Monday, June 05, 2006

Drug deaths

What kills heroin addicts? It has long been known that it is older, more experienced heroin users who die through heroin use rather than new users. This is important since so-called ‘overdose’ deaths are the major way intravenous drug users kill themselves around the world and hence are the major social cost of illicit drug use.

The story used to be that polydrug use was most common among older, experienced heroin users who used heroin in conjunction with alcohol and benzodiazepines. This suggested that the term heroin ‘overdose’ was a misnomer - deaths were in fact due to the synergistic effects of these other drugs on the respiratory depressant effects of heroin. Then even normal heroin doses could prove fatal.

In the newspapers this morning the higher incidence of death among older injecting heroin users (the press release is here) is re-attributed to the fact that older heroin users have damaged livers which are unable to metabolise heroin. It is unclear that it is the heroin use itself that is liver-destroying rather than the spread of hepatitis through injecting equipment but still it is the wonky livers that seem to cause many of the deaths.

One thing that surprised me about the polydrug theory was that overdose deaths fell off so rapidly in the wake of the so-called heroin drought of 2001. I would have though that polydrug substitutions, with the limited amount of heroin that was around, would have induced a spate of overdose deaths. In fact the number of fatal overdoses fell from 968 in 1999 to 306 in 2001. This evidence is more consistent with the wonky liver theory than polydrug theory.


Sam Ward said...

I don't understand why overdose deaths are seen as a "social cost". What is the cost to the community when a junkie dies? Not much I wouldn't think. It could even be a benefit.

People need to stop looking at this sort of thing as a "disease" that needs a cure and recognise it for what it really is - a choice made by morons to fuck up their own lives.

It's not like there is a shortage of people in the world. Why should we waste time and money saving people who don't want to be saved?

I have never understood why the community at large feels the need to prevent people from hurting themselves. If that's what they want to do then let them do it.

If it is someone I know and value their company then I would do everything in my power to bring them back - but as far as I am concerned if someone I don't know dies from some self-inflicted stupidity then they are just doing the whole world a favour by improving the gene pool.

hc said...

Sam, Would you leave a junkie to die if he or she was having an overdose?

If you would leave him or her to die on the grounds that their lives were worthless, would you think it a good idea to add poison to their heroin to hasten their demise? After all such actions would improve 'the gene pool'.

Agreed drug use is a choice but it is a foolish choice - not a rational one. What is the scope for mistakes and should people have to live to bear the full costs of their mistakes?

For example what if there are reasons for the mistakes - childhood emotional or sexual abuse or psychiatric disorders - virtually all drug users suffer from such co-morbidities.

I generally agree with opposition to the nanny state but I think here the issues are not as clearcut as you suggest.

conrad said...

Another reason that deaths get high when the price drops (and hence vice-versa) is that the purity also increases, and hence people are more likely to take a larger dose than they expect, so it isn't a fair comparison with peak times (like 1999).

hc said...

Conrad, I think the evidence is that users are able to judge well the purity of the heroin they use - they are generally informed customers. When the drought ended there were claims the overdose rate would rebound but it didn't.

Lee said...

In California it has been found recently that the rate of baby boomer addict deaths is actually increasing, with deaths mainly linked to their overall poor state of health but also documented among those who stop (for whatever reason) and then resume use at previous doses - they overdose because either they've lost tolerance or the drugs have become purer and more potent. (This kind of kills the theory that users are able to judge purity - where did you find that evidence Harry?). I think the point about older more entrenched users tending to use alone rather than in groups may also be very valid: See:

hc said...

Lee, The experience here is that deaths are concentrated among older more experienced users - I'll certainly chase up the site.

This in itself suggests that users can judge quality and purity. Further evidence is in:

Lee, L.W. 1993, ‘Would Harassing Drug Users Work?’, Journal of Political Economy, vol. 101, pp. 939-959.

I assume that is not you.

Sam Ward said...

Harry, of course I would render aid if I was in a position to. That is a totally different question.

The point I was making is that the effort to reduce drug use is no different to the effort to reduce use of other drugs like tobacco and alcohol.

Using these substances is a choice people make (albeit a bad one in your eyes). Spending public money and time and trying to stop people from harming themselves is not only a waste of money, but also not something we have the right to do.

"What is the scope for mistakes and should people have to live to bear the full costs of their mistakes?"

Undoubtedly yes. People should bear the cost of their mistakes, the public should certainly not.

This sort of thing is always trumpeted when another anti-smoking crusade is initiated (Smokers cost public health funds!!!!!!!).

Unfortunately what these nannies dont tell you is that smokers already pay about 10 times more in tax than it costs the public health system to treat smoking-related illnesses (definition of a smoking related illness: any illness that a smoker gets).

If you go and put your live savings on black and the roullette wheel comes up red, the government doesn't give you your money back. They shouldn't come to your aid when you make any other sort of bad decision either. It's your life and your successes and failures are your own.

There are many worthless people in the world. I don't advocate rounding them up and shooting them Harry, but neither do I advocate special government programs to try and make them less worthless.

You can't polish a turd, as they say.

"For example what if there are reasons for the mistakes - childhood emotional or sexual abuse or psychiatric disorders - virtually all drug users suffer from such co-morbidities."

Yes, everyone's a victim.

I was beaten mercilessly for 5 years at boarding school and emotionally tortured for being academically gifted all throughout my school life. Should I go on with my life or is there some sort of government department I should apply to now to receive a large compensation package?

After all, it significantly changed my life. I should have been a nobel prize winning scientist, but Im only a professional gambler. It must be someone else's fault other than mine, right? Where's my money?

patrick not the lefty said...

I must admit that the OD deaths are surely not the major social cost of drug use.

I do think they are a tragedy and should be prevented if possible, but I think the attendant property crime, broken-down relationships, funding for organised crime syndicates, sexual degradation, police corruption and even 'neighbourhood deterioration' are probably each and certainly taken together the major social cost of illicit drug use.

On topic, the boomer deaths is not inconsistent since livers don't usually heal, at least not much, and not at all if you keep drinking a bottle of Napa Valley's finest a night three nights a week.

Sam Ward said...

" I think the attendant property crime, broken-down relationships, funding for organised crime syndicates, sexual degradation, police corruption and even 'neighbourhood deterioration' are probably each and certainly taken together the major social cost of illicit drug use."

All of those things except the second are the result of the prohibition, not the drugs themselves. You don't see people breaking into your house so they can afford to buy panadols.

FXH said...

harry - it always seemed to me from observation that overdoses increased with new, generally higher quality and strength, dope became available. Also after experienced older users had been getting used to lower potency or had come back from a period of lower use or non use eg out of jail. The information about a new set of "more pure" dope, takes a while to filter through to users and retail sellers. One of the way information gets around is by overdoses and information spread through ambos and emergency deprtments.

Not all or even most overdoses end in death either.

FXH said...

I find anything that Major Matters says hard to believe without going further into the data.

The hardline Salvos, of which he is clearly one, have as their mission, abstinence, from alcohol, smokes and drugs. There is no harm minimisation or Sam Ward libertarianism in their mind at all. So they spin every bit of data a their disposal and every comittee finding to support their cause.

Oh and Sam they certainly don't approve of gambling at all. Try selling a raffle ticket to a Salvo.

hc said...


I'd be very interested if you had specific evidence that improvements in heroin quality cause deaths. It might well be true but if so the evidence has escaped my radar - of course I know the claim itself is very widely made. At the end of the heroin drought when quality improved the overdose rate did not rise strongly.

Apart from being an important factual point the observation has a bearing on the work I am doing trying to understand the micro-structure of heroin markets. My general view is that they are reasonably efficient with buyers generally being able to judge quality well.

If you had evidence and a link I'd appreciate it.

FXH said...

harry - no I don't have any evidence re purity and deaths. I worked at street level in the late 60's and early 70's and other levels since then but not right now. I keep up with old contacts and scan a bit of the journals but I wouldn't say I'm at the edge at all.

I find talking to users useful to gain an insight but wouldn't accept everything they say for several reasons, mostly simply that most small consumers of anything have a distorted view of how the market works, still you can get a useful angle from the end consumer so to speak. Cops and Ambos and Emergency depts are sometimes ignored but they too can have useful angles and can also be very wrong. Same with clinicians and just about everyone else.

I guess I'm not telling you anything you don't already know.

Over the 30 years the thing that strikes me the most is that poly drug use has increased dramatically and heroin and coke especially have been democratised. In the "good old days" heroin was to a very large extent a middle class and arty drug, at least in melbourne, with a smattering of sex workers (also artists I suppose)and needle use was confined mainly to H and other opiates and fetishised. There wasn't much poly use and most users had their favourite drug of choice and didn't consider any close substitutes. Except the common meeting ground was alcohol in times of scarcity.

Now needles are commonplace for almost any drug and mixing and (non) matching are all the go. H moved to the working class suburbs as well and a bit later speed moved into to the middle class suburbs and both moved into the rural regionals. Although speed certainly had a foothold in many regionals early on because of the bikie / manufacturing / goldfields chemical connection.

I'm wondering, no evidence, just wondering, if there is now better /quicker information around about potency from ambos, ED and drug agencies. After all you only need an information lag of a few days or hours to send overdose rates up. Might it also be a factor that cops and ambos now have better diagnosis / interventions at their disposal when responding to an overdose and thus an overdose is less likely to lead to death. Ditto users themselves.

I find teh liver failure theory very attractive myself. Especially given rates of Hep C etc and the bashing some of these people give alcohol at times plus general ill health and neglect.

Shouldn't that be reflected over time with a constant of the older people dying of overdose?

But then you have to allow for the fact that younger users are less savvy?

What do the spreadsheets say?

FXH said...

I've always wondered if you decided that all (or most)overdoses were suicide and then did figures on suicide and run the slide rule over it what would it say?

But then you'd need to assume all single person vehicle accidents were suicide, and farm deaths and hang gliders and mountain climbers. sigh!