Heroin and Prohibition Are a Lethal Combination

How the government promotes deaths from drug poisoning


After the esteemed actor Philip Seymour Hoffman died in February 2014, press coverage of the "heroin epidemic" exploded. Mentions of that phrase in the newspaper and wire service articles cataloged by Nexis rose from 681 in 2013 to 3,222 in 2014, an increase of almost 400 percent. Yet Hoffman—who by his own account used heroin in his early 20s, then abstained for more than two decades before taking up the habit again in 2013—was hardly representative of the upward trend in heroin use that began around 2008, which consisted mainly of people trying the drug for the first time.

Hoffman was typical in at least one respect, however. He died not from a "heroin overdose," as widely reported, but from "mixed drug intoxication" involving cocaine, amphetamine, and benzodiazepines as well as heroin. The combination of heroin and benzodiazepines, a class of drugs that includes Valium and Xanax, presumably was what killed him, since both depress respiration. The dangerous combination of depressants is a very common theme in so-called heroin overdoses, a fact that may help explain why such deaths have climbed dramatically in recent years—more dramatically than you would expect based on the increase in heroin consumption.

According to the National Survey on Drug Use and Health (NSDUH), the number of past-month heroin users rose from 161,000 in 2007 to 289,000 in 2013, an increase of about 80 percent. During the same period, according to the U.S. Centers for Disease Control and Prevention (CDC), the number of "drug-poisoning deaths involving heroin" rose from 3,041 to 8,257, an increase of 172 percent. In other words, the increase in heroin-related deaths was more than twice as big as the increase in past-month use, which means heroin users are more likely to die from drug poisoning than they used to be. 

NSDUH misses an unknown number of regular heroin users who either do not respond to the survey, do not respond honestly, or are not part of the household population the sample is designed to reflect. But even if we assume the actual number of past-month users was substantially higher in 2007 and in 2013, it still looks like heroin use has become more dangerous in recent years. The question is why.

As illustrated by the untimely ends of celebrities such as Hoffman, Janis Joplin, John Belushi, Chris Farley, River Phoenix, Heath Ledger, Cory Monteith, and Amy Winehouse, the vast majority of heroin-related deaths involve multiple drugs. According to CDC data presented by Kenneth Anderson, executive director of the HAMS Harm Reduction Network, at last month's International Drug Policy Reform Conference in Arlington, Virginia, two-thirds of heroin deaths in 2013 involved alcohol or other drugs in addition to heroin. Anderson notes that the true share may be higher because death certificates do not necessarily mention other substances in mixed intoxication cases involving heroin. In New York City, which keeps better track of such details than many other jurisdictions, 94 percent of deaths related to heroin or other opioids in 2013 involved multiple drugs.

Although the share of heroin deaths involving other drugs does not seem to have risen since 2007, the frequency of such mixing by heroin users may have, which could help account for the disproportionate increase in deaths. One reason to think the dangerous habit of combining depressants has become more common is the influx of inexperienced heroin users who may be less aware of the hazards such mixtures pose.

A lot of those new heroin users switched from prescription opioids such a hydrocodone and oxycodone after a government crackdown made those drugs more expensive and harder to get. In recent years, as heroin use has been rising, nonmedical use of opioids has been declining. Trends in poisoning deaths involving the two kinds of drugs also have been moving in opposite directions. According to a 2014 JAMA Psychiatry study, younger heroin addicts entering treatment generally started with prescription opioids, a pattern that is much less common among older addicts. More than nine out of 10 addicts who switched from painkillers to heroin reported that they did so because heroin was cheaper and easier to obtain.

Polydrug use may be even more common among prescription opioid users than it is among heroin users. In 2013, according to the CDC's data, 77 percent of deaths related to prescription painkillers involved mixtures, compared to 67 percent of heroin-related deaths. As with heroin, increases in prescription opioid deaths have far exceeded increases in use. The number of opioid-related deaths more than doubled between 2002 and 2011 (from 7,456 to 16,917), even as the number of past-month users remained about the same. Anderson thinks that disparity may be partly due to an increase in the average size or frequency of the doses that opioid users take.

Opioid users who tend to mix drugs face a greater hazard when they switch to heroin because the purity of the latter drug is so unpredictable. While prescription painkillers come in carefully measured doses, heroin potency varies widely over time, across dealers, and from city to city. That variation, a familiar feature of the black market created by prohibition, can be deadly, whether heroin is combined with other drugs or consumed by itself. A heroin user who comes across a batch that's more potent than he expected, whether because it is purer than usual or because it is spiked with something like fentanyl, can easily take too much, especially if he is consuming another depressant at the same time. Novice heroin users accustomed to legally produced drugs sold in standard doses are apt to be less aware of this danger. Another hazard for switchers: The difference between an effective dose and a lethal dose is smaller for heroin than for prescription painkillers.

The war on drugs magnifies the risk of drug poisoning by making heroin purity inconsistent, by pushing prescription opioid users toward heroin, by making friends and acquaintances of users who need medical attention reluctant to call for help, and by discouraging harm reduction measures as simple as cautioning people against mixing heroin or painkillers with other depressants. By design or not, these effects of prohibition presumably discourage drug use by making it more dangerous, but only by sacrificing the lives of those who are undeterred.

This article originally appeared at Forbes.com.

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  1. Also if you are taught that ‘addiction is a disease’ and you have to confess that you have it, well, you can guess what happens next. This dynamic is particularly insidious for actors, especially good ones.

    1. the “disease model” is bullshit. people are trying to be nice to alcoholics I guess but they either dont realize or don’t care that they’re disrespecting people with actual illnesses, and actually concretely making their (our) lives more difficult

      1. Addiction may be mental/physical for some substances but it isn’t a disease. People who are addicts most likely have mental health issues that could include mental illnesses and drink alcohol, etc., to cope with those issues. But calling addiction itself a disease avoids one’s responsibility for trying to fix those underlying and emotionally complex issues by just focusing on not consuming the product that you’re addicted to.

        1. No it’s a disease I saw a movie about it. I don’t remember the name but Philip Seymour Hoffman was in it. Also there was one with River Phoenix. Also there was one with Heath Ledger and Corey Monteith. Hm.

        2. PTSD. We are making war on the traumatized.

    2. If a psychiatric disease is a pervasive, maladaptive pattern of behavior that substantially negatively influences functioning in one or more major life areas (work, relationships, etc.) how does addiction not qualify?

  2. I think part of the problem is that people were functional addicts on painkillers before the big ‘stop opiate addiction’ train rolled through town. I know that opiate prescriptions were common in the mining towns in the Appalachians and such, which is understandable considering their working environment. But once you took away those functional addicts’ source, they were going to move to something else and heroin is easy to get and relatively similar to what they’d experience on pain killers, assuming the dosages were about the same.

    Since it was a new drug to these kinds of people, you brought exciting new misuses from trial and error – after all, it’s not like you can ask for expert advice on how much heroin is okay from your family doctor.

    1. reply to test

  3. new comment

  4. my co-worker’s sister-in-law makes $71 every hour on the computer . She has been fired for five months but last month her income was $16368 just working on the computer for a few hours. see page………. http://www.earni8.com

    1. “Just for working for a few hours”? At $71 per hour, those are 55 hour weeks your sister is putting in.

  5. I imagine that if opiates were legal, many people would be satisfied with some kind of pill, snort heroin instead of inject it, or some preparation of raw opium, which all, to me, seem to be safer. I once read that before opiates were regulated, doctors would switch alcoholics to morphine because it’s less harmful long-term.

    1. *less physically harmful

      1. People used to dope their kids with heroin and morphine to stop them from crying and also to alleviate coughs. There was no wide-spread infant mortality from this state of affairs.

      2. Dr William Halstead was a founding father of Johns Hopkins Medical school. As promising young doctor, he invented nerve blocks using Cocaine, then discovered “better” uses of cocaine. He was hard core Coke-addict for 5 years, having tried every rehab facility on East coast, but always failing within few months.

        Finally, he showed up seemingly cured of the Coke addiction. Over next 30 years, he changed surgery from “hacking and slashing” to the precise science of today, thereby opening the way for organ transplants and heart surgery.

        His magical cure for cocaine addiction? Morphine? In a 50 year time capsule,it was revealed that Dr Halstead took morphine on daily basis for the last half of his life, which allowed him to be extremely productive. And yes, he performed surgery after taking morphine in the morning, and never had a complaint.

        1. Hasltead is featured prominently in the book “Emperor of All Maladies,” and his use of substances is mentioned. He certainly helped change the way doctors do surgery, especially mastectomies and other cancer related surgeries.

          1. I really do know how to spell Halstead.

  6. Slightly OT: apparently, there’s such a crime as using a cellphone in furtherance of a drug trafficking offense.

    I’m impressed.

    1. I’m not. We have let these scofflaws off long enough.

      I propose another additional crime to bring order to this lawless land:
      *”Being within 1,000 feet of any illegal substance, stolen good, or civil or criminal violation.” Penalty? Shot once for each foot closer than 1,000 feet from the illegal substance, stolen good, or civil or criminal violation.

      We will be crime free within six days after this passes.


    2. One has to wonder how many drug dealers are charged with income tax evasion?

  7. You can thank the cia for their Afghan heroin pipeline Pat Tillman tried to warn us about.

    1. Don’t forget Afghani hashish.

  8. Governments of the world (UK, U.S, etc.) should decriminalize and legalize all drugs, and take responsibility for the manufacture and distribution of them in a cost effective manner.

    Addiction should be treated as a health issue.

    The sad thing is, it’ll never happen. As it would require them to admit their drugs policies and the war on drugs were complete and utter fucking failures.

    Why admit you were wrong when you can just continue pissing into the wind.

    1. “…and take responsibility for the manufacture and distribution of them in a cost effective manner.”

      Whoa, hold up there! If you really want drugs to be cost effective, then you don’t want government in charge of the manufacture and distribution! Just decriminalize and legalize, please.

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