Some Thoughts about Opiate Deaths

I met my first opiate addict in the late 1960’s. We called them junkies back then. I was about 14 and “Crazy Al”, a disabled Korean War veteran, lived in the apartment below my friends. Crazy Al was the first person I saw shoot up, and in the next few years I would get to know five or six other junkies.

As a young female I rather liked junkies. They were kinder and calmer than speed freaks, more predictable than drunks, and they didn’t hit on me for sex. One guy had a steady job selling music records at a department store, one was a Vietnam veteran, a few were hippies, including a brother-in-law. I spent long afternoons listening to Nina Simone with one, and took walks with another opiate- addicted man. They all seemed pretty harmless to me and I’ve never understood why opiate addicts are so despised. What interests me now is that none of them overdosed and some are still alive today.

Why are so many opiate users dying of overdoses today? My belief is that it’s because the supply of opiates is far more variable. What you got in the 1960’s, ‘70’s, and ‘80’s was heroin, and heroin got weaker as it passed through the drug dealer chain, cut it with benign fillers.  One shipment might be a little stronger than the last, it wasn’t ten or fifty times stronger. That changed in the mid-1990’s when the fentanyl, a synthetic opiate said to be 50 to 100 times stronger than heroin, was approved by the FDA for “break through pain.” Illegally manufactured fentanyl is now commonly added to low quality heroin to improve its boost. Opiate products sold on the streets often contain unknown amounts of fentanyl and methadone (a longer acting synthetic opiate) as well as heroin. It’s the variability from dose to dose is killing even experienced opiate users today.

A gal I know lost her brother, a competent businessman and pilot, when he crashed his plane. He got hooked on painkillers after a car accident. After his doctors cut him off he started on street drugs. He died in his first year of shooting heroin.

Opiate and heroin-related deaths have tripled since 2010.  During 2014, 47,055 drug overdose deaths occurred in the United States. 61% of those were opiate-related. Some were prescription drug overdoses and some were related to street drug overdoses. Opiate overdoses occur when high amounts of opioids act on the part of the brain that regulates breathing. Opioids in high dosage cause respiratory depression whether the person is addicted or not. Fentanyl is known to produce more respiratory depression that other opiates, yet it is now commonly mixed with heroin. Naïve users may overdose the first time, especially if they mix in alcohol, benzodiazepines, or other central nervous system depressants. There are a lot of new opioid users. The number of opiate prescriptions issued in the U.S. soared from 76 million prescriptions in 1991 to 207 million prescriptions in 2013. But even careful and experienced opiate users now die due to the variability in street heroin.

There has been little mention or in news of the variability of opiates. There has been little effective public response to the opiate epidemic. Fortunately naloxone, an opiate antagonist, is becoming more widely available.  If naloxone is given soon enough it can bring someone back from an overdose.

Naloxone is available to hospitals, police departments and first aid responders, but still not available to drug users or their families. Many people object to helping opiate addicts. But imagine being the parent or friend of an opiate user and watching your child or loved one die before first aid responders arrive.  A European study reported that over half of the opiate users surveyed had witnessed at least one overdose. In Italy naloxone is available in pharmacies without prescription. Wouldn’t it make sense to make naloxone easily available to opiate users and their friends and family? The World Heath Organization recommends that naloxone be made available to anyone who might witness an opiate overdose.

Most people were horrified by Philippine President Duterte’s recent comments. He said, "Hitler massacred three million Jews. Now there are three million drug addicts. I’d be happy to slaughter them.” And he is doing just that. In the USA we don’t want to slaughter opiate addicts but we are allowing them to die in large numbers. The junkies I knew when I was a teenager would most likely have died of overdoses if they were using today. It didn’t used to be like that. But it is now.

Someone told me recently that Janis Joplin traveled with a man who bought and tested the heroin she used and let her know how strong a dose to take. Janis overdosed and died on a night when he was away. If naloxone had been available she’d still be singing. If we can’t stabilize the supply of street opiates the least we can do is make naloxone available.