement, there is an associated degree of uncertainty. However, WEIGHING SOMETHING is about as straightforward as it gets. I don't know of any scale in use with a standard error of 70 lbs.

The work was sloppy, this individual clearly has an agenda, therefore, his conclusions are suspect. (That's me saying it nicely.) Either he's professionally incompetent, or he's a self-agrandizing jerk using the death of someone famous to get facetime. Come to think of it, those aren't mutually exclusive. (That's me saying it less nicely.)

[Jacob]

On the issue of death rates raised by Sean, the industry estimates that somewhere between 12 million and 17 million Americans consume a total of around 3 billion ephedra doses a year. The commonly cited estimate for deaths linked to ephedra is "at least 100." The RAND Corporation, which looked at every adverse event report in the FDA's files and the medical literature, found only two deaths in which the presence of ephedra was verified and there was at least some investigation to rule out other causes.

By contrast, in a single year (1999), the Drug Abuse Warning Network counted 641 deaths linked to Benadryl, 427 linked to acetaminophen, and 104 linked to aspirin. In all of these cases, the presence of the drug was verified, although (as with ephedra) it may not have been a decisive factor in the death.

Even if these drugs were used 10 or 20 times as often as ephedra, there still would be a substantial gap. Recall that the DAWN figures are for a single year, while the FDA figures presumably cover a decade or so (the length of time ephedra products have been on the market).
No wonder FDA Administrator Mark McClellan concedes that "serious adverse events from ephedra appear to be infrequent."

[Jon H]

You don't mention that ephedra will give you a prostate the size of a grapefruit...

[Paul]

"But if ephedra was not the "triggering factor," Bechler would still be dead even if he hadn't consumed the herbal stimulant."

Really? How do you know that? Can you prove your statement? Can anyone?

[joe]

So you attribute his death to fact this he was doing much harder physical work, in a much more strenuous environment, than his body could handle. Nope, no reason to blame stimulants here.

[Jacob]

Paul, I'm assuming that by "triggering factor" Perper meant a factor that made a decisive difference, a factor in the absence of which Bechler would not have died. Overexercising in hot, humid weather obviously was one such factor. The question is whether taking ephedra was too. If not, then by definition Bechler would still have died even if he hadn't taken it. But you're right in suggesting that we're never going to get a conclusive answer to that question.

[Rand]

Yes, ephedra was INVOLVED in Bechler's death. As was the heat, his obesity, prior medical problems, etc. etc. All of these problems fell into perfect unfortunate alignment and ALL contributed to his death. Yet ephedra gets the lion share of blame. If we're going to ban this product because it has been LINKED to "hundreds of deaths," why aren't we banning cigarettes that have been linked to MILLIONS?

[Lefty]

Here in the land of the Democratic Farm Labor Party and the football Vikings we had a similar death last year. Kelsy Stringer, a 350 pound offensive lineman died of heat stroke and the family is suing the team for inadequate medical attention. Interestingly, he had an ephedra containing potion in his locker but in the autopsy they never checked for it in his system.

Which is beside the point. Fat people should be more careful. Shit happens.

[Sean]

The fact that there are more deaths attributed to Tylenol, Benadryl, and aspirin than ephedra is a rather meaningless stat. What is the deathrate per usage? More people die in car wrecks than trainjumping each year, but that doesn't necessarily make the latter safer.

[md]

As one who has taken ephedrine as a diet aid, study aid, and party aid, it is pretty clear when you're taking it that your heart rate goes *way* up, and presumably, so does your blood pressure. Just using common sense, I would probably not choose to strenuously exercise in the heat in that condition, particularly if I were overweight and out of shape. This is the same common sense that eludes those who drink all day in the sun, and pass out from dehydration/heat stroke. Alcohol is usually cited as a contributing factor in those incidents as well. However, I see no calls to make beer a prescription drug.

[Jon H]

md wrote: " Just using common sense, I would probably not choose to strenuously exercise in the heat in that condition, particularly if I were overweight and out of shape. "

But that's pretty much the perceived right time to use
ephedra - as a way to get more out of your workouts,
perform better, and lose more weight. That's certainly
how it seems to be marketed, though the fine print
might suggest you shouldn't do that. The fine print
probably also says you should ask your doctor before
using it, but how many people do that?

Jacob wrote:
"Even if these drugs were used 10 or 20 times as often as ephedra, there still would be a substantial gap."

I wonder, though, how often those non-ephedra deaths
were due to intentional overdoses. I'd think that far
more people would intentionally OD on common OTC
medications simply because they're more likely to
be handy. And, they're cheaper.

Also, I'd be willing to bet that the OTC meds you
mention are used far, far, far more often than ephedra.
Those products aren't marked up as much, and are
more general purpose than ephedra. Hell, everyone's
taking aspirin every day for their hearts.

Finally, I'd take the ephedra industry's sales figures
with a jeroboam of salt. I wouldn't take their word
for how you spell 'ephedra'. I mean, they're part
of an industry which is based on questionable and
flimsy claims and minimal research on safety
and efficacy. In my book, their credibility is on
par with Miss Cleo's.

[Anonymous]

Let's get to the real root cause of Bechler's death.

Why was a man who was overweight, had high blood pressure, abnormal liver function, and taking ephedra be excercising hard in hot, humid Florida weather to which he was not acclimated? Because someone was going to pay him a lot of money to do it. If he was just some average Joe playing baseball for fun or excercise, he wouldn't have pushed himself as hard. It wasn't the ephedra that killed him, it was pro sports.

Therefore, if you really want to prevent similar deaths, we should ban pro baseball.

[Maceiras Rachel]

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