Meet the pathologist who sounded the alarm about sodium nitrite and suicide

On May 2, after a month-long investigation, Peel Regional Police in Ontario arrested a local man and charged him with two counts of counselling or aiding suicide. The police claim that Kenneth Law was selling sodium nitrite online and marketing it to those intending self harm. Media reports suggest he may have shipped as many as 1,200 packages of the substance to 40 countries, causing at least two deaths in Ontario alone. Dr. Tyler Hickey, forensic pathologist with the Ontario Forensic Pathology Service, knows all about sodium nitrite and the similar substance sodium nitrate, which are crystalline powders normally used as food preservatives. It was he who, in 2021, published a report showing that ingesting these salts in large amounts, causing methemoglobinemia (MetHb), was a rising cause of death in the province. “I see that as part of my work; acting as a bit of a sentinel or canary in the coal mine,” says Dr. Hickey. Since his report came out, awareness of this phenomenon is growing, as is preventative action. Toxic salts Dr. Hickey tracked deaths between 1980 and 2020 in Ontario, discovering that 28 were caused by sodium nitrite or sodium nitrate. Almost all of those deaths (25) showed evidence of the poisoning being intentional. Most worrisome: 23 happened in the final two years of the study. The report concluded that “intentional ingestion of sodium nitrate or sodium nitrite shows that this is an increasingly employed method of suicide in our region.” He recently stated that he felt Health Canada should undertake a formal review of these substances. Dr. Hickey confirms he still thinks this is a good idea, as the government could learn more and perhaps limit availability to the public without disrupting the commercial sector. “It’s pretty easy with a click of a button to have a lot of things brought right to your house,” he says. “It’s ideal to not have that accessibility for someone to do something that ends their life.” As well, a review could lead Health Canada to alert physicians to this approach to self harm. “Sometimes people are in a dire condition and the underlying cause is not known when they first get to hospital,” says Dr. Hickey. Tracking something new Back in 2019, Dr. Hickey noticed a few deaths from MetHb. “I have a bit of interest in the more uncommon ways people die and paying attention to these things, especially as an uncommon cause of death can grow into a more significant contributor to death for a particular region.” He looked to the literature and found case reports of these salts used for intentional deaths. So, he decided to run a study, and was surprised to track a significant spike. This study got media attention when it was published in Forensic Science International in 2021. That same year, the Institute for Safe Medication Practices Canada issued a safety bulletin asking hospitals to have an adequate supply on hand of methylene blue, the treatment for MetHb. Since then, more researchers have published on the phenomenon, including a case report in 2022 out of Korea and another the same year from the Mayo Clinic. Also in 2022, an actress from the TV show Empire used sodium nitrite to end her life. More media reports came out regarding web sites that promoted suicide and this substance’s use in self harm. Online sellers have become increasingly aware—and involved—in this issue. In 2021, eBay stated publicly that it has prohibited the sale of sodium nitrite since 2019. In 2022, a group of parents sued Amazon for selling the compound online. As of May 23, 2023, Google will ban ads for products containing more than 10% sodium nitrite. In February, a New York State senator introduced legislation banning the online and in-person sale of sodium nitrite to anyone under 21 and those who cannot prove use for “institutional or scientific purposes.” Health Canada spokesperson Mark Johnson told the Medical Post in an email that, “Health Canada has been made aware of reports of people intentionally ingesting sodium nitrate or nitrite with the intent of self-harm and is taking action to address this concerning trend.” He says the agency has assessed the common uses of sodium nitrite and found it safe when used as intended, and made no indication that it will undertake a further, formal review. Dr. Hickey is pleased to see his work has had an impact on public awareness. And while he’ll keep talking on the subject, he knows it’s up to others to enact change. “As a reporting scientist, I’m just trying to bring attention to this issue,” he says. “I think all physicians act as advocates for health against harm. As a physician, I’m happy to have that role.”

Meet the pathologist who sounded the alarm about sodium nitrite and suicide

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