Two lethal self-poisoning cases by an analgesic preparation (Optalidon®).

Introduction: Analgesic preparations containing short-acting barbiturates, especially Butalbital, are most taken by patients with frequent migrainous attacks. Abuse of common prescribed combination analgesics can produce rebound effects and also physical dependence, that was particularly frequent in the '60-'70's; at that time acute intoxications were about 3-4% considering all types of poisoning and 17,5% of barbiturates poisoning. Methods and Results: During the seventies some lethal cases due to Optalidon® intoxication were observed at the Forensic Institute of Milan (Italy). We report two more recent cases: Case 1: 29.11.92 - V.R.R. a 76-year-old woman died in hospital three hours after arrival; resuscitation and intense therapy were ineffective in the unconscious woman. The medical history of V.R.R. revealed a dated depressive syndrome and a past suicide attempt by unidentified drug-poisoning (1980); once at home near the woman Lexotan® ¿ drops and an unidentified powder were found. The autopsy revealed only non specific visceral findings. The toxicological generic screening revealed: Butalbital, Propifenazone, Diazepam and caffeine; the specific, quantitative analyses revealed: Butalbital (blood: 28.13mcg/ml; brain: 21,75mcg/ml), Propifenazone (blood: 66.06mcg/ml; brain: 23.08mcg/ml), Diazepam (blood: 16.64mcg/ml; brain: 18,92mcg/ml). Considering the organ/site-target of Butalbital and Diazepam and their elevated blood/brain concentrations, death was the result of a combined acute intoxication of Butalbital and Diazepam. Case 2: 25.04.02 - P.A. a 52-year-old woman was found dead in her house cellar. External examination of the corpse revealed only some linear, superficial cutting lesions at the wrists covered with curdled blood without remarkable blood loss. At home, empty packaging of Optalidon® and Tavor® were found. The medical history of P.A. revealed a chronic misuse of analgesics and alcohol abuse. The autopsy revealed only non specific visceral findings; the stomach contains abundant material mixed with whitish, friable granules. The toxicological generic screening revealed: Butalbital, Propifenazone and caffeine; the specific, quantitative analyses revealed: Butalbital (blood: 30.46mcg/ml). Considering the organ/site-target of Butalbital and his elevated blood concentration, death was the result of an acute intoxication of Butalbital. Conclusions: Currently the analgesic preparation, Optalidon® (Novartis) available in Italy contains: Butalbital (50mg), Propifenazone (125mg) and caffeine (25mg) in form of tablets or with triple single drug concentrations as suppositories. We discuss the Italian medical prescriptive limitations of Optalidon® and present a brief history of this classic antimigrainous product in term of lethal, "ancient" casuistic and type of toxicological analytical methods applied in the seventies and nowadays by our toxicological laboratory. These two cases showed that lethal abuse or self-poisoning, in medico legal context, is rare to observe and reaffirms the need to discourage prescriptions of analgesic preparations with barbiturate components because of the severe risk of dependence, considering the availability of safer products.