A recent Huffington Post Live interview featured the headline "Deaths From Heroin Exceed Car Accidents" followed by the statement "In 36 states deaths from heroin overdoses exceed the number of fatalities caused by car accidents."
A Virginia newspaper carried the headline "Heroin deaths exceed traffic fatalities in Virginia, Fredericksburg area" followed by the statements "Deaths from heroin and opioid use outnumbered highway fatalities in Virginia for the first time last year, according to state records. Records show that 728 Virginians died from drug overdoses in 2014, while 700 people died on the state’s roads."
There is just one problem with these statements: they are either patently untrue or thoroughly misleading and are the result of reporters' laziness in failing to get the facts straight and downright knavery in their desire to present sensationalistic scare heads to the public. Only a small minority of drug poisoning deaths are the result of heroin, and likewise, only a minority of opioid poisoning deaths are due to heroin.
Let's look at the real facts:
According to the CDC, in 2013 there were 43,982 deaths due to drug poisoning of which 23,153 involved an opioid, either a prescription opioid or heroin or both. 16,235 deaths involved prescription opioids and 8,260 involved heroin. In other words, just over half of all drug poisoning deaths (52.64%) involved an opioid of some sort, just over a third (36.91%) involved a prescription opioid, and a little over one sixth (18.78%) involved heroin.
What is involved in all the other drug poisoning deaths? Everything from Tylenol to high blood pressure pills to antidepressants. Tylenol and related compounds alone resulted in 675 deaths in 2013. (For details on how data was extracted from the CDC database, see the note at the end of this article.)
So how does this all stack up compared to traffic fatalities? According to the CDC there were 33,804 traffic fatalities in 2013. However, there was not one single state where heroin-involved deaths exceeded traffic fatalities. Only in Washington DC did the number of heroin fatalities exceed the number of traffic fatalities, and it should be noted that the rate of traffic fatalities in Washington DC (4.5 per 100,000) is lower than that of any state in the union.
In only 4 states does the number of prescription opioid deaths exceed the number of traffic deaths, and in only 14 states does the number of deaths from any opioid exceed the number of deaths from traffic fatalities. It is only if we look at all drug poisoning deaths that we see there are 36 states in which drug poisoning fatalities exceed traffic fatalities.
Figure 1 gives the details of how traffic fatalities stacked up compared to drug poisonings, opioid poisonings, and heroin poisonings in 2013.
Another of the media's favorite myths is to blame the increase in heroin-involved deaths on increased heroin purity, as we see in this New York Post story which quotes a DEA agent as saying that heroin is much purer now than it was 20 years ago. Yet according to the DEA's own data, heroin purity peaked in the US 20 years ago and has been going down ever since 1995. In 1995 heroin averaged just over 40% pure nationwide, in 2012 (the most recent year for which the DEA has released data to the public) this is down to just over 30% pure nationwide.
Another of the media’s favorite myths is to blame the increase in heroin-involved deaths on increased heroin purity...-Kenneth Anderson Yet another myth promulgated in the media is that the increase in heroin and other drug poisoning deaths is due to an explosive increase in the number of heroin users; however, the actual data does not bear this out either.
According to SAMHSA's National Survey on Drug Use and Health (NSDUH), the percentage of people in the US over age 12 who had used heroin in the past year in 1999 was 0.16%; by 2013 this had only increased to 0.25%, a 56% increase (1.56 fold). By way of contrast, CDC data tell us that heroin poisoning death rates increased from 0.7 deaths per 100,000 in 1999 to 2.61 deaths per 100,000 in 2013; this is a 273% (3.73 fold) increase.
What can account for this huge increase in heroin involved deaths? It is clearly not purity, since purity is dropping; nor is it the number of new users since the increase in new users is far too small to account for the increase in death rate. Something else must be going on here.
Let's take a look at the CDC data on heroin poisoning by age and urbanization and how it has changed from 1999 to 2013.
Figure 2 shows the heroin poisoning death rates by age for 1999 and 2013.
What we see is a huge increase in the deaths of young people from around age 20 to age 35. If we use the CDC data to calculate which age group has the greatest death rate due to heroin poisoning, we find that in 1999 it is 40 to 44 year olds. In 2013 it is 25 to 29 year olds.
In Figures 3 and 4 we show the increases in heroin poisoning deaths from 1999 to 2013 in terms of urbanization. Figure 3 shows the increases in heroin poisoning death rates from 1999 to 2013 by urbanization. Figure 4 shows the percentage by which heroin poisoning deaths increased by urbanization.
Figure 5 looks at the heroin poisoning death rate by both age and urbanization in 2013. Here we see that in big cities the highest death rates are among older users aged 45 to 54 years old, similar to the pattern seen in 1999.
Not a great deal seems to have changed in big cities over the years; there are more users and more deaths but the increase in number of users seems fairly consonant with the increase in numbers of deaths. However, in all the less urbanized areas we see that the highest death rates are in the age range from 25 to 34 years old, in sharp contrast to what we see happening in major cities.
The less urban areas are also where the death rates are increasing most rapidly as we see from Figure 4, although they still have a long ways to go to catch up with the big cities as we see in Figure 3. The big cities appear to have the most users and hence the most total deaths, but the less urban areas seem to have the most naive and inexperienced users and hence the highest death rates per user.
Figure 6 shows the number of past year heroin users per age group for 1999 and 2013 according to the National Survey on Drug Use and Health (NSDUH). What we see here is a large increase in the number of users aged 20 to 34: the same group showing the highest rates of heroin poisoning death.
Taking all the above data together, the most logical conclusion is that new young, less urban heroin users have much higher death rates than older and more urban heroin users. Why should this be so? Heroin users in major cities have great access to harm reduction services and information. Older urban users have a lot more knowledge about how to shoot heroin and not die than do the naive younger and less urbanized heroin users. Therefore, the greatest single service the media could do is to make this harm reduction information available.
I would like to see The New York Times publish a front page story tomorrow titled "How Not to Die When Using Heroin" and containing the following information:
A) Recognizing an Overdose
First of all forget everything you ever saw in bad movies and TV shows like Pulp Fiction or Breaking Bad because it's all wrong.
Only about 15% of heroin overdose deaths are of the sudden, needle in the arm type. The rest occur over a period of one to three hours and there is nothing dramatic about them. They start with the victim dozing off to sleep. Next the breathing gradually gets shallower and the victim slips into a coma. Often the person turns blue due to lack of oxygen: this may be particularly noticeable around the lips and fingernails.
The following information from the Harm Reduction Coalition will help you tell the difference between someone who is really high and someone who is overdosing:
If someone is really high and using heroin or prescription opioids:
- Pupils will contract and appear small
- Muscles are slack and droopy
- They might "nod out"
- Scratch a lot due to itchy skin
- Speech may be slurred
- They might be out of it, but they will respond to outside stimulus like loud noise or a light shake from a concerned friend.
The following are symptoms of an overdose:
- Awake, but unable to talk
- Body is very limp
- Face is very pale or clammy
- Fingernails and lips turn blue or purplish black
- For lighter skinned people, the skin tone turns bluish purple, for darker skinned people, it turns grayish or ashen.
- Breathing is very slow and shallow, erratic, or has stopped
- Pulse (heartbeat) is slow, erratic, or not there at all
- Choking sounds, or a snore-like gurgling noise (sometimes called the "death rattle")
- Loss of consciousness
- Unresponsive to outside stimulus
If you are worried that someone is getting too high, it is important that you don’t leave them alone. If the person is still conscious, walk them around, keep them awake, and monitor their breathing. If someone is making unfamiliar sounds while "sleeping" it is worth trying to wake him or her up.
Many loved ones of users think a person was snoring, when in fact the person was overdosing. These situations are a missed opportunity to intervene and save a life. If you’re having a hard time telling if someone is overdosing or not, it is best to treat the situation like an overdose - it could save someone’s life.
B) Carry Narcan (naloxone)
Getting Narcan into the hands of first responders and police is a good policy, but by itself, it is woefully inadequate. All people who use opioids and their friends and family should always carry Narcan (naloxone). Heroin kills by binding to the receptors on the respiratory center and stopping breathing. The ONLY thing which can reverse a heroin overdose is an opioid antagonist like Narcan which knocks all the opioid molecules off of the brain's opioid receptors. Narcan is the standard because it works the best.
Getting Narcan into the hands of first responders and police is a good policy, but by itself, it is woefully inadequate.-Kenneth Anderson Narcan has a shorter half life than heroin, so someone who has been revived with Narcan must be watched so they don't fall back into overdose when the Narcan wears off. Don't let them use again and call 911 to get them to a hospital. Old wives tales about using salt shots or milk shots to reverse an overdose are just that: they are completely ineffective.
And remember that Pulp Fiction is a movie; even if you had adrenaline, it would be completely ineffective in reversing an opioid overdose, since what is needed is to get the opioid molecules off of the receptors in the brain. Narcan kits have full instructions on how to check for overdose, administer, and do rescue breathing: so get yours today!
C) Be Wary of Using Alone
The Harm Reduction Coalition gives the following information about using alone:
While using alone isn’t necessarily a cause of overdose, it increases the chance of fatally overdosing because there is no one there to call for help or take care of you if you go out. Many fatal overdoses have occurred behind closed or locked doors where the victims could not be found and no one was there to intervene.
- Fix with a friend!
- Develop an overdose plan with your friends or partners.
- Leave the door unlocked or slightly ajar.
- Call someone you trust and have them check on you.
- Some people can sense when they are about to go out. This is rare, but if you are one of the people that can do this, have a loaded syringe or nasal naloxone ready. People have actually Naloxone’d themselves before!
If you do choose to use alone then double down on all the other safety tips here.
D) Be Wary of Drug Mixing
According to the CDC, at least two thirds of so called heroin overdose deaths are actually due to mixing alcohol or another drug with heroin. It is always safest not to mix heroin with other drugs. If you must mix, then be aware that the most dangerous mixes with heroin include alcohol, benzodiazepines, cocaine, and prescription opioids. If you choose to mix drugs then it is a good idea to double down on all the other safety precautions on this list.
E) Tester Shots and Heroin Testing
Any time you buy a new batch of heroin it is essential to start with a small tester shot to gauge the purity before injecting a whole dose. This is true even if you get it from your regular dealer: never assume the strength is the same. Alternatively, there are now testing kits you can buy on the internet to gauge the purity of your heroin. Since the DEA reports that heroin sold on the street can vary in purity from 3.9% pure to 83.4% pure, testing is always essential.
F) Be Aware of the Safety Ratio
The safety ratio indicates the difference between the amount of the drug it takes to get you high and the amount it takes to kill you. It is similar to the therapeutic ratio which indicates the difference between an effective dose and a lethal dose.
The safety ratio of heroin is much lower than that of prescription opioids; this is why it is much easier to overdose on heroin than prescription opioids. It is also far more dangerous to mix drugs like alcohol or benzos with heroin than with prescription opioids; trying to use the same drug mixes you used with prescription opioids is far more likely to kill you if you substitute heroin for the prescription opioid - even if the effect feels the same.
If you switch from prescription opioids to heroin be doubly cautious about everything.
G) Know About Tolerance and How It Changes
Using heroin again after any period of abstinence is risky because tolerance soon drops back to the level of a new user. This is why risk of overdose is greatly increased after incarceration or abstinence based drug treatment.
If you use again after a period of abstinence be very cautious to use small quantities; do not try to pick up again where you left off or it could kill you. Tolerance also drops in novel situations. If you are using in a new location or environment, be careful to use less.
H) Route of Ingestion
Snorting is safer than smoking and smoking is safer than injecting. Once there is too much heroin in your vein, there is no way to get it out.
I) Other Factors
If you have had a non-fatal overdose you are at greater risk for fatal overdose. Older people and those in poor health are more likely to die of overdose than those who are young and healthy; be extra cautious using if you are sick.
The following codes were used to extract the data from CDC WONDER:
- All drug poisoning deaths: UCD X40-X44, X60-X64, X85, Y10-Y14
- Heroin: UCD X40-X44, X60-X64, X85, Y10-Y14; MCD T40.0-.1
- Prescription opioids: UCD X40-X44, X60-X64, X85, Y10-Y14; MCD T40.2-.4
- Any opioid: UCD X40-X44, X60-X64, X85, Y10-Y14; MCD T40.0-.4
- Tylenol and related compounds: UCD X40-X44, X60-X64, X85, Y10-Y14; MCD T39.1
- Traffic fatalities: UCD V02-V04[.1,.9],V09.2,V12-V14[.3-.9],V19[.4-.6],V20-V28[.3-.9],V29-V79[.4-.9],V80[.3-.5],V81.1,V82.1,V83-V86[.0-.3],V87[.0-.8],V89.2
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