Heroin overdoses and overdose-related deaths are a regular feature of both urban and suburban American society. But to many, the definition of what constitutes an overdose seems to be an ambiguous one. The complexity of this question stems from the subjectivity of several factors; the purity of the drug, dosage and the general health of the user all contribute to the potential for an acute heroin overdose. In order to assess possible methods of prevention, an understanding of opiate overdose must first be gained. 

Heroin is one of the most potent synthetic opiate derivatives known to man. Its depressant properties are great in their effect, often inducing states of semi-consciousness and extreme stupor. Well documented is the fact that heroin users are at a substantially greater risk of premature death than their non-using peers. Indeed, various studies have estimated mortality rates in heroin dependent persons to be between six and 20 times higher than those of the regular population belonging to the same age and gender.⁽¹⁾

Deaths from heroin overdose have increased dramatically within the last 10 years. However, recent research has indicated that many of these deaths could have been prevented. This research also suggests the need for a revision of some of society's conventional views on heroin use and dependency.

Postmortem evaluations from a significant number of cases have revealed the presence of other depressant drugs such as alcohol and benzodiazepines have contributed to overdose. More than 70% of users reported using another drug at the time of their last overdose.⁽²⁾  High levels of alcohol in the blood can potentiate the depressant qualities of very low levels of opioids, increasing the lethal potential for overdose.

Instant death from heroin overdose is extremely uncommon; most decedents are estimated to have died 1-3 hours after injection.⁽³⁾  This statistic clearly indicates the considerable potential that exists in preventing a heroin-related death.

Sadly, the threat of police involvement often plays into the overdose scenario with tragic consequences. 86 percent of users witnessed an overdose in the last year, and yet in all witnessed emergency situations, calling an ambulance was the first action in only 14 percent of the cases.⁽³⁾

Statistics

Within the last several years, the number of heroin overdoses in the United States alone has reached new levels of alarm. Jumping exponentially just between 1990 and 1996, the number of heroin-related emergencies doubled from 33,900 to 70,500.⁽⁴⁾

There exist some very clear trends within the heroin using population. Most heroin-related deaths occur in users who are in their late twenties to early thirties and have used heroin consistently for five to 10 years. It must be stressed that the 'typical' heroin user is not a novice, but rather, an opioid dependent person.⁽¹⁾

A consistent number of hospital patients (13 percent) report their last overdose shortly after release from incarceration.⁽³⁾  Use after a period of abstinence often carries higher risks for heroin users, often prompting them to misjudge the dose (as they seek to return to states of intoxication built at the peak of their tolerance).  

Overdose in Medical Terms

The focus of overdose studies falls almost entirely upon intravenous use. 'Harder' opioids, such as heroin achieve their greatest effect through injection.

Via this route of administration, heroin crosses the brain barrier within 15-20 seconds, quickly providing users with the pleasurable effects they seek.⁽³⁾

As heroin becomes active in the serum (peaking in under a minute), 68 percent becomes absorbed by the brain, in contrast with under 5 percent of IV morphine.⁽³⁾  This rapid deposition of heroin and its metabolites into the CNS is described as the almost instantaneous "rush" that heroin users often describe.

Heroin produces its sought-after effects by acting as an agonist on the mu, kappa and delta receptors in the central nervous system (CNS). Activation of these receptors produces a triad of symptoms including depressed levels of consciousness, miotic pupils and decreased respiration.⁽³⁾

Within 30 minutes, heroin is metabolized into morphine. Excess morphine levels in the blood often indicate the presence of an overdose. Numerous recent cases show that these levels are often skewed toward the lower end of the range, thus pointing to polydrug use or heroin impurities as more likely causes of overdose.⁽¹⁾

Prevention Through Harm Reduction

Given the nature of heroin's effects on the central nervous system and the typical habits of the average heroin user, it is safe to assume that the majority of fatal overdoses can be prevented.

A multi-faceted approach to harm reduction must be implemented in order to bring about a decrease in the number of fatal scenarios. Research conducted to date has found several factors contributing to the exacerbation of overdose potential. A reduction in the use of other CNS depressants with heroin would certainly reduce the amount of heroin overdoses.⁽¹⁾  

Interventions targeted towards the removal of concurrent drug use seem warranted, as does an increase in availability of education programs. Certain periods in a heroin-addicted person's life have proven to hold more danger than others; namely the first 12 months after discontinuing addiction treatment and the two weeks following release from prison.⁽³⁾  Opiate users should be made aware of these facts through all possible means.

Through various studies, methadone maintenance has been shown to help protect against heroin-related deaths in opiate-addicted individuals.⁽³⁾  Expanding current programs would most probably see a reduction in overdoses and deaths caused by acute opiate intoxication.

Role of Naloxone in Prevention

One of the major reasons for the high rate of mortality among heroin users is the inadequacy of their peers' response in a scenario involving overdose.⁽⁵⁾ Reluctance to call for an ambulance and ineffective attempts at resuscitation often end tragically. Many physicians feel that access to take-home naloxone would aid in the short term prevention of fatal overdose.

Naloxone is a potent antagonist at the mµ, kappa and delta receptors, acting as a counter to the acute effects of opiate intoxication. Its effects peak in the brain within 15 minutes after achieving its onset within less than two minutes when administered intravenously.⁽³⁾  It has thus become the primary mode of rapid resuscitation in hospital emergency rooms.

Naloxone has proven extremely effective in the reversal of respiratory failure. It is also considered a safe revival agent and possesses a very low abuse potential.⁽⁶⁾ Its qualities make it perfect for its distribution to the heroin-using community. The combination of take-home naloxone and harm reduction education would make for the most effective approach against overdose.

The availability of naloxone would also help to avoid confrontations between heroin users and the authorities. Historically, distrust of the police has played an important role in the failure to save many users from death.⁽⁶⁾  Take-home naloxone provides an effective alternative and acts as an additional preventative measure against fatal overdose.

Other Alternatives to Consider  

Another possibility for harm reduction lies in safe injection rooms. Since the mid-1980s, government sanctioned heroin clinics have existed in Switzerland and other parts of Western Europe.⁽⁷⁾  At these heroin clinics, users may inject their own drugs, provided that they stay no longer than half and hour. Medical personnel are present at all times, as a protection against overdose and to monitor the handling of the equipment provided to the public. Users are free from the fear of incarceration at the clinics, and may come and go as they please.

After the Swiss government observed lowered rates of HIV and hepatitis infection, it continued with an even bolder attempt at treatment-heroin prescriptions Since 1994, hardened addicts in Switzerland may receive free heroin on prescription at 20 different clinics across the country.⁽⁷⁾   The program is for addicts who have who have physical or mental health problems, have tried other methods of treatment and have been addicted for 10 or more years.⁽⁷⁾

The provision of safe injection rooms and prescription heroin may not reduce the addiction rate among the drug using population, but it has been shown to make heroin use safer. Risk of overdose is significantly reduced by medical supervision, as is the threat of epidemic. Purity of the drug is also ensured when prescribed; after all, many overdoses have been found to be the result of high levels of toxic "cutting agents."⁽¹⁾

With the level of danger that heroin use prevents to the user, it is imperative that all alternatives be considered. The sharp increase in heroin-related emergencies of the last few years is a clear enough indication of the need for drug policy reform. Only with an open-minded perspective of the situation may this nation see the rehabilitation of its citizens.

Footnotes

(1) Shane Darke and Deborah Zador. 1996 "Fatal heroin 'overdose': a review." Addiction. vol. 91 pages 1765-1772.

(2) Wayne D. Hall. 1996 "How can we reduce heroin 'overdose' deaths?" The Medical Journal of Australia. vol. 164. page 197.

(3) Phillip O. Coffin, editor. 2000. "Acute Heroin Overdose." Heroin Overdose: Research and Interventions. pages 4-13.

(4) BBC News. 1999. "US heroin overdoses soar." April  7.  <online>

(5)  J. Strang, S. Darke, W. Hall, and others. 1996. "Heroin Overdose: the care for take-home naloxone" British Medical Journal. vol. 312. pages1435-1436.

(6)  S. Burris, J. Norland, and B. Edlin . 2001. "Legal aspects of providing naloxone to heroin users in the United States" International Journal of Drug Policy. vol 12. pages 237-248.

(7) Bowman, John.  2002. "Heroin Clinics." CBC News Online. April 11.

For a list of other materials used on this website, see References.