How Not to Die of an Overdose

Late summer is a particularly painful time for Denise Cullen, who lost her 27-year-old son, Jeff, to an overdose of morphine and Xanax on August 5, 2008. Cullen didn't just mourn, however: She organized, propelled by a desire that no other family ever undergo that pain.

New efforts to fight overdose—like a recently announced Obama administration initiative—are underway. But surprisingly, for a condition that is so common and so deadly, some key details remain widely unknown—details that could be life-saving in the right hands. If we want to prevent overdose, we need to gather and distribute this information to those who need it most.

"We absolutely aren't doing enough," Cullen tells me.

As a founder and executive director of GRASP / Broken No More, Cullen told me she planned to spend the night before International Overdose Day—today, August 31—at a walk, lighting candles and tossing rose petals off Huntington Beach Pier in California. Marchers were to honor lost loved ones and call for more humane and effective policies to prevent overdose and treat addiction.

Cullen, unfortunately, has plenty of company. GRASP, which stands for Grief Recovery After a Substance Passing, now has 100 chapters in 31 states and Canada, which provide support groups for families; Broken No More is the part of the group that works for political change.

The organization's growth parallels the frightening rise in overdose deaths, which almost quadrupled between 2000 and 2013, according to the Centers for Disease Control (CDC). Overdose now kills nearly 44,000 people annually—and more than half of these deaths, like Jeff's, involve opioids like heroin or prescription drugs.

We're missing some important opportunities to prevent these deaths, as Jeff's case tragically illustrates. Research has long suggested that a significant proportion of overdose fatalities are due to situational factors like how recently someone has been incarcerated, where the drugs are taken, and what combination of drugs are used. Many users are not aware of the nature of these risks.

Less than two days before Jeff died, he'd been released from jail, where he'd served four months for driving while under the influence of drugs, as the Orange-County Register reported in 2013.

In a sensible system, of course, he'd have been treated for his addiction rather than incarcerated, or have gotten treatment in jail—but that didn't happen. And the treatment he did receive between earlier arrests never addressed his real problems.

Jeff had been a well-loved only child. His mom is a social worker and former police dispatcher and his father, who now helps run GRASP, is a businessman. "He was a really caring, compassionate person," Cullen says.

Jeff's troubles started early: He was diagnosed with attention deficit/hyperactivity disorder (ADHD) at age nine and was never able to overcome the impulsivity linked with that condition. He began getting involved with drugs at 14, eventually injecting methamphetamine and later heroin.

But just before he died, it seemed as though he was about to turn a corner. He'd been sentenced to six months followed by treatment on a driving under the influence of drugs charge—and his mom had finally found a rehab for him that would allow him to try new medication for ADHD, rather than require he completely abstain from drug use.

However, the jail released him before the center had an open slot, basically setting him up to fail. He was also likely given no warning about his extraordinarily high risk of overdose at the time, which was related to the fact that after withdrawal and abstinence in jail, he had little tolerance for doses of heroin that he had previously relied on.

It's hard to exaggerate the nature of this risk—during the first days and weeks after release, it is multiplied by a factor of between 40 and 129, according to research.

What's more, there's a well-known way to reduce it: educating the former inmates and their families and friends about the problem, and providing access to the overdose reversing drug, naloxone—a nontoxic and non-intoxicating substance that can mean the difference between life and death in overdoses that include opioids.

"None of that was happening," according to Cullen, who learned about programs to distribute naloxone to families only after Jeff had died. She says the drug should be in every first-aid kit and that everyone should know the signs of overdose and what to do if they see them. (You can find out where to get naloxone here).

The day of his death, Jeff apparently met up with an old drug connection, from whom he probably obtained morphine pills. He took them along with Xanax, which he had been prescribed. This is among the most dangerous combinations because both can suppress the brain's breathing centers.

Kenneth Anderson, who runs a harm reduction organization aimed at helping alcohol and other drug users called HAMS, recently set up a website and Facebook page to try to get the word out about the risks of drug mixing.

He cites statistics from the New York City health department which show that 94 percent of recent overdose deaths here involved multiple drugs. In other studies, at least two-thirds of "opioid" overdoses are in fact linked to mixtures. Arguing that the media misinforms the public by labeling these deaths "heroin overdoses" or "prescription drug overdoses," Anderson says they should be called "poly-drug poisoning or drug-mixing deaths."

"I'm hoping to spread this information a bit more and help people to be safer and die less," he says.

Another strong influence on overdose risk appears to be the setting in which the drug is taken. A study published in Science magazine way back in 1982 found that 50 percent of rats given a dose of heroin that they had previously tolerated in one cage would die from that same dose if it was given in an unfamiliar place.

Other research shows the same effects in humans with heroin addiction: far more than you would expect, people who were treated for overdose reported that they had taken their typical dose, but in an unusual situation.

What's probably going on here is that the brain unconsciously learns cues that normally predict the experience of a drug—like entering the room where you usually get high—and responds with tolerance that prevents overdose. When those cues aren't present, tolerance isn't evoked or doesn't counteract the drug in time.

"Tolerance is a manifestation of association," says Shepard Siegel of McMaster University in Canada, the author of the Science paper and several follow-up studies. "By changing the environment, you don't see the expected level of tolerance."

Siegel is concerned that this issue isn't getting much attention as overdose numbers rise. "I have bemoaned fact this has not gotten enough publicity as a cause for overdose," he says, adding that I was the only journalist he's heard from recently, despite dozens of articles being written on the "overdose epidemic."

Siegel also points out that deaths that appear to be due to drug-mixing may really be linked to the way tolerance relies on a predictable sequence of drug effects. If a new drug is taken first or even simultaneously, the brain may not recognize the experience as one to which it has become tolerant—and the usual dose may become an overdose.

More research is needed to determine what types of environmental cues are most important for tolerance. But people at risk for overdose should be taught that if they take their usual dose in a different place, with different kinds of drugs, or in an extreme emotional state, their risk may be higher.

When Jeff was found dead, he was lying on lawn, near an apartment building. He'd been there for at least four hours—but because he was a young man, passersby probably assumed he was sleeping off a drunk night, homeless, or both.

"We don't care about these people," says Cullen, describing what she sees as callous indifference. "'Oh no, it's just another lazy homeless person.'"

And those hours that passed were precious: Opioid overdose kills slowly, by stopping the breathing process, and if help had come sooner, Jeff might have been saved with a shot of naloxone. But by the time someone finally noticed that he hadn't moved for a long time and called 9-1-1, it was too late.

Cullen doesn't blame the drug dealer who sold Jeff the stuff, knowing that users tend to sell to keep themselves supplied and that Jeff could have just as easily been the seller, not the one who died. "If your kid has been using for long enough, they probably dealt," she says.

But she does blame the apathy of those who saw her son and did nothing, along with the treatment system, which is frequently punitive and often fails to accept medical evidence. And she blames American drug policy for treating a health condition like a crime and failing even to coordinate treatment and punishment.

Ultimately, what kills overdose victims is stigma: a failure to see drug users as human beings whose lives are worth saving. Every overdose victim is someone's child—and may also be a spouse, sibling or parent. Every victim is a person, who can make a contribution, when given the right opportunities. But there is no recovery from death—and we can do much better at preventing overdose and addiction from killing.

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