Date: Mon, 22 Dec 1997 10:16:00 -0500
From: L P 
Subject: alcohol OD's attrib [1/9


 >>> Part 1 of 9...

-=> Quoting Lee Bonnifield to L P <=-

 LB> I can't find the article! Please repost it if you can, or somebody
 LB> else repost it, or any related research. Thanks!

Here it is.  It is well-documented and well worth reading:

From:
http://www.pantless.com/~pdxnorml/CU_12_Heroin_OD_Mystery_1972.html

"The Heroin Overdose Mystery And Other Hazards Of Addiction",
Chapter 12 from The Consumers Union Report on Licit & Illicit Drugs,
by Edward M. Brecher and the editors of Consumer Reports,
Little, Brown and Company, Boston, 1972.

Nothing has changed since 1972 - the government, media and medical
profession are still incapable of informing the public about the most
basic factual information.

From:
http://www.druglibrary.org/schaffer/library/studies/cu/cumenu.htm

"The Consumers Union Report on Licit & Illicit Drugs," pp. 101-114,
by Edward M. Brecher and the editors of Consumer Reports
(Little, Brown and Company, Boston, 1972), ISBN 0-316-10717-4,
available for $14.95 plus $1.75 postage from New Morning Books in
Mt. Morris, IL (800) 851-7039. (Stock # HB/44)

Chapter 12.

The "Heroin Overdose" Mystery And Other Hazards Of Addiction

Chapter 4 of this Report reviewed in detail the effects of heroin and
other opiates on addicts, including deleterious physiological effects
traceable to the drugs themselves. Narcotics addicts today face other
physiological hazards that are traceable to the narcotics laws, to the
adulteration, contamination, and exorbitant black-market prices that
those laws foster, and to other legal and social (as distinct from
pharmacological) factors. Dr. Jerome H. Jaffe has described some of
these risks in Goodman and Gilman's textbook (1970): "Undoubtedly,
the high cost and impurities of illicit drugs in the United States
exact their toll. The high incidence of venereal disease reflects the
occupational hazard of the many females who earn their drug money
through prostitution. The average annual death rate among young,
adult heroin addicts is several times higher than that for nonaddicts
of similar age and ethnic backgrounds. . . . The suicide rate among
adult addicts is likewise considerably higher than that of the general
population." [1]

Because "the preferred route of administration is intravenous," Dr.
Jaffe continues, "there is sharing of implements of injection and a
failure to employ hygienic technics, with a resultant high incidence
of endocarditis, and hepatitis, and other infections." [2]

The exorbitant price of black-market heroin, Dr. Jaffe might have
added, is one of the factors that makes intravenous injection "the
preferred route of administration," for "mainlining" is the cheapest
way to forestall withdrawal symptoms. And the laws restricting
possession of injection equipment, under penalty of imprisonment,
increase the risk of needle-borne infections by encouraging the sharing
of implements.

There remains to be considered yet another risk of heroin addiction,
the most publicized hazard of all - death from "heroin overdose."
Because these deaths are a source of such widespread concern, and
also because they are so widely misunderstood, even by authorities on
heroin addiction and by addicts themselves, we shall examine the data
in detail. Much of the discussion that follows is focused on New York
City, since the deaths attributed to heroin overdose are most numerous
there and since the New York City data are published in convenient form.

"Prior to 1943, there were relatively few deaths among addicts from
overdosage." [3]  By the 1950s, however, nearly half of all deaths among
New York City addicts were being attributed to "acute reaction to dosage
or overdosage." [4]  In 1969, about 70 percent of all New York addict
deaths were assigned the "overdose" label [5] - and in 1970, the
proportion was about 80 percent. [6] The number of deaths so designated
by New York City's Office of the Chief Medical Examiner increased from
very few or none at all before 1943 to about 800 in 1969 and 1970. [7]

During this same twenty-eight-year span, addict deaths from all other
causes - infections, violence, suicide, and so on - increased very
little. The enormous increase in number of deaths among addicts shown
in Figure 2 was attributed almost entirely to "overdose" deaths.

The number of deaths throughout the United States attributed to heroin
overdose from 1943 to date must total many thousands. In New York City
it was reported that narcotics, chiefly heroin, were the leading cause
of death in 1969 and 1970 in all males aged fifteen to thirty-five, [8]
including nonaddicts. This can properly be characterized as an epidemic;
the general alarm over these deaths is thoroughly warranted.

There are two relatively simple ways, however, to prevent deaths from
heroin overdose.

*First*, addicts can be warned to take only their usual dose of heroin

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 >>> Part 2 of 9...

rather than risking death by taking too much.

*Second*, even in cases where an addict takes a vastly excessive dose
despite the warning, death usually can be readily prevented, for death
from an overdose of opiates is ordinarily a slow process. "In cases of
fatal poisoning with morphine, the time of death may vary roughly from
one to twelve hours." [9]  The first signs are lethargy and stupor,
followed by prolonged coma. If, after a period of hours, death does
ensue, it is usually from respiratory failure. During the minutes or
hours following the injection of a potentially fatal overdose, death can
be readily forestalled by administering an effective antidote: a
narcotic antagonist known as nalorphine (Nalline). [10]  Nalorphine
brings a victim of opiate overdose out of his stupor or coma within a
few minutes. Since there is plenty of time and since nalorphine is
stocked in pharmacies and hospital emergency rooms throughout the
country, the death of anyone due to heroin overdose is very rarely
excusable.

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."

[Figure 2 on page 103, omitted from this web transcript, features a
graph showing "Deaths from Narcotics Abuse in New York City, 1918-
1971." [11]  To summarize briefly, the graph shows that such deaths
hovered in a narrow range of about 50 to 75 between 1918 and the early
1950s. Deaths increased throughout the 1950s, surpassing 200 in 1960,
and rose from about 300 in 1965 to more than 1,200 in 1971. [Source:
New York City Medical Examiner's Office]

Let us review these three bodies of data in detail.

(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 O.
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 "had no
change in respiratory center or any other vital organs." [23]

(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

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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.

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]

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(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]

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.

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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.

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. [*]

Even Chief Medical Examiner Helpern eventually became convinced that
the "heroin overdose" publicity emanating from his office was
"dangerously wrong." In testimony before the Select Committee on Crime
of the United States House of Representatives on June 27, 1970, Dr.
Helpern stated:

"A difficulty has been that people have considered these fatal reactions
the result of overdose. Now, to some people the designation overdose
means [taking] more than usual with the implication that if you are
careful of how much is taken there is no danger of anything other than
the usual effect. This impression which many addicts have is dangerously
wrong." [38]

Yet a full year after Dr. Helpern testified, neither he nor Dr. Baden
nor anyone else had yet ventured to correct the "dangerously wrong" view
that was being foisted on the New York and national news media. Almost
everyone who did not read Dr. Helpern's and Dr. Baden's papers in the
medical journals still believed that heroin addicts by the hundreds were
dying of overdose. Worse yet, nobody had as yet even begun to
investigate seriously the crucial question:  If these hundreds of addicts
a year aren't dying of overdose, what are they dying of?


Fortunately, enough is already known to suggest some promising directions
for immediate research.

Most deaths from so-called overdose, as noted above, are characterized
by suddenness and by pulmonary edema. No other cause of death - such as
tetanus, bacterial endocarditis, hepatitis, or a knife or gunshot
wound - is found. In approximately 60 percent of autopsies, a 1970
study indicates, there is also cerebral edema (accumulation of fluid in
the brain) along with widespread fragmentation of the astrocytes (star-
shaped cells) in the brain. [39]  A death with these characteristics,
occurring in a heroin addict, constitutes a dramatic and readily
identifiable syndrome which Dr. Helpern has called "acute fatal reaction
to the intravenous injection of crude mixtures of heroin and other
substances." We shall here apply a less cumbersome label: "Syndrome X."

One clue to the true cause of Syndrome X is its initial appearance about
1943, its relative rarity for the next few years, and its recent rapid
increase in frequency. The time sequence obviously suggests that the
cause of Syndrome X must be some factor introduced about 1943 and
affecting a vastly increased number of addicts during 1969 and 1970.
Heroin clearly does not qualify; it was widely used long before 1943.
Indeed, a highly significant fact about Syndrome X is that it has become
more and more frequent as the amount of heroin in the New York City bag
has gone down and down. These deaths are, if anything, associated with
"underdose" rather than overdose.

One theory sometimes advanced is that Syndrome X deaths are caused by
the quinine in the bag. Quinine was introduced as an adulterant of
heroin sometime after 1939, when an epidemic of malaria spread by
contaminated injection needles hit New York City addicts; [40]  thus the
time of introduction fits the Syndrome X timetable. Some addicts
discovered that the quinine contributed to the sensation known as a
"rush" immediately after injection. Heroin traffickers also discovered
that the bitter taste of the quinine makes it impossible for addicts to
gauge the concentration of heroin in the bag by tasting the mixture. For
these and possibly other reasons, quinine has remained a standard
adulterant of New York City heroin ever since.

Perhaps the first suggestion that quinine might be causing New York
City's Syndrome X deaths came from Dr. F. E. Camps, the United Kingdom
Home Office pathologist in charge of investigating opiate deaths in
England. At a conference of the Society for the Study of Addiction held
in London in September 1966 (which Chief Medical Examiner Helpern
attended), Dr. Camps stated: "The only comparable drug to heroin which
causes rapid death with pulmonary edema is quinine. In this case
patients start off with discomfort in their chest, and then rapidly die.
It is conceivable that this could have some relation to [New York
City] heroin deaths." [41]


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At the same conference an American pathologist, the late Dr. Rudolph
J. Muelling of the University of Kentucky Medical School, added that a
type of lung lesion similar to that found in Syndrome X deaths "is
found to occur when one studies pure quinine cases. In the United States
this kind of lesion has been found in several nurses attempting to
induce abortions on themselves. They take the quinine orally and the
condition comes on quite rapidly. The patients die of quinine
alone." [42]

A second possible cause of Syndrome X deaths can best be illustrated by
two examples.

One is the case of "C. G.," a heroin addict long accustomed to
mainlining his drug, who one day got drunk, took his "customary
injection of heroin and collapsed shortly thereafter." Subsequent
X-rays showed lung edema. [43]

Another is the case of a heroin addict whose death was recently
reported by Dr. George R. Gay and his associates at the Haight-Ashbury
Medical Clinic, San Francisco. This addict first "shot some reds" (that
is, barbiturates) and then "fixed" with heroin following the
barbiturates. He died of what was diagnosed as "overdose of
heroin." [44]

Cases such as these have given rise to the question whether Syndrome X
deaths may result from injecting heroin (with or without quinine) into
a body already laden with a central-nervous-system depressant such as
alcohol or a barbiturate.

Addicts themselves would seem to deserve credit for first suspecting
that so-called "heroin overdose" deaths might in fact result from the
combined action of alcohol and heroin. Back in 1958, a team headed by
Dr. Ray E. Trussell and Mr. Harold Alksne interviewed more than 200 New
York City addicts - alumni of the Riverside Hospital addiction treatment
program (see Chapter 10). In this as in other pre-1960 studies, few
addicts drank alcohol while on heroin, and they did not drink much.
When asked why, the addicts commonly gave two reasons.

One was that the effect of alcohol is "offensive" to a man on heroin.
"The narcotic alone has an analgesic effect which tends to quiet the
individual. Alcohol, on the other hand . . . has the capacity to
agitate the individual in his relationships with other people. This
generally is offensive to the addict." [45]

The other reason given by addicts in 1958 for not drinking while on
heroin is the first extant clue to the possible relationship between
alcohol and death from "heroin overdose." Addicts, the Trussell-Alksne
team noted, "believe that the use of narcotics and alcohol in
combination is dangerous and might possibly lead to the death of an
individual." [46]  By the 1960s, this awareness of the hazard of
shooting heroin while drunk had disappeared from the addict scene.
Addicts, like others, were evidently convinced by the official
announcements that those deaths were indeed due to heroin overdose.

If the theory is sound that even an ordinary dose of an opiate injected
while drunk can produce death, then death could occur when an ordinary
drunk who is not addicted is brought into a hospital emergency room
with a painful injury and is given a routine (10 milligram) injection
of morphine to ease his pain. Drs. William B. Deichmann and Horace W.
Gerarde report in their _Toxicology of Drugs and Chemicals_ (1969
edition) that death may in fact occur under such conditions.

"The ordinary safe therapeutic dose of morphine," they warn, in
italics, in their textbook, "may be fatal to persons who have been
drinking alcoholic beverages. Morphine in therapeutic doses [similar
to the doses commonly injected by addicts] resulted in fatalities in
individuals whose blood alcohol levels ranged from 0.22 to 0.27%.
Morphine is also synergistic with barbiturates and related drugs." [47]
Thus the hazard of death from shooting an opiate while drunk on alcohol
or a barbiturate is familiar to some toxicologists even though it has
been ignored by authorities on drug addiction - and by coroners and
medical examiners - through the years.

If this alcohol-heroin and barbiturate-heroin explanation is correct,
the fact is of the utmost practical importance - for hundreds of deaths
a year might be prevented by warning addicts not to shoot heroin while
drunk on alcohol or barbiturates.

The alcohol-barbiturate hypothesis fits the Syndrome X time schedule.
Throughout the nineteenth century and well into the twentieth, opiate
addicts were known for their *dislike* of alcohol while on opiates. As
noted earlier, they turned to alcohol only when deprived of their
opiate supply or when trying to "kick the habit." This remains generally
true today; an addict rarely drinks while *on* heroin. He often drinks,
however, when his heroin supply runs out and withdrawal symptoms set in.
During World War II, many heroin addicts were abruptly deprived of their
heroin supply for longer or shorter periods. If some of them turned to
alcohol, then connected with a fresh heroin supply and "shot up" while
still drunk, the first few identified Syndrome X deaths might have
occurred. The recent sharp increase in Syndrome X deaths might similarly
be explained by an increased tendency to alternate alcohol or
barbiturates with heroin as a result of high heroin prices. As the
amount of heroin in the New York City bag went down and down, according
to this theory, more and more addicts got drunk - and died of Syndrome
X following their next "fix."


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Evidence in recent years for the use of alcohol by addicts shortly
before their death has been assembled from the New York City files by
Drs. Jane McCusker and Charles E. Cherubin. They reviewed 588 city
toxicology reports found in the files on addicts who died in 1967. In
549 of these cases, tests for alcohol had been run - and in 43 percent
of the cases tested, alcohol was in fact found. [48]  (Barbiturates were
not reported on.) Their findings led Drs. McCusker and Cherubin to
suggest that further research be promptly launched into the possible
role of alcohol and the barbiturates in so-called "heroin overdose"
cases.

The same suggestion has been tentatively made by Dr. Gay of the
Haight-Ashbury Medical Clinic. Thirty-seven percent of the addicts
attending the clinic, Dr. Gay states, report using barbiturates "for
sedation and sleep" when heroin withdrawal symptoms set in; and 24
percent report using alcohol similarly. [49]  Thus the stage is set for
shooting heroin while drunk on one or the other - and, perhaps, for
sudden death from overdose."

Two of the most publicized "overdose deaths" of 1970, Dr. Gay informed
the National Heroin Conference in June 1971, fit precisely this pattern.
These were the deaths of the rock musician Jimi Hendrix and the singer
Janis Joplin. Hendrix was known to use both alcohol and barbiturates -
and possibly also heroin. Janis Joplin "drank [alcohol] like an F. Scott
Fitzgerald legend," Dr. Gay adds - and also used narcotics. [50]

The magazine _Time_ reported on October 19, 1970, shortly after Janis
Joplin's death:

"The quart bottle of Southern Comfort [whiskey] that she held aloft
onstage was at once a symbol of her load and a way of lightening it.
As she emptied the bottle, she grew happier, more radiant, and more
freaked out....

"Last week, on a day that superficially at least seemed to be less
lonely than most, Janis Joplin died on the lowest and saddest of
notes. Returning to her Hollywood motel room after a late-night
recording session and some hard drinking with friends at a nearby
bar, she apparently filled a hypodermic needle with heroin and shot
it into her left arm. The injection killed her." [51]

Janis Joplin's death, of course, was popularly attributed to
"heroin overdose." If the alcohol-barbiturate-heroin theory is
correct, her fatal injection of heroin while drunk on alcohol was
the prototype of many other deaths similarly mislabeled "overdose."

The British experience with deaths attributed to heroin overdose is
consistent with the alcohol-barbiturate hypothesis. Dr. Ramon Gardner
of the Bethlem Royal Hospital and Maudsley Hospital in London studied
the records of 170 deaths known to have occurred among addicts in
Britain during the five-year period 1965 through 1969. Twenty of these
deaths were deemed suicides, 24 were traceable to infections, 12 were
from natural causes, 11 were drownings, falls, murders, or other
accidents, and 6 occurred during treatment (of which two followed
abrupt withdrawal of narcotics when the addicts were imprisoned). Eight
more were due to overdose of barbiturates or other nonopiate drugs.
This left a maximum of 89 mysterious deaths out of 170 which might have
been caused by accidental opiate overdose - or by something else. [52]

Dr. Gardner then went on to study in more detail 47 of these deaths
*possibly* due to heroin overdose. In a number of cases, he found that
the addicts bad been confined in a hospital, prison, or detention center
or had for other reasons been abstinent from opiates for a week or
longer, and had thus lost at least a portion of their tolerance for
opiates. They had then injected an opiate - some of them on the day of
discharge, others within the next day or two. Thus these deaths *might*
have been due to overdose - though evidence was lacking that the victims
had in fact taken fatally large doses. (Merely doubling or quadrupling
the dose, it will be recalled, will not kill even nonaddicts.)

But in at least 21 of the 47 cases, there had been no withdrawal from
opiates prior to death, so that tolerance had *not* been lost. And in
some cases, the dose preceding death was so small - as little as 20 or
30 milligrams of heroin, for example - as to establish beyond question
that overdose was *not* the cause. [53]

These British deaths, accordingly, remain mysterious, like deaths from
Syndrome X in the United States. Among several likely explanations, Dr.
Gardner himself noted, is the possibility that these addicts may have
taken some other drug, perhaps a central-nervous-system depressant, at
the same time. Since there is no quinine in British opiates, that drug
must be exonerated in the British deaths.

Another British drug authority adds that in Britain as in the United
States, "many of those who die, in fact, have taken barbiturates as
well [as opiates] at the same time." [54]

It might prove absurdly easy to confirm the alcohol-barbiturate
hypothesis. All that might be necessary would be to addict a few
monkeys or other primates to heroin, intoxicate them on alcohol or
barbiturates, and then inject modest doses of heroin. If the monkeys
drop dead of Syndrome X, a warning against shooting heroin while drunk
on alcohol or barbiturates might save many hundreds of lives a year
throughout the world.

Several other possible explanations of Syndrome X deaths have been

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offered. No theory has yet been proved. Worse yet, no theory has ever
been experimentally tested. The time has surely come to determine the
cause (or causes) of Syndrome X and bring to a close this tragic series
of deaths. If 800 respectable citizens instead of heroin addicts had
dropped dead in New York City of a mysterious syndrome in 1970, a
gargantuan research program would no doubt have been promptly launched.

If the Syndrome X deaths are due to quinine or to any other adulterant
or contaminant in the bag, the responsibility clearly rests with the
American heroin black market for selling unsafe mixes. If the cause of
these deaths is the shooting of heroin while drunk on alcohol or
barbiturates, the black-market distribution system remains at least
indirectly responsible, for it is largely the high cost of black-
market heroin that makes heroin users turn to alcohol and barbiturates
on occasion - and thus, perhaps, to risk death from Syndrome X.

The two steps which must now be taken are (1) to stop sweeping these
mysterious deaths under the carpet by falsely labeling them "overdose"
and (2) to launch an intensive clinical and experimental search for what
is in fact killing these addicts.

[End]
* 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]

Chapter 12
[footnotes, pp. 550-552]
1. Jerome H. Jaffe, in _Goodman and Gilman_, 4th ed. (1970),
   p. 286.
2. Ibid.
3. Milton Helpern and Yong-Myun Rho, "Deaths from Narcotism in New
   York City," _New York State Journal of Medicine,_ 66, (1966): 2393.
4. Ibid., Table XI, p. 2402.
5. Richard Severo in "News of the Week in Review," _New York Times_,
   February 1, 1970.
6. _New York Times_, December 30, 1970.
7. Michael M. Baden, quoted by Barbara Campbell in the _New York Times_,
   December 16, 1969; _New York Times_, December 30, 1970.
8. _New York Times_, December 30, 1970.
9. A. K. Reynolds and Lowell O. Randall, _Morphine and Allied Drugs_
   (Toronto: University of Toronto Press, 1957), p. 119.
10. Jerome H. Jaffe, in _Goodman and Gilman_, 4th ed. (1970),
    pp. 252, 268.
11. _New York Times_, June 21, 1970.
12. Reynolds and Randall, _Morphine and Allied Drugs_, pp. 176-177.
13. Jerome H. Jaffe, in _Goodman and Gilman_, 4th ed. (1970), pp. 252.
14. Robert H. Dreisbach, _Handbook of Poisoning: Diagnosis and
    Treatment_, 7th ed. (Los Altos, Cal.: Lange Medical Publications,
    1971), p. 247.
15. Reynolds and Randall, _Morphine and Allied Drugs_, p. 119.
16. William T. Salter, _A Textbook of Pharmacology_ (Philadelphia and London:
W.B. Saunders Company, 1952), p. 77.
17. Reynolds and Randall, _Morphine and Allied Drugs_, p. 119.
18. Lawrence Kolb and A. G. Du Mez, _U.S. Public Health Reports_, 46 (1931):
698.
19. A. B. Light and E. B. Torrance, _Archives of Internal Medicine_, 44 (1929):
875.
20. Ibid., pp. 377-379.
21. Ibid., p. 394.
22. Ibid., p. 381.
23. Mary Jane Kreek in _Proceedings, Second Methadone Conference_,
    p. A-72.
24. Donald B. Louria, "The Major Medical Complications of Heroin
    Addiction," _Annals of Internal Medicine_, 67 (1967): 2; also,
    Helpern and Rho, "Deaths from Narcotism in New York City,"
    pp. 2405-2407.
25. Helpern and Rho, pp. 2405-2407.
26. Ibid., p. 2402.
27. Ibid., 2403.
28. Ibid.; see also Michael M. Baden, "Medical Aspects of Drug Abuse,"
    _New York Medicine_, 24 (1968): 464-466.
29. Milton Helpern in _Pharmacological and Epidemiological Aspects of
    Adolescent Drug Dependence_, Proceedings of the Society for the
    Study of Addiction, ed. C. W. M. Wilson (London: Pergamon Press,
    1968), p. 228.
30. Helpern and Rho, "Deaths from Narcotism in New York City,"
    pp. 2402-2403.
31. Michael M. Baden, "Pathological Aspects of Drug Addiction,"
    _Proceedings of the Committee on Problems of Drug Dependence_
    (Washington, D.C.: Division of Medical Sciences, National Academy
    of Science-National Research Council, 1969), p. 5792.
32. Michael M. Baden, "Medical Aspects of Drug Abuse," p. 466.
33. Ibid., p. 464.
34. Michael M. Baden, in _Proceedings, Second Methadone Conference_,
    pp. A-58, A-59.
35. Mary Jane Kreek, in _Proceedings, Second Methadone Conference_,
    p. A-72.
36. Michael M. Baden, in _Proceedings, Second Methadone Conference_,
    p. A-74.
37. Barbara Campbell, reporting in _New York Times_, December 16, 1969.
38. Milton Helpern, testifying at Hearings, House Select Committee on
    Crime, 91st Cong., 2nd Sess., June 27, 1970, p. 188.
39. Ralph W. Richter, John Pearson and Michael M. Baden, paper
    presented at 51st annual session, American College of Physicians,
    Philadelphia, 1970.
40. Milton Helpern, "Epidemic of Fatal Malaria Among Heroin Addicts in
    New York City," _American Journal of Surgery_, 26 (1943): 111.
41. Quoted by Milton Helpern in _Pharmacological and Epidemiological

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    Aspects of Adolescent Drug Dependence_, p. 248.
42. Rudolph F. Muelling in _Pharmacological and Epidemiological Aspects
    of Adolescent Drug Dependence_, p. 248.
43. Robert Silber and E. P. Clerkin, "Pulmonary Edema in Acute Heroin
    Poisoning," _American Journal of Medicine_, 27 (July, 1959): 190.
44. George R. Gay et al., "Short Term Heroin Detoxification on an
    Outpatient Basis," mimeographed, unpublished, p. 9.
45. Harold Alksne, Ray E. Trussell, and Jack Elinson, _A Follow-up
    Study of Treated Adolescent Narcotics Users_ (New York: Columbia
    University School of Public Health and Administrative Medicine,
    1959), unpublished, p. 101.
46. Ibid.
47. William B. Deichmann and Horace W. Gerarde, _Toxicology of Drugs
    and Chemicals_ (New York and London: Academic Press, 1969),
    pp. 407-408.
48. Charles E. Cherubin, Jane McCusker, Michael M. Baden, Florence
    Kavaler, and Zilu Amsel, "The Epidemiology of Death in Narcotics
    Addicts," _American Journal of Epidemiology_, in press.
49. George R. Gay et al., "Short Term Heroin Detoxification on an
    Outpatient Basis," p. 18.
50. George R. Gay at National Heroin Symposium, San Francisco, June
    1971.
51. _Time_, October 19, 1970, p. 54.
52. Ramon Gardner, "Deaths in United Kingdom Opioid Users, 1965-
    1969," _Lancet_ (September 26, 1970): 650-651.
53. Ibid., p. 651.
54. Personal communication, October 11, 1971.
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