Soldiers, police inject drugs openly in rural Myanmar; stark sign of nation losing

[S.J.B.]

"However, the number of deaths increases fourfold when calculated by the multiple-cause method."

For the longest time I have been trying to find CDC poisoning death statistics that mention the prevalence of alcohol but can't find it anywhere. In fact, from the CDC press releases it seems as if they are trying their very hardest to omit any mention of alcohol. Tell me if this makes sense:

In 2000, there were approximately 17,000 drug poisoning deaths in the United States.

Let's assume, for the moment, that alcohol prevalence during these deaths matches that of the Scottish data I linked, and to be conservative I'll choose the year with the lowest alcohol prevalence rate: 37.1%. That would give us 6,300 drug poisoning deaths involving alcohol, a far cry from the 1,300 listed in the article you linked. Why the discrepancy? Maybe Americans drink less than Scots, but I think a large part is the fact that alcohol is most likely ignored in polydrug deaths where opioids and benzodiazepines are also involved. The Scottish data would discount this practice as absurd: given that single-drug use is almost never the cause of poisoning death, how can the addition of alcohol be discounted?

The #1 statistic that I have wanted to know for ages is the percentage of drug poisoning deaths involving opioids in the United States where alcohol is also present. If you find it you will be my favourite person!

 

[opi8]

she'll find something that has that data, I wouldn't really trust it though.

 

[pmoseman]

For the longest time I have been trying to find CDC poisoning death statistics that mention the prevalence of alcohol but can't find it anywhere. In fact, from the CDC press releases it seems as if they are trying their very hardest to omit any mention of alcohol. Tell me if this makes sense:

In 2000, there were approximately 17,000 drug poisoning deaths in the United States.

Let's assume, for the moment, that alcohol prevalence during these deaths matches that of the Scottish data I linked, and to be conservative I'll choose the year with the lowest alcohol prevalence rate: 37.1%. That would give us 6,300 drug poisoning deaths involving alcohol, a far cry from the 1,300 listed in the article you linked. Why the discrepancy? Maybe Americans drink less than Scots, but I think a large part is the fact that alcohol is most likely ignored in polydrug deaths where opioids and benzodiazepines are also involved. The Scottish data would discount this practice as absurd: given that single-drug use is almost never the cause of poisoning death, how can the addition of alcohol be discounted?

This does not appear to be a publication but rather an internal memo...

Alcohol poisoning deaths in 2002:
355 unintentional, 26 suicide, 25 undetermined (see page 5).

edit: F10-F19 are deaths from mental or behavorial disorders associated with psychoactive substance abuse.

https://www.google.com/url?sa=t&source=web&cd=5&ved=0CDYQFjAE&url=http://www.cdc.gov/nchs/ppt/injury/poisoning_definition.ppt&ei=_z0tU5_rEcbg2AXE44Aw&usg=AFQjCNEdTBf-XEQQDqX64iIb_UJmFB0hhQ&sig2=Z9VAJKl58XqeVXDTRo2-kQ&bvm=bv.62922401,d.b2I

Why 1,300 is not closer to 6,300?
"Previous studies have suggested that the prevalence of alcohol poisoning deaths is extremely low in the United States compared with some European countries (Notzon et al. 1999; Department of Health and Human Services [DHHS] 1995; Poikolainen and Vuori 1985; Caces et al. 1991)."
(from study in previous post)

 

[pmoseman]

The #1 statistic that I have wanted to know for ages is the percentage of drug poisoning deaths involving opioids in the United States where alcohol is also present. If you find it you will be my favourite person!

In the case of opiates/opioids, it seems that analyzing the data directly may be your simplest solution. You would have a precise answer to your question, but doubtfully an accurate one.

With heroin the number is probably near 50% (Coffin, 2003).

What question are you trying to answer with this figure?

 

[S.J.B.]

Why 1,300 is not closer to 6,300?
"Previous studies have suggested that the prevalence of alcohol poisoning deaths is extremely low in the United States compared with some European countries (Notzon et al. 1999; Department of Health and Human Services [DHHS] 1995; Poikolainen and Vuori 1985; Caces et al. 1991)."
(from study in previous post)

Once again, this doesn't answer whether or not this low stated prevalence is due to an actual lack of alcohol's presence in poisoning deaths, or due to the fact that alcohol's involvement is dismissed when it shows up in polydrug deaths.

In the case of opiates/opioids, it seems that analyzing the data directly may be your simplest solution. You would have a precise answer to your question, but doubtfully an accurate one.

With heroin the number is probably near 50% (Coffin, 2003).

What question are you trying to answer with this figure?

I find there is a wide lack of acknowledgement in society regarding the role that drug combinations play in overdose deaths. I would go so far as to state that the failure to properly acknowledge this is a major factor contributing to the prevalence of these deaths. My gut feeling (corroborated by the Scottish data I posted) is that alcohol (and, to a comparable extent perhaps, benzodiazepines) is intrinsically tied to the rise in so-called opioid poisoning deaths that is occurring in the United States at the moment. I would like to know if I am correct or not.

 

[pmoseman]

Once again, this doesn't answer whether or not this low stated prevalence is due to an actual lack of alcohol's presence in poisoning deaths, or due to the fact that alcohol's involvement is dismissed when it shows up in polydrug deaths.

I find there is a wide lack of acknowledgement in society regarding the role that drug combinations play in overdose deaths. I would go so far as to state that the failure to properly acknowledge this is a major factor contributing to the prevalence of these deaths. My gut feeling (corroborated by the Scottish data I posted) is that alcohol (and, to a comparable extent perhaps, benzodiazepines) is intrinsically tied to the rise in so-called opioid poisoning deaths that is occurring in the United States at the moment. I would like to know if I am correct or not.

From 2010 to 2011 the number of drug overdose cases in Scotland increased by 20% while the frequency of alcohol being detected in such cases decreased by 40%.

Having examined studies in the United States it appears much the same has happened. The increased prevalence of death from accidental drug poisoning, largely from prescription drugs, has not been related to alcohol.

Although it may seem to you that society is unaware of the potential dangers found when mixing alcohol and opiates, the professional community is well aware of this and also has made me more aware that certain drug combinations make overdosing much easier.

According to the record, alcohol poisoning in the United States contributed to only 7.5% of the deaths by drug overdose and in Scotland alcohol was detected in 37.1% of such cases.

1) In Scotland, out of the 37.1% detections of alcohol, only 55% of the time was alcohol said to contribute to the death.

2) In the United States, 1269 alcohol poisonings contributed to drug overdose, but including excessive blood alcohol content to the data would implicate alcohol an additional 205 times (note the figure from Scotland is not based on alcohol poisoning, but on alcohol).

3) Another difference is that Scotland drinks 35.6% more ethanol per capita.

4) Also 17,000 is the total number of all drug overdose deaths in 1999 and these studies deal with unintentional deaths only. Which it can be seen from slide 4 were closer to 11,000 in number.

While this does not explain the whole difference. You would now, after accepting the above adjustments to be accurate, be comparing a figure of 1700 to 1500 instead of 6300 to 1300.

 

[drug_mentor]

Isn't having a cheap, pure source of easy to access heroin supposed to make people functioning addicts?

I think the issue is that although the drugs seem cheap by Western standards, if you look at what people earn there then for most of the locals the price there probably works out similarly expensive to somebody in a first world country paying a lot more for the drugs but also having a much higher income. I admit I know very little about the situation in Myanmar right now, but I would wager this is likely to be the case. Even if a drug habit is not as relatively expensive as it is in the West, I think it is hard to argue that the seemingly low price of drugs over there is not deceptive if you consider what the average person is likely making.

 

[S.J.B.]

Having examined studies in the United States it appears much the same has happened. The increased prevalence of death from accidental drug poisoning, largely from prescription drugs, has not been related to alcohol.

I don't agree with this at all, but like I said, don't have the specific data to prove or disprove it. But neither do you. You posted data estimating that 50% of heroin deaths involve alcohol. Why would it be so different for prescription drugs?

1) In Scotland, out of the 37.1% detections of alcohol, only 55% of the time was alcohol said to contribute to the death.

This is what I have a hard time with. If a drug rarely kills by itself, but kills relatively often when alcohol is consumed along with it, how can alcohol be discounted as not contributing to the death? When 37% of the deaths involved alcohol and only 3% involved solitary drugs? It is a biased attitude which pins the blame squarely on the more disdained drug, when these deaths are clearly combined-depressant poisonings.

Doctors are still prescribing patients opioids and benzodiazepines simultaneously, which seems preposterous to me, yet from the media attention you would think that it's just OxyContin killing everyone all by itself.

 

[pmoseman]

I don't agree with this at all, but like I said, don't have the specific data to prove or disprove it. But neither do you. You posted data estimating that 50% of heroin deaths involve alcohol. Why would it be so different for prescription drugs?

The recent increase has been prescription analgesics and half those deaths involved one drug.

Although alcohol remains a consistent problem it is proportionally less, due to this rapid increase.

Benzodiazepine and other opiods make up the difference. The risk of alcohol is the same for each group, it is just with analgesics there are many more deaths that do not involve alcohol.

The important thing is that these statistics are consistent. That way they allow comparisons to be made. The increase in deaths from drug overdoses we did not see an increase in the percent of alcohol detected because there was an increase in deaths but no alcohol. There were still plenty of people dying from mixing alcohol and drugs, but this portion did not increase as much.

This is what I have a hard time with. If a drug rarely kills by itself, but kills relatively often when alcohol is consumed along with it, how can alcohol be discounted as not contributing to the death?

"3) at blood ethanol concentrations between 0.20 and 0.29 g/dL, the morphine concentrations in heroin deaths increased significantly, 4) at blood ethanol concentrations greater than 0.30 g/dL, morphine became less of a factor than the ethanol in causing death."
http://www.ncbi.nlm.nih.gov/m/pubmed/7595326/

Perhaps after having a beer Sam decided to take a hefty overdose of benzodiazepine, heroin, and cocaine. The beer would be detected but would not play any significant role. After having 5 beers Sam would have died with lower concentrations of the other drugs because Sam would have died before taking them.

I do not know where they decided to draw the line, but it probably makes some sense after you look into it.

 

[S.J.B.]

The recent increase has been prescription analgesics and half those deaths involved one drug.

Can you show me the source for this?

"3) at blood ethanol concentrations between 0.20 and 0.29 g/dL, the morphine concentrations in heroin deaths increased significantly, 4) at blood ethanol concentrations greater than 0.30 g/dL, morphine became less of a factor than the ethanol in causing death."
http://www.ncbi.nlm.nih.gov/m/pubmed/7595326/

Perhaps after having a beer Sam decided to take a hefty overdose of benzodiazepine, heroin, and cocaine. The beer would be detected but would not play any significant role. After having 5 beers Sam would have died with lower concentrations of the other drugs because Sam would have died before taking them.

From the article you linked:

"From the data, we conclude that 1) the use of even small amounts of ethanol with heroin is clearly a risk factor in deaths due to heroin..."

 

[pmoseman]

I guess I got that wrong. 33% involved one drug. Nearly half involved one other drug.
http://www.cdc.gov/homeandrecreationalsafety/rxbrief/

This is an article I found interesting. Especially the graph of different drug combinations on page 8.
https://www.google.com/url?sa=t&sou...=_FMpaTuFPtYXP9IsXXkX8w&bvm=bv.62922401,d.b2I


These are a little outdated, 2006 and 2005, but these were what I happened upon looking for that alcohol statistic

.....

I read that part of the article, you seem to be missing the point. The point is that having a beer and shooting up an extra gram of benzodiazepine should not be counted as alcohol contributing to the death. Rapidly consuming 5 beers and shooting the same amount of opiate you are accustomed to is a death due to the alcohol.

I don't know exactly where they cut it off at but the cut off line may very well be 4 beers in rapid succession.

After going through a great deal of effort explaining to you how Scotland and the United States are statistically consistent you seem to have not adjusted your theory any.

 

[S.J.B.]

I guess I got that wrong. 33% involved one drug. Nearly half involved one other drug.
http://www.cdc.gov/homeandrecreationalsafety/rxbrief/

This is an article I found interesting. Especially the graph of different drug combinations on page 8.
https://www.google.com/url?sa=t&sou...=_FMpaTuFPtYXP9IsXXkX8w&bvm=bv.62922401,d.b2I


These are a little outdated, 2006 and 2005, but these were what I happened upon looking for that alcohol statistic

Once again, both of these data sets are based on a coroner's interpretation of what drugs contributed to a death, and not what drugs were present at death. Compare these to the Scottish figure, where multiple substances were present for 97% of the deaths.

Similarly: between 1999 and 2008, every single oxycodone-related poisoning death in New South Wales involved polydrug use.

I have yet to see American data that shows the proportion of drug poisoning deaths where multiple drugs were present in the toxicological screens.

I read that part of the article, you seem to be missing the point. The point is that having a beer and shooting up an extra gram of benzodiazepine should not be counted as alcohol contributing to the death. Rapidly consuming 5 beers and shooting the same amount you are accustomed to is the problem.

I am not missing the point.

You take a gram of drug X every day.

One day, you take two grams of drug X. You don't take anything else. You don't die.

You continue to take a gram of drug X every day.

One day, you take two grams of drug X and drink a couple beers. You die.

Coroner says: drug X is the sole cause of death!

But I would have to disagree.

Here are some studies that argue the point I am making:

Does alcohol increase the risk of overdose death: the need for a translational approach

"The positive epidemiological evidence shows that opiate overdose deaths rarely involve a single drug; that alcohol is the most common other drug involved; that there is a negative association between alcohol and morphine concentration at post mortem; and that post-mortem levels of morphine are often below the levels expected of highly tolerant individuals. The evidence is consistent with the hypothesis that heroin users who drink may require less heroin to overdose than those who do not drink (all other factors being equal) because of a pharmacological interaction."

Heroin overdose: research and evidence-based intervention

"Possibly the most important finding to emerge from heroin overdose research is the role of polydrug use. The overwhelming majority of overdoses, both fatal and nonfatal, involve the concomitant consumption of heroin with other drugs. The extensiveness of polydrug use among “heroin” overdoses suggests that “polydrug toxicity” is a better description of the toxicology of overdose."

In effect, almost no one is dying of an OxyContin overdose just by taking their OxyContin.

 

[pmoseman]

Everything that you've done in your life has contributed to your death. The question I have to ask you is where do you draw the line?

 

[S.J.B.]

Everything that you've done in your life has contributed to your death. The question I have to ask you is where do you draw the line?

When it comes to drug poisoning deaths I think that could be answered by answering this question: "would this person have died at this time if he had not consumed this particular drug?"

When it comes to alcohol (or a benzodiazepine) combined with an opioid, with no other drugs present, I would argue that the answer to the aforementioned question would be "no" for both of the consumed drugs in most circumstances (therefore both alcohol and the opioid contributed to the death).

If it were a lot of alcohol, a lot of heroin, and a cup of coffee, I would lean towards answering "yes" for the coffee (therefore the coffee did not contribute to the death).

Clearly there is no way to prove this one way or the other on a case-by-case basis, but on a population basis, the studies I have mentioned tend to support my conclusion regarding the role of alcohol as a contributor to poisoning deaths.

 

[pmoseman]

What do you mean by "most circumstances"?

 

[TheRightStuff]

Things tip the scales of death all the time but that doesn't mean that they are the cause it it can be justified. Also 37 deaths in 30 years.. this just makes me smile as really it may be the least likely thing of anything on this planet to kill you. If you have time pmose please list something, anything that has just caused 37 (claimed and not proven) in 30 years.


It can be claimed that heroin only kills because of lack of narcan.

A mountain-climber (serious mountain-climber, Everest, K2 etc) once told me that he has a 1/6 chance of dying. Yet no one is advocating we ban mountain-climbing. Horses for courses.

 

[TheRightStuff]

Everything that you've done in your life has contributed to your death. The question I have to ask you is where do you draw the line?

In 2011, deaths attributed to drugs (per 100,000) over-took deaths attributed to automobiles for the first time ever. At the time, it was reported breathlessly - "OMFG drugs are killing more people than automobiles now!!" - but there's something we quite happily let go over any line you wish to draw. We ban drugs but we don't ban automobiles? Despite the fact that we are so aware about the great risk they pose to human life that we expect them to kill more people than illicit drugs. Yet drugs are illegal? So, yes, you pose a good question - where DO we draw the line? Wherever it is it seems pretty bloody arbitrary to me. Whatever the reason we ban drugs, the risk of mortality evidently is not it.

 

[S.J.B.]

What do you mean by "most circumstances"?

As the links I have provided in previous posts show, solitary drugs rarely kill, combined drugs kill much more often, ergo the drugs contributing to these fatal combinations are necessary for the deaths to occur in most circumstances.

 

[pmoseman]

In 2011, deaths attributed to drugs (per 100,000) over-took deaths attributed to automobiles for the first time ever. At the time, it was reported breathlessly - "OMFG drugs are killing more people than automobiles now!!" - but there's something we quite happily let go over any line you wish to draw. We ban drugs but we don't ban automobiles? Despite the fact that we are so aware about the great risk they pose to human life that we expect them to kill more people than illicit drugs. Yet drugs are illegal? So, yes, you pose a good question - where DO we draw the line? Wherever it is it seems pretty bloody arbitrary to me. Whatever the reason we ban drugs, the risk of mortality evidently is not it.

We expect automobiles to kill people because of what happened the year before. Do you think this makes anyone happy?

They haven't banned automobiles and they haven't banned prescription drugs either, which are the cause of the increase in drug related deaths. Why? Because law abiding citizens who use these products benefit from them without taking on too much risk.

The risk of prescription pain medications are, for the most part, killing people who mix drugs, have no prescription, or are getting multiple prescriptions. Changes in regulations are intended to lower the risk for both groups.

Traffic accidents are also not caused by driving and following the laws. The risks of speeding and driving under the influence of drugs are major contributors.

The risk to benefit ratio is a bit arbitrary, but was not the line I was hoping to discuss. Not driving and abusing narcotics is a far greater risk than someone who chooses to drive and not abuse drugs. So you can say whatever you like.

We had been discussing alcohol and the risks of accidental poisoning. If you look at the numbers of deaths caused by alcohols and the number of deaths caused by narcotics and hallucinogens, you see the latter causes more than 10 times the number of deaths. This is in the United States during 1999 through 2010.

The evidence is clear even before you compare the size of these two populations, and obviously more people drink. Which is what you would do to answer a question of risk. Obviously if I do not go into the ocean my risk of death from marine life is nill.

11.2% percent of narcotics and hallucinogens deaths had alcohol as a secondary cause.

I am sure you missed the rest of the discussion where I pointed out "alcohol poisoning" does not mean alcoholic beverages, but includes denatured alcohol and isopropyl alcohol as well. It is difficult, actually, for someone to kill themselves using ethanol alone unless they have an unusually high tolerance.

 

[pmoseman]

As the links I have provided in previous posts show, solitary drugs rarely kill, combined drugs kill much more often, ergo the drugs contributing to these fatal combinations are necessary for the deaths to occur in most circumstances.

These statistics do not give credence to your theory. They contradict your logic by showing fatalities caused by combining alcohols and opiates are less prevalent than the fatalities caused by mixing opiates with other drugs and that one drug, an analgesic by itself, contributed to a great number of these deaths. They included studies that lead to creating an emperical cut-off line for contributing alcohol to various opiate deaths. Your speculation that other countries report these statistics differently flew like a rock.

The coroners are crediting the cause of death to drugs when both alcohol and drugs are involved, but these are known differences that remain in their reports and do not change the overwhelming weight of the evidence even when this is taken fully into account.

I am asking you to show how coroners make that distinction and any reason why they should change how it is made.