Friday, May 31, 2013

Exploring the Heroin Overdose Myth

Most fatal overdoses attributed to heroin are not actually the result in taking too large a dose. Heroin overdoses are largely a myth.

What causes people to overdose on heroin? The conventional wisdom states that because heroin users do not know the purity of the drug they are consuming, they misjudge the strength of the dose. If only users knew the exact dosage, they wouldn't overdose.
    This is largely a myth. The Consumers Union Report on Licit and Illicit Drugs exposed this myth back in 1972:
But alas, the two standard precautions against overdose--- warnings against taking too much and administration of an antidote--- are in fact wholly ineffective in the current crisis, for the thousands of deaths attributed to heroin overdose are not in fact due to heroin overdose at all. The evidence falls under three major rubrics.
(1) The deaths cannot be due to overdose.
(2) There has never been any evidence that they are due to overdose.
(3) There has long been a plethora of evidence demonstrating that they are not due to overdose.
Why these deaths cannot be due to overdose. The amount of morphine or heroin required to kill a human being who is not addicted to opiates remains in doubt but it is certainly many times the usual dose (10 milligrams) contained in a New York City bag. "There is little accurate information," Drs. A. J. Reynolds and Lowell. Randall report in Morphine and Allied Drugs (1967). "The figures that have been reported show wide variation." This ignorance no doubt stems from the rarity of morphine or heroin overdose deaths. The amounts of morphine or heroin needed to kill a nonaddict have been variously estimated at 120 milligrams (oral), 200 milligrams, 250 milligrams, and 350 milligrams - though it has also been noted that nonaddicts have survived much larger doses. 
The best experimental evidence comes from Drs. Lawrence Kolb and A. G. Du Mez of the United States Public Health Service; in 1931 they demonstrated that it takes seven or eight milligrams of heroin per kilogram of body weight, injected directly into a vein, to kill unaddicted monkeys. On this basis, it would take 500 milligrams or more (50 New York City bags full, administered in a single injection) to kill an unaddicted human adult.
Dr. Helpern's associate, Deputy Chief Medical Examiner Baden, went on to further discredit the already implausible overdose theory at a joint meeting of two American Medical Association drug-dependency committees held in Palo Alto, California, in February 1969.
"The majority of deaths," Dr. Baden told the AMA physicians, "are due to an acute reaction to the intravenous injection of the heroin-quinine-sugar mixture. This type of death is often referred to as an 'overdose,' which is a misnomer. Death is not due to a pharmacological overdose in the vast majority of cases."  
At the same AMA committee meeting and at a meeting of the Medical Society of the County of New York, Dr. Baden cited six separate lines of evidence overturning the "heroin overdose" theory. 
First, when the packets of heroin found near the bodies of dead addicts are examined, they do not differ from ordinary packets. "No qualitative or quantitative differences" are found. This rules out the possibility that some incredibly stupid processor may have filled a bag with pure heroin instead of the usual adulterated mix.
Second, when the syringes used by addicts immediately before dying are examined, the mixture found in them does not contain more heroin than usual.
Third, when the urine of addicts allegedly dead of overdose is analyzed, there is no evidence of overdose.
Fourth, the tissues surrounding the site of the fatal injection show no signs of high heroin concentration.
Fifth, neophytes unaccustomed to heroin rather than addicts tolerant to opiates would be expected to be susceptible to death from overdose. But "almost all of those dying" of alleged overdose, Deputy Chief Medical Examiner Baden reported, "are long-term users."
Sixth, again according to Dr. Baden, "addicts often 'shoot' in a group, all using the same heroin supply, and rarely does more than one addict die at such a time." 

So if heroin overdoses are not truly due to taking too much heroin, what is killing heroin users?

1. Mixing opiates with other central nervous system depressants, especially alcohol and benzodiazepines.

The depressant effect of opiates on breathing can be countered by conscious effort and opiates rarely result in a loss of consciousness. When combining opiates with CNS depressants, the drugs work synergistic ally to depress breathing, doses which may be well tolerated when taken alone can be fatal when combined. If an individual stops breathing in the presence of others an overdose can be avoided by waking the person up. Alcohol and benzodiazepines cause a loss of consciousness which preclude this possibility.

The combination of opiates and other CNS depressants account for at least half of all overdoses attributed to opiates, and in all probability are responsible for more than 50%. Educating people not to mix depressants with opiates would do more than any other preventative, educational campaign. It would certainly save more lives than just saying don't use heroin.

2. Deliberate Overdosing. Suicide is a major contributor to the overdose statistics.

Poor mental health and feelings of hopelessness are associated with overdose. Opiate addicts are far more likely to attempt suicide, four times as likely for men and eleven times as women. Overdose suicides are almost certainly under reported, so this rate may be much higher.
     Unless the evidence for suicide is overwhelming most overdoses are considered accidental.  Establishing the number of suicide-overdoses is difficult.  One method involves asking persons who survived an overdose if it was intentional, then extrapolating this rate to those who died from an overdose.  Studies done in the UK indicate that up to a third of overdoses may have been intentional.  One of the few prospective studies followed British opiate and cocaine addicts notified by doctors.  The rate of confirmed suicides was 4 times higher than the general population for men and 11 times for women; 45% used an overdose of drugs as the method.  In British studies of persons on methadone deliberate, non-fatal overdose is twice as common as accidental.  A London study of opiate injectors not in treatment found that 1 in 10 overdoses is deliberate.  It is hard to determine the number of overdoses that are intentional, but it seems that somewhere around 10-30% are deliberate.

3. Fluctuations in tolerance.

Addicts are more likely to OD when their tolerance is at its lowest. Users are most at risk for an overdose when they drop out (or are kicked from) an opioid maintenance program, after a period of forced abstinence  (usually due to incarceration), or after discharge from a detoxification hospital. This is more of a risk factor than a cause, but I included it in the list.

4. Homelessness and Street Use

An oft overlooked aspect of heroin use involves the mindset of the user and the environment where he/she is using. Opiate tolerance is not a purely physiological phenomenon, tolerance is also situation specific. Most regular opiate users have a ritual of preparation prior to ingesting the drug. Situation-specific tolerance is also a piece of the opiate overdose mystery:
The fatal consequence of the heroin injection may have been caused by the failure in the action of conditioned tolerance. As the figure shows, when a conditioned place preference arises, the user has to take a bigger dose each time to achieve the same effect as the user who does not have the opportunity for secondary conditioning with environmental stimuli since he or she constantly changes the place where the drug is taken [6]. When the drug is taken in a strange environment the conditioned tolerance does not operate since the organism is not "expecting" the drug. The end result is that the otherwise accustomed dose leads to an overdose and thereby to death. This is why the term "overdose" is misleading since the quantity taken was not greater than other doses taken without fatal complications
A case report: Pavlovian conditioning as a risk factor of heroin 'overdose' death. József Gerevich1, Erika Bácskai1, Lajos Farkas and Zoltán Danics. [Link]

Heroin concentration levels in a case A after conditioning in an accustomed place (A1) and in a new place (A2), and in a case B without conditioning.

Most "overdoses" involving opiates are chalked up to the use of opiate drugs regardless of the circumstances around the death (polydrug use, ect.)  This is well documented and known among those that care about the lives of users.  Unfortunately most people simply do not care about users and medical examiners readily attribute the cause of death to opiate drugs regardless of the toxicology.

Putting these factors together it becomes clear that drug prohibition itself contributes to overdoses among opiate users. Opiate prohibition causes inflated prices, users may add other drugs to augment the expensive opiates. Without prohibition, the cycle of addicts coming in and out of jails, prisons, detoxes and rehabs would come to an end. Each time an addict has their tolerance lowered they are at increased risk for an overdose.

The constant drug war propaganda in the media portrays opiate addicts, and especially heroin addicts, in an extremely negative light. Addicts are stereotyped as dangerous criminals, out of control and in need of rehabilitation. The uniformly negative view of addicts, combined with blatant stigma and discrimination (discrimination even written into the law), causes most addicts to hide their use. The situation today is not unlike how homosexuality was treated in the early 20th century. Today most addicts remain in the closet, for very good reasons. Being constantly reminded that one is both sick and a criminal (two charges also once leveled against homosexuals), takes its toll. The rate of suicide among homosexuals was also high during the peak periods of homophobia.

The artificially high cost of black market opiates causes many addicts to fall into abject poverty. Not only does homelessness make hygiene difficult, but it contributes to "street use" (use outside of one's usual place of consumption, such as a public bathroom). This contributes to a lowering of situation specific tolerance, further putting the user at risk of an overdose.

More on this topic to come.

References and Further Reading:

The Consumers Union Report on Licit and Illicit Drugs by Edward M. Brecher and the Editors of Consumer Reports Magazine, 1972
Chapter 12. The "heroin overdose" mystery and other occupational hazards of addiction [Link]

The Persistent, Dangerous Myth of Heroin Overdose by Stanton Peele [Link]

Drug and Alcohol Findings Issue 4 2000. Overdosing on opiates Part I Causes by David Best et al. [Link]

Drug and Alcohol Findings Issue 5 2001.Overdosing on opiates Part II Prevention by David Best et al. [Link]

Reducing heroin ‘overdose’ death risk [Link]

Siegel S, Hinson RE, Krank MS, McCully J: Heroin "overdose" death: Contribution of drug-associated environmental cues. Science 1982, 216:436-437


  1. BZD and alcohol create 100 x more issues than opiate .
    Should be banned !!

  2. I am 34 yrs old and have been injecting heroin intravenously, since I was 15, mainly as management, for pain, due to several automobile accidents, as well as quite a few"extreme sports" accidents, that landed me in the hospital, and almost always, was given a prescription for anywhere between 10-30 lortabs, that never came with the option for refills, if needed, and therefore I was basically left to fend for myself, as far as finding a method to manage the, more often than not, extreme pain I was in, due to being given inadequate amounts of medication, in relation to the severity, of my injuries, in which my rehabilitation ranged in duration, from 6 weeks-9+ months. I am now homeless, jobless, severely depressed, disabled, and madly, deeply, hopelessly inLOVE with my Heroin. I have seriously been wanting to put an end to what little life I feel I actually have left inside myself. Naturally, an overdose of Heroin would be, in my mind, the most ideal way to go about this, but my tolerance is considerably high, due to my continued, long-term use, and all previous "attempts" have done nothing but gotten me really high, and as far as I can tell, nowhere even close to overdosing. I actually have prided myself on the fact that, in my 18+ years of use, I have never once overdosed

    1. Got the blues in my coffee
      got the blues in my head
      If I die in the gutter....God almighty now
      At least I'd be dead

      I don't much like livin' but I don't wanna die
      Cuz if I was dead....God almighty now
      I'd miss gettin' high

      The Nectar of God--Patrick Sky

  3. Wow that storey sounds somewhat familiar. except when i was having those thoughts of suicide with the needle and heroine i put myself in treatment and when they asked what brought me to treatment i explained my depression was getting the best of me and with this drug of choice i have the thoughts of suicide was scaring me so i felt i should get help only to wake up with a cop two EMT s standing over me telling me if i didnt coroperate then i would be put in straight jacket infront of all my fellow detox friends that i have gotton to know in the past 3days how embarrassing anyway i ended up going to hospital and the checking out of rehab as soon as i returned

    1. You were having thoughts of suicide with a needle and a female hero (a heroine)?

      Just kidding, I know you meant heroin.

      Actually a similar situation happened to a friend of mine who went to the hospital saying he was an addict and suicidal. They put him in the psych unit but did not give him any medication for the withdrawals. When he complained they threatened to restrain him by tying him down to a bed.

      His mother thought he would actually get treated and was flabbergasted at the inhumane treatment he received. She ended up sneaking in heroin to him while he was still inpatient.

      While such shameful treatment by medical professionals may not be universal, far too many view addicts as criminal malingerers undeserving of the basic dignity afforded to other patients suffering from mental illness.

    2. don't we all pay taxes ?if not our families do. we all deserve equal treatment !!! addicts or not

  4. These two stories above are terrible! Basically, people seeking treatment and being honest towards medical professionals are "rewarded" by being shamed and punished. What a lovely way to treat someone who is suicidal and depressed.

    I don't take heroin, but have been dependent on alcohol and benzos for many years and have been feeling suicidal lately and really want to go by heroin overdose. But this leaves so many people at risk. Me, if I survive and am committed to a psych unit for what should be my decision. Anyone who supplies me with heroin (I have one close friend who uses, but would never ask him as he might get a prison sentence for assisted suicide even though I wouldn't tell him why I wanted heroin). The local needle exchange, which I know has been harassed by police if there are overdose cases (nice harm minimisation strategy). The one or two good friends who have stood by me when I've been at my lowest. Even my GP, who legitimately prescribed me Xanax and sleeping pills because I'm a lifelong insomniac with frequent panic attacks.

    The attitude of many lawmakers, police and medical professionals - that they don't deserve care and dignity - is ridiculous. I guess their coke and MDMA binges don't count. They're professionals, and not using needles. Never mind that the medical profession is notably rife with addiction.

    Personally, I don't see a difference between someone whose coping mechanism is sticking a needle in their arm and those who are workaholics, binge drinkers, smoking addicts, tanning addicts (you will get skin cancer), dangerous diet dependents, or even people whose nutrition comes entirely from fast-food restaurants. The only difference I've found is that illegal drug addicts are usually more honest and penalised for it. The rest of us lie about how many standard drinks we have a week, how much exercise we do etc. We're the real malingerers.

  5. I am British. Not only do do we have a free healthcare system, it is illegal to to restrain a person without very good reason, training and government policy, including government policy (THE MENTAL HEALTH ACT). If picked up on the street and deemed unsafe to be on a danger to themselves or the public they will be picked up on a 136 of the MENTAL HEALTH ACT and taken to a place of safety i.e. police station for assessment by mental health workers, including a psychiatrist registered mental health nurse RMN. If a person self presents themselves they will be taken to a mental health ward for assessment.however unlike some countries perhaps yours, we do not treat people who are drug users or have mental health problems as not deserving dignity and respect. We have not used strait jackets for I'm going to say 40 years or more. If the police find heroin on registered drug user they are usual let go. The police do not confront a drug user without good reason but will chat to find out if they are okay or had anything issues they may want to discuss and the person may know the police by first name basis.

    1. In the US the police go out of their way to find drug users (constitutional rights be damned, ever hear of stop and frisk?). If they find heroin it is an arrest, usually followed by a cold-turkey detox in a dank cell.

      Just being a drug addict can get one committed in some parts of the US. In many ways the (massive and sprawling) US prison has become our mental health system

    2. Oh my! Britain must be the mecca of mental health issues! I dont think so! I have a good friend that lives in the UK (born and raised), her sister is in DIRE need of mental health treatment! But...awww, no, wait...she IS NOT suicidal! Sorry! Cant help ya unless you are suicidal! Come back when you ARE suicidal! THEN we will give you an appointment with a doctor. RIDICULOUS!

  6. People wo wish use heroin (espeicailly prior IV users( should be left the hell alone, espicailly by the Police who could give two shits about really helping. If somone wants to die, they WILL find a way. Regulate it, JUST LIKE CIGARETTES! Which have killed FAR far more people than heroin ever did or likely ever will.

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  8. I was fairly heavy heroin user for 3 consecutive years, which was preceeded by 5 years of pain management using opioid therapy in varying forms and strength. At the time I was cut off from pain management, I was being prescribed 5-30mg oxycodone/day, 4-80mg morphine sulfate extended release, and 1-100mcg Fentanyl Patches every 60/72 hours. One cannot financially maintain a tolerance that heavy buying on the street. We all know how the story goes from there. I was using (snorting and/or smoking as route of administration) a minimum of 14 bags a day (1 bundle where I'm from). Obviously when I had access to more it would go up to 28-35 bags (2.5 bundles) in a 24hr period. I have been through detox, rehab and vivitrol extended release shots, which averages 30 days of "blocking" per injection.

    I've been opiate free for about 11-12 weeks/3 months. It's been a little more than 30 days since my last vivitrol dose. How much would it take to be fatal and over what period of time? I'm under the impression that my tolerance should be relatively nonexistent right now, but the "heroin overdose is a myth" are basically stating that reported cases of overdose are not actually due to the quantity used but rather from the effects of other substances used in conjunction with heroin.

    So I should be able to snort at least 14 bags and not die as long as I'm not mixing substances. Right?


    1. Don't push your tolerance if you have been clean for 11 months

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  11. Only the use of heroin to get "high" is a misnomer. Do you take one aspirin or painkiller pill after pill, until your headache is gone? No! You take one or two, get on your way with your headache and before you know it you are being productive and your headache is gone. Stupid people and the ignorant and indulgent get ready to die. Stop consuming heroin and whining how you have not had enough. Get a life. Use half a "bag", get on your way and if you need another one , take it later. Get a "way" if you don't have one. Be a superperson, not another stupid dead junkie. Use drugs. Do not abuse drugs. Obsessively taking aspirin until your headache is gone is as stupid as taking heroin until you are high. You are giving use a bad name. Change your ways or get on with dying so we can change the irrational negative stigma associated with use. If you are using it to escape , get counselling. Life is good.

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