If you’ve ever wondered what happens to epinephrine if you thoroughly abuse it, I have your answer!
A few years ago, I stopped disposing of expired EpiPens. I had the vague intention of having a family Epi Practice Party, but instead they just sat there. Then I began thinking about the few studies that have been done on epinephrine storage conditions. I wondered if I could make the solution in the pens get discolored using heat or cold? After all, appearance is the only user-level indicator as to whether epinephrine is good or not.
I waited for the hot days of summer, so I could use my car as an oven. My hope was that this would replicate the conditions that someone in the “real world” might put their pens through. I decided that my freezer would work just fine for providing cold.
Discoloring the epinephrine proved much harder than I expected, so I shifted my focus to how the abused EpiPens would fire. The results surprised me! Watch the video below to see!
About my methods
I began on June 28, 2018 with three EpiPen Jrs, all from the same lot and with the same expiration. The first, I marked as “Control,” the second as “Hot Car,” and the third as “Freezer.” I put the control EpiPen on my counter, Freezer in my freezer, and Hot Car in my car.
My freezer measured at around -12 degrees Fahrenheit. To get my car hot I parked it outside in our driveway, facing south, with the pen on the dash in direct sunlight. It was supposed to be a 100 degree day. The hottest it got inside the car was between 180 and 200 degrees Fahrenheit. (Unfortunately, my thermometers did not agree with one another.)
I checked the pens and measured the temperature hourly on that first day. After about three hours, the solution in the pen in the Freezer started to look like an ice cube. I could see the little striated lines that you would typically see in ice. None of my pictures really picked that up, but it’s what I could see in person. I thought the Hot Car pen looked a little cloudier a few times, but that was just wishful thinking, because when I compared it to the Control, it was still just as clear.
After a few more hours, I learned that checking the Hot Car pen hourly was completely unnecessary. I was doing this epinephrine abuse experiment live in our Instagram stories, and several followers told me that they’d left EpiPens (accidentally or on purpose) in the car for YEARS, and the solution never discolored.
Changing the goal of my Epinephrine Abuse Experiment
After that, I gave up on hourly checking, but decided to keep going for a while. I left the frozen pen in the Freezer for 12 days straight, day and night.
I continued to move my car into the garage at night, but I parked it in the driveway again every day for the next two weeks. We did get some cloud cover in the afternoons, but the temperature got nice and hot for a portion of most days.
On day 3, I added a second pen to the freezer and the dash. It occurred to me that the abused EpiPens might behave differently fresh out of the freezer (or hot car) than if they were allowed to return to room temperature.
All 5 pens had the same expiration (August ’17), though the 4th and 5th pens came from a different lot than the first three.
I labeled them “Hot Car 1,” “Hot Car 2,” “Freezer 1,” and “Freezer 2.” Pen 1 of each pair were the ones I started with on June 28. Pens 1 were also the ones that I allowed to return to room temperature. Pens 2 were the ones that stayed hot/cold until moments before firing.
So to make sure it’s clear, the Control, Hot Car 1, and Freezer 1 were all from the same lot (ended in 78). Hot Car 2 and Freezer 2 came from a lot ending in 75.
Time to gather results!
On Monday, July 9th I stopped cooking the first hot pen, and pulled the first frozen pen out of the freezer. The other pens stayed in the hot car and freezer. I had intended to fire them that day, but the day got away from me, as did Tuesday, so I fired them late afternoon on Wednesday, July 11, 2018. (So by losing track of time, the extra epinephrine received as much abuse as the first ones.)
As for how they looked (my first objective,) the hot pens never discolored. As mentioned above, the frozen pens looked frozen, but upon thawing, the solution from the frozen pen looked clear again.
So on Wednesday, July 11, it was time to find out how well the EpiPens would fire!
I fired each pen into the air, rather than into a piece of fruit or other solid object. I did this by holding each pen with both hands with the orange tip away from me, placing my thumbs on either side of the tip (being careful to keep them away from the needle hole), and pulling the tip towards the pen using both thumbs. The esteemed Dr. Julie Brown uses this method of firing EpiPens for demonstration and I wanted to too. Seeing the needle during firing was important to me, because I suspected that the epinephrine in the still-frozen pen was an ice block. I thought it might refuse to fire at all, or misbehave in some other way. Injecting the EpiPens into fruit would not have revealed whether medication came out of the needle.
Firing the abused EpiPens
So how did it work out?
Well, if you haven’t watched the video, I’ll tell you that not all of the pens fired normally!
I fired the Control EpiPen first, so viewers (and myself) would know how an EpiPen is supposed to behave.
After that, I fired Hot Car 1, the EpiPen that had been cooked and returned to room temperature. Or at least, I attempted to fire it. Because it jammed and did not fire! I tried it several times myself, had my husband try, and finally attempted to inject it into an apple so I could apply force in a more normal direction for an EpiPen. But despite our repeated attempts, Hot Car 1 remained unfired.
Hot Car 2, the EpiPen that I pulled fresh from my dashboard, fired normally.
Freezer 1, the frozen and thawed EpiPen, also fired normally.
Freezer 2 however, the EpiPen that came fresh from the freezer, fired its needle but did not dispense any medication. The needle fired dry.
It’s important to note that after sitting for several minutes, the frozen epinephrine thawed and leaked out of the Freezer 2 EpiPen. But of course, the medication is of no use to anyone once it can no longer be injected.
Even more interestingly, the Hot Car 1 EpiPen fired spontaneously some hours later. So in our repeated attempts to fire it, we DID trigger the firing mechanism. But after the abuse we doled out, it fired unpredictably.
Epinephrine Abuse Experiment Conclusions
I suspected that something might go wrong with Freezer 2. After all, there’s no real reason to expect a liquid medication to dispense when it is frozen. However I thought this made a powerful visual. After all, if someone keeps an EpiPen in their car, another danger is sub-freezing nights in the winter. If you run out to your car to grab your EpiPen in the dead of winter, it might not occur to you that the medication may be frozen. Therefore you might think you received medication when you feel the needle go into your leg, but you would be wrong.
Although the frozen pen did not surprise me, the hot pen did. I honestly am horrified at the thought of trying to administer an EpiPen to my child (or myself,) pushing hard enough to bruise, yet having the pen fail to fire–only to see it’s life-saving medication blast into the air several minutes later.
However, I’m now wondering whether Hot Car 1 would have jammed no matter what? In other words, did the heat cause the problem, or was this pen defective in the first place? Mylan DID have a recall last year. None of our EpiPens were included in the recall, but I remember the recall making me scratch my head a few times. I wondered if there were more defective pens than the recall suggested.
To this end, I fully intend to expand this experiment. I’d like to cook several more pens to see if this problem happens again. So stay tuned to this blog and our Social Media–I’ll update as information becomes available!
Since my initial day of experimentation, I’ve been in close contact with Jen Burch of Blue Bear Aware. She had been performing some of her own tests, trying out a temperature sensor and corresponding app for epinephrine monitoring. We’ve shared a lot of info on the effects of temperature on epinephrine. The two of us understand that epinephrine does degrade in extreme temps, though the studies have indicated that some of the drug is still viable.
It seems that epinephrine needs to go through substantial abuse of certain types in order to become discolored. That means that clear solution DOES NOT mean epinephrine is 100% potent. Almost all studies done on the subject have been done on epinephrine in vials, not in auto-injectors, so we have no real idea how the different storage methods might affect the medication. Unfortunately, neither of us has the tools to actually test the epinephrine for efficacy.
Jen also graciously shared one of her temp devices with me, so my further experiments will have more accurate temperature data. As the two of us nerds get more information on user effects of temperature on auto-injectors, we will compile it and share with all of you!
Edit: The following September I posted the results of my follow-up Epinephrine Abuse Experiment–Extreme Heat. It confirms the Hot Car results found here! Please read!