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  "The disadvantage of continuing to describe heroin-related fatalities as 'overdoses' is that it attributes the cause of death solely to heroin [opiates] and detracts attention from the contribution of other drugs to the cause of death. Heroin users need to be educated about the potentially dangerous practice of concurrent polydrug and heroin use."

Source: Zador, Deborah, Sunjic, Sandra, and Darke, Shane, "Heroin-related deaths in New South Wales, 1992: toxicological findings and circumstances," The Medical Journal of Australia, published on the web at http://www.mja.com.au/public/issues/feb19/zador/zador.html last accessed on November 17, 2000.

For opiates the medicinal, recreational and toxic effects are dose related with little difference between the various ones which are commonly used for intoxication. The body of evidence indicates conclusively that regular users of opiates die not from taking too much but rather from a reaction with other drugs already in their body.  MICHAEL JACKSON DIED FROM A DRUG REACTION, not an opiate overdose.    

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

Condensed by JK

In 1969, about 70 percent of all New York addict deaths were assigned the "overdose" label 5 and in 1970, the proportion was about 80 percent.  The number of deaths so designated by New York City's Office of the Chief Medical Examiner increased from very few or none at all before 1943 to about 800 in 1969 and 1970.  {The article then goes on to show the mistake of this determination of the cause of death}


Second, even in cases where an addict takes a vastly excessive dose despite the warning, death usually can be readily prevented, for death from an overdose of opiates is ordinarily a slow process. "In cases of fatal poisoning with morphine, the time of death may vary roughly from one to twelve hours." 9 The first signs are lethargy and stupor, followed by prolonged coma. If, after a period of hours, death does ensue, it is usually from respiratory failure. During the minutes or hours following the injection of a potentially fatal overdose, death can be readily forestalled by administering an effective antidote: a narcotic antagonist known as nalorphine (Nalline).  Nalorphine brings a victim of opiate overdose out of his stupor or coma within a few minutes. Since there is plenty of time and since nalorphine is stocked in pharmacies and hospital emergency rooms throughout the country, the death of anyone due to heroin overdose is very rarely excusable. 

(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.


(1) 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.


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. 


Virtually all of the victims whose deaths are falsely labeled as due to heroin overdose, moreover, are addicts who have already developed a tolerance for opiates--- and even enormous amounts of morphine or heroin do not kill addicts. In the Philadelphia study of the 1920s, for example, some addicts reported using 28 grains (1,680 milligrams) of morphine or heroin per day.  This is forty times the usual New York City daily dose. In one Philadelphia experiment, 1,800 milligrams of morphine were injected into an addict over a two-and-a-half-hour period. This vast dose didn't even make him sick.


Nor does a sudden increase in dosage produce significant side effects, much less death, among addicts. In the Philadelphia study, three addicts were given six, seven, and nine times their customary doses--- "mainlined." Far from causing death, the drug "resulted in insignificant changes in the pulse and respiration rates, electrocardiogram, chemical studies of the blood, and the behavior of the addict."  The addicts didn't even become drowsy.

Recent studies at the Rockefeller Hospital in New York City, under the direction of Dr. Vincent P. Dole, have confirmed the remarkable resistance of addicts to overdose. Addicts receiving daily maintenance doses of 40 milligrams to 80 milligrams of methadone, a synthetic narcotic (see Chapter 14), were given as much as 200 milligrams of unadulterated heroin in a single intravenous injection. They "had no change in respiratory center or any other vital organs."


(2) There is no evidence to show that deaths attributed to overdose are in fact so caused. Whenever someone takes a drug--- whether strychnine, a barbiturate, heroin, or some other substance--- and then dies without other apparent cause, the suspicion naturally arises that he may have taken too much of the drug and died of poisoning an overdose. To confirm or refute this suspicion, an autopsy is performed, following a well-established series of procedures.

If the drug was taken by mouth, for example, the stomach contents and feces are analyzed in order to identify the drug and to determine whether an excessive amount is present. If the drug was injected, the tissues surrounding the injection site are similarly analyzed. The blood, urine, and other body fluids and tissues can also be analyzed and the quantity of drug present determined.

Circumstantial evidence, too, can in some cases establish with reasonable certainly that someone has died of overdose. If a Patient fills a prescription for a hundred barbiturate tablets, for example, and is found dead the next morning with only a few tablets left in the bottle, death from barbiturate poisoning is a reasonable hypothesis to be explored. Similarly, if an addict dies after "shooting up," and friends who were present report that he injected many times his usual dose, the possibility of death from heroin overdose deserves serious consideration.

Further, in cases where an addict has died following an injection of heroin, and the syringe he used is found nearby or still sticking in his vein, the contents of the syringe can be examined to determine whether it contained heroin of exceptional strength. And there are other ways of establishing at least a prima facie case for an overdose diagnosis.


A conscientious search of the United States medical literature throughout recent decades has failed to turn up a single scientific paper reporting that heroin overdose, as established by these or any other reasonable methods of determining overdose, is in fact a cause of death among American heroin addicts. The evidence that addicts have been dying by the hundreds of heroin overdose is simply nonexistent.

No coroner, of course, wants to be in a position of having to answer "I don't know" to such queries. A coroner is supposed to know--- and if he doesn't know, he is supposed to find out. . . . At some point in the history of heroin addiction, probably in the early 1940s, the custom arose among coroners and medical examiners of labeling as "heroin overdose" all deaths among heroin addicts the true cause of which could not be determined. These "overdose" determinations rested on only two findings: (1) that the victim was a heroin addict who "shot up" prior to his death; and (2) that there was no evidence of suicide, violence, infection, or other natural cause. . . .  Thus, in common coroner and medical examiner parlance, "death from heroin overdose" is synonymous with "death from unknown causes after injecting heroin."

A striking feature of this mysterious new mode of death is its suddenness. Instead of occurring after one or more hours of lethargy, stupor, and coma, as in true overdose cases, death occurs within a few minutes or less--- perhaps only a few seconds after the drug is injected. Indeed, "collapse and death are so rapid," one authority reports, "that the syringe was found in the vein of the victim or on the floor after having dropped out of the vein, and the tourniquet was still in place on the arm."

An even more striking feature of these mysterious deaths is a sudden and massive flooding of the lungs with fluid: pulmonary edema. In many cases it is not even necessary to open the lungs or X-ray them to find the edema; "an abundance of partly dried frothy white edema fluid [is seen] oozing from the nostrils or mouth." Neither of these features suggests overdose--- but since "overdose" has come to be a synonym for "cause unknown," and since the cause of these sudden deaths characterized by lung edema is unknown, they are lumped under the "overdose" rubric.  Not all of the deaths attributed to heroin overdose are necessarily characterized by suddenness and by massive pulmonary edema, but several studies have shown that a high proportion of all "overdose" deaths share these two characteristics.

(3) Evidence demonstrating that these deaths are not due to overdose is plentiful. This evidence has been summarized in a series of scientific papers, beginning in 1966, by New York City's Chief Medical Examiner, Dr. Milton Helpern, and his associate, Deputy Chief Medical Examiner, Dr. Michael M. Baden. At a meeting of the Society for the Study of Addiction held in London in 1966, Dr. Helpern explained that the most conspicuous feature of so-called "overdose" deaths is the massive pulmonary edema. When asked the cause of the edema, he cautiously responded:

This is a very interesting question. To my knowledge it is not known why the pulmonary edema develops in these cases.... This reaction sometimes occurs with the intravenous injections of mixtures, which as far as is known, do not contain any heroin, but possibly some other substance. The reaction does not appear to be specific. It does not seem to be peculiar to one substance, but it is most commonly seen with mixtures in which heroin is the smallest component.

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.

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."

Most deaths from so-called overdose, as noted above, are characterized by suddenness and by pulmonary edema. No other cause of death--- such as tetanus, bacterial endocarditis, hepatitis, or a knife or gunshot wound--- is found. In approximately 60 percent of autopsies, a 1970 study indicates, there is also cerebral edema (accumulation of fluid in the brain) along with widespread fragmentation of the astrocytes (star-shaped cells) in the brain.  A death with these characteristics, occurring in a heroin addict, constitutes a dramatic and readily identifiable syndrome which Dr. Helpern has called "acute fatal reaction to the intravenous injection of crude mixtures of heroin and other substances." We shall here apply a less cumbersome label: "Syndrome X."  {Quinine was introduced as a cut when Malaria was being spread through shared needles in the late 30s.  Being bitter it masks the taste of heroin, thus making it impossible for the customer to perform a simple taste test to gauge the heroin concentration.  It still the preferred cut.}  Quinine was proposed as the cause of Syndrome X.


A second possible cause of Syndrome X deaths can best be illustrated by two examples.

One is the case of "C. G.," a heroin addict long accustomed to mainlining his drug, who one day got drunk, took his "customary injection of heroin and collapsed shortly thereafter." Subsequent X-rays showed lung edema.

  Another is the case of a heroin addict whose death was recently reported by Dr. George R. Gay and his associates at the Haight-Ashbury Medical Clinic, San Francisco. This addict first "shot some reds" (that is, barbiturates) and then "fixed" with heroin following the barbiturates. He died of what was diagnosed as "overdose of heroin."

Cases such as these have given rise to the question whether Syndrome X deaths may result from injecting heroin (with or without quinine) into a body already laden with a central-nervous-system depressant such as alcohol or a barbiturate.

Addicts themselves would seem to deserve credit for first suspecting that so-called "heroin overdose" deaths might in fact result from the combined action of alcohol and heroin. Back in 1958, a team headed by Dr. Ray E. Trussell and Mr. Harold Alksne interviewed more than 200 New York City addicts--- alumni of the Riverside Hospital addiction treatment program (see Chapter 10). In this as in other pre-1960 studies, few addicts drank alcohol while on heroin, and they did not drink much. When asked why, the addicts commonly gave two reasons.

One was that the effect of alcohol is "offensive" to a man on heroin. "The narcotic alone has an analgesic effect which tends to quiet the individual. Alcohol, on the other hand ... has the capacity to agitate the individual in his relationships with other people. This generally is offensive to the addict."

The other reason given by addicts in 1958 for not drinking while on heroin is the first extant clue to the possible relationship between alcohol and death from "heroin overdose." Addicts, the Trussell-Alksne team noted, "believe that the use of narcotics and alcohol in combination is dangerous and might possibly lead to the death of an individual."  By the 1960s, this awareness of the hazard of shooting heroin while drunk had disappeared from the addict scene. Addicts, like others, were evidently convinced by the official announcements that those deaths were indeed due to heroin overdose.

If the theory is sound that even an ordinary dose of an opiate injected while drunk can produce death, then death could occur when an ordinary drunk who is not addicted is brought into a hospital emergency room with a painful injury and is given a routine (10 milligram) injection of morphine to ease his pain. Drs. William B. Deichmann and Horace W. Gerarde report in their Toxicology of Drugs and Chemicals (1969 edition) that death may in fact occur under such conditions.

"The ordinary safe therapeutic dose of morphine," they warn, in italics, in their textbook, "may be fatal to persons who have been drinking alcoholic beverages. Morphine in therapeutic doses [similar to the doses commonly injected by addicts] resulted in fatalities in individuals whose blood alcohol levels ranged from 0.22 to 0.27%. Morphine is also synergistic with barbiturates and related drugs."  Thus the hazard of death from shooting an opiate while drunk on alcohol or a barbiturate is familiar to some toxicologists even though it has been ignored by authorities on drug addiction--- and by coroners and medical examiners--- through the years.

If this alcohol-heroin and barbiturate-heroin explanation is correct, the fact is of the utmost practical importance--- for hundreds of deaths a year might be prevented by warning addicts not to shoot heroin while drunk on alcohol or barbiturates.

The recent sharp increase in Syndrome X deaths might similarly be explained by an increased tendency to alternate alcohol or barbiturates with heroin as a result of high heroin prices. As the amount of heroin in the New York City bag went down and down, according to this theory, more and more addicts got drunk--- and died of Syndrome X following their next "fix."

 Evidence in recent years for the use of alcohol by addicts shortly before their death has been assembled from the New York City files by Drs. Jane McCusker and Charles E. Cherubin. They reviewed 588 city toxicology reports found in the files on addicts who died in 1967. In 549 of these cases, tests for alcohol had been run--- and in 43 percent of the cases tested, alcohol was in fact found. (Barbiturates were not reported on.) Their findings led Drs. McCusker and Cherubin to suggest that further research be promptly launched into the possible role of alcohol and the barbiturates in so-called "heroin overdose" cases.

Two of the most publicized "overdose deaths" of 1970, Dr. Gay informed the National Heroin Conference in June 1971, fit precisely this pattern. These were the deaths of the rock musician Jimi Hendrix and the singer Janis Joplin. Hendrix was known to use both alcohol and barbiturates--- and possibly also heroin. Janis Joplin "drank [alcohol] like an F. Scott Fitzgerald legend," Dr. Gay adds--- and also used narcotics.

Last week, on a day that superficially at least seemed to be less lonely than most, Janis Joplin died on the lowest and saddest of notes. Returning to her Hollywood motel room after a late-night recording session and some hard drinking with friends at a nearby bar, she apparently filled a hypodermic needle with heroin and shot it into her left arm. The injection killed her.


For a collection of links to articles http://skeptically.org/recdrugs/id13.html



http://www.druglibrary.org/Schaffer/LIBRARY/studies/cu/cu12.htm which is chapter 13 of the Consumers Union Report on Licit and Illicit Drugs, 1972

Journal of Forensic Sciences, Vol 35, No. 4, July 1990, pp. 891-900

Addiction. 98(4):463-470, April 2003.
Fugelstad, Anna 1; Ahlner, Johan 2; Brandt, Lena 1; Ceder, Gunnel 2; Eksborg, Staffan 3; Rajs, Jovan 4; Beck, Olof 5


Aims: To detect risk factors for sudden death from heroin injection.

Design: Evaluation of data from forensic investigations of all fatal cases of suspected heroin death in a metropolitan area. Only cases with detectable morphine and 6-monoacetylmorphine (6-MAM) in blood were included in order to select heroin intoxication cases.

Setting: Stockholm, Sweden.

Measurements: Autopsy investigation and toxicological analysis of blood and urine; and police reports.

Findings: In two-thirds of the 192 cases, death occurred in public places, and mostly without any time delay. Blood concentrations of morphine ranged from 50 to 1200 ng/g, and of 6-MAM from 1 to 80 ng/g. Codeine was detected in 96% of the subjects. In the majority of cases the forensic investigation indicated polydrug use, the most common additional findings being alcohol and benzodiazepines [valium]. However, in one-quarter of the cases other drug combinations were found. Previous abstinence from heroin and use of alcohol were identified as risk factors. For 6-MAM there was also a correlation with the presence of THC and benzodiazepines. Despite a high frequency of heart abnormalities (e.g. myocarditis and focal myocardial fibrosis), these conditions did not correlate with morphine or 6-MAM blood concentrations.

Conclusions: We confirm that alcohol intake and loss of tolerance are risk factors for death from heroin use, whereas no connection to heart pathology was observed. Further, prospective, studies should focus on other possible risk factors.



Warning as to true cause of heroin overdose. About 30 years ago Consumer Report did an article on heroin in which they pointed out that the death from ...
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