But alas, the two standard precautions against overdose--- warnings against taking too much and administration of an antidote--- are in fact wholly ineffective in the current crisis, for the thousands of deaths attributed to heroin overdose are not in fact due to heroin overdose at all. The evidence falls under three major rubrics.
(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.
Let us review these three bodies of data in detail.
Top of Page
(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. "There is little accurate information," Drs. A. J. Reynolds and Lowell 0. Randall report in Morphine and Allied Drugs (1967). "The figures that have been reported show wide variation." 12 This ignorance no doubt stems from the rarity of morphine or heroin overdose deaths. The amounts of morphine or heroin needed to kill a nonaddict have been variously estimated at 120 milligrams (oral), 13 200 milligrams, 14 250 milligrams, 15 and 350 milligrams 16 --- though it has also been noted that nonaddicts have survived much larger doses. 17
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. 18 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. 19 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. 20
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." 21 The addicts didn't even become drowsy. 22
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 "bad no change in respiratory center or any other vital organs." 23
Top of Page
(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 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.
At this point the mystery deepens. If even enormous doses of heroin will not kill an addict, and if there exists no shred of evidence to indicate that addicts or nonaddicts are in fact dying of heroin overdose, why is the overdose myth almost universally accepted? The answer lies in the customs of the United States coroner-medical examiner system.
Whenever anyone dies without a physician in attendance to certify the cause of death, it is the duty of the local coroner or medical examiner to investigate, to have an autopsy performed if indicated, and then formally to determine and record the cause of death. The parents, spouse, or children of the dead person can then ask the coroner for his findings. Newspaper reporters similarly rely on the coroner or medical examiner to explain a newsworthy death. 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.
Top of Page
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. 24 No evidence that the victim had taken a large dose was required to warrant a finding of death from overdose. This curious custom continues today. Thus, in common coroner and medical examiner parlance, "death from heroin overdose" is synonymous with "death from unknown causes after injecting heroin."
During the 1940s, this custom of convenience did little apparent harm. Most deaths among heroin addicts were due to tetanus, bacterial endocarditis, tuberculosis, and other infections, to violence, or to suicide, and they were properly labeled as such by coroners and medical examiners. It was only an occasional death which baffled the medical examiner, and which was therefore signed out as due to "overdose." But, beginning about 1943, a strange new kind of death began to make its appearance among heroin addicts. 25 The cause of this new kind of death was not known, and remains unknown today--- though it is now quite common.
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." 26 This explains in part why nalorphine and other narcotic antagonists, highly effective antidotes in true opiate overdose cases, are useless in the cases falsely labeled overdose.
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" 27 when the body is first found. 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. 28
Top of Page
(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. 29
In a paper published in the New York State Journal of Medicine for September 15, 1966, Dr. Helpern again cast doubt on the myth that these deaths are due to overdose. "Formerly such acute deaths were attributed to overdose of the heroin contained in the sample injected," Dr. Helpern reported--- but he went on to cite several lines of evidence arguing against the overdose theory:
... Unexpected acute deaths may occur in some addicts who inject themselves with heroin mixtures even though others who take the same usual . . . dose from the same sample at the same time may suffer no dangerous effect. In some fatal acute cases, the rapidity and type of reaction do not suggest overdose alone but rather an overwhelming shocklike process due to sensitivity to the injected material. The toxicologic examination of the tissues in such fatalities, where the reaction was so rapid that the syringe and needle were still in the vein of the victim when the body was found, demonstrated only the presence of alkaloid, not overdosage. In other acute deaths, in which the circumstances and autopsy findings were positive, the toxicologist could not even find any evidence of alkaloid in the tissues or body fluids. Thus, there does not appear to be any quantitative correlation between the acute fulminating lethal effect and the amount of heroin taken. . . . 30
Dr. Helpern's associate, Deputy Chief Medical Examiner Baden, went on to further discredit the already implausible overdose theory at a joint meeting of two American Medical Association drug-dependency committees held in Palo Alto, California, in February 1969.
"The majority of deaths," Dr. Baden told the AMA physicians, "are due to an acute reaction to the intravenous injection of the heroin-quinine-sugar mixture. This type of death is often referred to as an 'overdose,' which is a misnomer. Death is not due to a pharmacological overdose in the vast majority of cases." 31
Top of Page
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. 32 This rules out the possibility that some incredibly stupid processor may have filled a bag with pure heroin instead of the usual adulterated mix.
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." 33
These definitive refutations of the heroin overdose theory should, of course, have led to two prompt steps: a warning to addicts that something other than overdose is causing these hundreds of addict deaths annually--- and an intensive search for the true cause of the deaths. But neither of these steps has been taken. Hence the news media go right on talking about "heroin overdose" deaths. "Death from acute reaction to heroin overdose" and other complicated phrases are also used; these phrases similarly conceal the fact that these deaths are not due to overdose.
How can the "heroin overdose" myth not only survive but flourish even after these repeated scientific debunkings? Two stenographic transcripts provide an answer.
The first is the transcript of a press conference held at the Rockefeller University on October 27, 1969, in connection with the Second National Conference on Methadone Treatment. In the course of his remarks to the assembled reporters, Deputy Chief Medical Examiner Baden there discussed at some length a case of what he described as an "addict who died of an overdose of heroin." 34 The reporters present naturally referred thereafter to this death as a "heroin overdose" case.
Top of Page
At the scientific meeting held in the same room on the same day, however, Dr. Baden described the same death in quite different terms. To the scientists he stated that the addict in question "died of acute reaction to injection of heroin, a so-called overdose." When even this description was challenged by a fellow physician, who pointed out that addicts don't die following even enormous doses, 35 Dr. Baden went on to explain that whenever I say 'overdose,' it is in quotation marks." 36
The reporters, of course, could not see those invisible quotation marks when they listened to Dr. Baden at his press conferences and interviews. They quite naturally took him literally--- and continued to inform the public that addicts were dying of overdose.*
* Thus in the New York Times for December 16, 1969, a reporter was led to state without qualification: "About 800 addicts of all ages died this year from overdoses, according to Dr. Baden." 37