Anywhere you turn today, you will hear cries of a prescription-painkiller epidemic. These painkillers are part of a class of drugs known as opioids, of which heroin is also a member. The touting of an epidemic is not incorrect: opioid overdoses have been rising dramatically in the United States over the past several years. The situation is similar in Canada, which has the second-highest level of opioid consumption per capita in the world according to the International Narcotics Control Board. However, there are some major misconceptions surrounding opioid addiction and overdose that lead to both stigmatization and an increased likelihood of overdose death among the population that uses these drugs.
The majority of people who try opioids recreationally do not become addicted. According to the U.S. National Survey on Drug Use and Health in 2012, 5.6% of people who had ever tried prescription opioids recreationally were considered to have abused or been dependent on them within the past year. To put that in perspective, 8.3% of people who had ever tried alcohol were considered to have abused it or to have been dependent on it in the past year by the same measure. Even among chronic pain patients using opioids long-term, a minority show signs of addiction. In a Pennsylvania study, 21.7% of non-cancer chronic pain patients on long-term opioid therapy showed moderate symptoms of addiction, and 13.2% showed signs of serious addiction.
Opioids used responsibly are not particularly lethal. They have a therapeutic ratio (average lethal dose divided by average effective dose) that is favourable enough for them to be considered safe and even essential medicines by every pharmaceutical regulatory agency in the world. However, the climate of drug prohibition (the “War on Drugs”) has created a situation where the harm from these drugs has been maximized due to several factors.
Drug overdose deaths occur almost exclusively after the consumption of multiple drugs, primarily multiple depressants (depressants are “downers,” drugs that slow your breathing and heart rate and relax your mind). In Scotland in 2012, it was found that 97.6% of all people who died of a drug overdose had multiple drugs in their system at the time of death. By far the most common class of drugs found were benzodiazepines (72.1%). In the state of New South Wales in Australia, a study was done on all overdose deaths involving oxycodone over a decade. In every single case, multiple drugs were found in the systems of the deceased, and once again, benzodiazepines were the most common (68.6%). Alcohol is another drug that is often present in drug overdose deaths. Drinking even a small amount of alcohol significantly increases one’s likelihood of dying while taking an opioid.
This simple truth about combining depressants is of such enormous importance for the livelihood of drug users that it should be hammered into their skulls long before they have the chance to actually use drugs. However, with drug prohibition comes a clear narrative for drug education: abstinence is presented as the only option. Our drug education mimics the sex education we abandoned (for the most part) sometime in the last century.
While we used to learn:
“Sex is bad, don’t have sex!”
We now learn:
“Abstinence from sex is the safest option, but if you do end up having sex, you will be much more likely to avoid the greatest harms if you make sure to use a condom.”
Meanwhile, we still learn:
“Drugs are bad, don’t do drugs!”
While we should be learning:
“Abstinence from drugs is the safest option, but if you do end up taking drugs, you will be much more likely to avoid dying of an overdose if you make sure not to combine depressants.”
Drug prohibition also increases the frequency of overdose deaths by pushing users towards adulterated products. Heroin users have no way of confirming if the dope that they are getting on the street is pure heroin or a number of other formulations, which means that many heroin users, even if they think they are only using heroin, are automatically using multiple drugs within a mixture. There is evidence that quinine, a common cut in heroin, often contributes to overdose deaths.
Despite the dangers of combined-depressant overdoses, there is actually a drug that can reverse them almost invariably when they involve opioids: naloxone. Even though it costs cents to manufacture per dose, has no recreational-use potential, and isn’t under patent protection, naloxone is not available to most of the Canadian public. In most jurisdictions, a prescription is necessary to obtain it. Most people are not aware that this life-saving elixir exists, and this is another case of insufficient education. Throughout North America, there is currently a push to make naloxone more available to everyone, so that friends and family of opioid users could administer the drug in the case of an overdose. Edmonton became the first municipality to set up a take-home naloxone program in Canada in 2005, and has since been followed by Toronto and Ottawa, among others. On the provincial level, both British Columbia and Ontario have recently begun to officially support local take-home naloxone programs.
To be clear: I am not saying that it is a good idea to try opioids. Some people, especially (but not exclusively) those with a significant amount of chronic emotional pain, will find opioids so soothing that they will never stop using them once they have started. However, many people can and will use them responsibly. For those who do become addicted, there is no reason their use should be a death sentence.
If you are interested in this topic, I highly recommend this book by Consumer Reports. It was published in 1971, but the analyses and conclusions are not dated at all, and you might find it surprising how questions that were answered so long ago can still be so terribly misunderstood today:
The Consumers Union Report; Licit and Illicit Drugs
Edward M. Brecher and the Editors of Consumer Reports Magazine
Also, if you are in the Toronto area, you might be interested in attending an upcoming public forum, entitled Apathy and Overdose. The event will examine various topics related to drug overdose and will take place at 454 College Street West in Toronto on the 18th of June at 7 p.m.