“How would you do it?”

“Oh, I think I’d take a whole bunch of pills.”

“Have you actually poured ‘a whole bunch of pills’ out into your hand?”

“No, never… it’s just something that’s crossed my mind.”

“Do you have access to a gun?”

“No—and even if I did, I wouldn’t use a gun. It’s too messy. I wouldn’t want to leave a mess behind for them to clean up…”

(Tangent: Some people seem to believe a bloody mess is more distressing than self-destruction. To me, this is a distortion of logic: When we learn of people killing themselves, are we more disturbed that they killed themselves or that the surrounding environment required disinfection? Seeing a pool of blood on the floor can be sickening, yes, but seeing a dead body due to a self-inflicted injury is horrifying.)

“… I just want it all to go away. You know, there’s no pain this way; just take a whole bunch of pills and fall asleep, never wake up.”

While it is occasionally true that swallowing a “whole bunch of pills” may induce immediate loss of consciousness (which is not “sleep”) and, eventually, death, this is not always true. People seem to believe that upon swallowing a large number of pills, their bodies will immediately shut down (within minutes, if not seconds, of the ingestion), thus resulting in sleep, and then they will die shortly thereafter. They romanticize suicide by pill overdose.

In fact, the following events are what may actually happen after swallowing a large number of pills:

>> Nothing. People often start checking the clock, wondering why “nothing is happening”. They start to feel frustrated that their efforts did not produce any results. A few people have told me that, after attempting suicide by overdose where nothing happened, they never attempted suicide again: “It didn’t work, so why bother?”

>> Cerebral edema. This is the fancy term for “brain swelling”. Because the skull holds a fixed volume, a swelling brain eventually ends up oozing out of the base of the skull, which can end life. This, however, is not a rapid event; it can take hours. People may be awake while their brains are swelling; they may notice that their breathing rates are irregular (which is psychologically distressing; think anxiety and panic). Sometimes they notice that their muscles get tight, thus making it more difficult to move. Their pulse rate may also drop, which can lead to dizziness and chest discomfort. Brain swelling is not a comfortable experience.

>> Renal failure. This means that the kidneys are either significantly impaired or they stop working. This also does not occur immediately; it usually occurs on the order of hours. Again, people may be completely awake and alert while this is happening, though they may start feeling nauseated and begin to barf. (Though nausea is not a type of pain, many people find nausea less tolerable.) Their appetites may drop, as well as the amount of urine they produce. If one is not peeing, one is not getting rid of body water, which means one may start bloat. The areas around the kidneys (”flanks”) may begin to hurt. Failing kidneys result in a miserable experience, which is why so many patients who do not attend their dialysis runs regularly often show up at the emergency room when they are “overdue” because the nausea and other sensations are simply intolerable.

>> Nausea, vomiting, diarrhea. This can occur independently of renal failure. The stomach lining may be irritated upon digestion of the large number of pills. Again, nausea isn’t pain, but it still sucks.

>> Tinnitus. (Debate rages whether this is pronounced “TIN-uh-tis” or “tin-EYE-tus”.) This refers to “ear ringing”. Not painful, but pretty dang annoying.

>> Hypokalemia. This is the fancy word for “low potassium”. This, too, does not occur immediately (there is a pattern here)—our bodies are amazing machines that try to adapt to physiologic stressors as effectively as possible. If the body does not have enough potassium, muscle function is compromised: One may start to feel numbness of tingling in various places; this can ultimately lead to paralysis. The diaphragm, which facilitates breathing, is a muscle. When one is not in control of one’s breathing, one freaks out. Choking and suffocation are both psychologically and physiologically distressing events. The muscles of the gastrointestinal tract can also be affected; see “nausea, vomiting, diarrhea” above. The heart, too, is a muscle; irregular heart rhythms can lead to chest discomfort—sometimes pressure, sometimes pain, but always uncomfortable and distressing.

>> Hyponatremia. This is the technical term for “low sodium”. Again, not immediate. See “nausea” above. People also experience headaches, body aches, and possibly seizures. People can eventually succumb to comas… unless they stop breathing first (see “when one is not in control of one’s breathing, one freaks out”).

>> Hypoglycemia. “Low sugar.” People with diabetes are often more familiar with this symptom than any of us would like to admit. This, too, is not an immediate event. When hypoglycemic, people report feeling hunger… and irritability. They also start to sweat, feel anxious, and experience unusual heart rhythms. People can also develop “neuroglycopenia”, which is the ornate name for “changes in thinking because of low blood sugar to the brain”. People can get confused and behave strangely… and, ultimately, if the blood sugar is not corrected, will pass out.

>> Coagulopathy. “Bleeding abnormalities.” Not immediate. People don’t melt into pools of blood, but if they bonk an elbow—or even firmly touch something with a leg—they may bruise significantly. Maybe their gums will start to ooze blood. If they’re endlessly oozing on the outside from minimal trauma, that also means it can happen on the inside, like in the gastrointestinal lining, in the lungs, in the spleen… and those have associated, uncomfortable symptoms.

Overdosing on pills is not a guaranteed method of painless suicide. In fact, the event may precipitate more problems than it solves (like a trip to the emergency room, hospitalization, an interview with one of those weird psychiatrists, a five-digit financial bill, and disruption in social support). Although suicide is always an option, it is one that we hope that people do not elect to pursue because, like overdosing, suicide may precipitate more problems than it solves—and is quite possibly the ultimate act of avoidance.

UpToDate provided the information to help me review the physiologic consequences of toxic ingestions.