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.
