Factors that lead to overdose and ways in which overdose risk can be minimized.
In general, any person who uses drugs should consider the following seven tips:
1. Understand your tolerance and be aware of when it might be lower (for example, when you have not been using for a while).
2. Avoid mixing drugs, and mixing drugs and alcohol.
3. Recognize that medications prescribed by a doctor may interact with street drugs and cause an overdose.
4. Take care of your health: eat well, drink plenty of water, and sleep.
5. If you have a new dealer or unfamiliar supply, use a small amount at first to see how strong it is.
6. Avoid using alone: if you overdose, you want someone around to help.
7. You’re less likely to overdose from snorting or smoking drugs than injecting them.
A person’s tolerance for a drug (or combination of drugs) can change for a variety of reasons. If a person has gained or lost weight, started taking new medications, is experiencing depression or exhaustion, or is beginning to use again after a period of abstinence, his body may not be able to handle the same dose that it is used to taking. The body’s tolerance decreases when there is not regular access to drugs. People should be especially mindful of reduced tolerance when resuming use after incarceration, drug treatment, detox, or a self-imposed hiatus. It is likely that a smaller dose than they previously used will get them high, and that the usual dose may cause overdose. It is always important to consider if your body or life have undergone any changes that might alter how your drugs affect you. If you are using a drug for the first time, be extremely careful, as you have no idea of your tolerance.
Mixing drugs of the same class like opiates, pills, and alcohol (all depressants) together can be very dangerous and is one of the most common reasons for overdose. Mixing intensifies the high but also greatly increases overdose risk. Mixing drugs also may increase the risk for passing out and vomiting, which can block a person’s airway if he or she chokes. Mixing drugs of different classes (i.e.: mixing stimulants and depressants) is also dangerous. Mixing prescription drugs with street drugs (as mentioned above) should be avoided if possible.
Mixing Drugs and Alcohol
Alcohol plays an important role in the majority of mixed substance overdoses and should be taken very seriously. Alcohol should not be discounted as a powerful sedative, especially when mixed with other depressants such as opiates and benzodiazepines. In addition, the dehydration caused by many stimulant drugs may be made much worse by consuming alcohol.
Sometimes a person overdoses because she simply did too much in too short an amount of time. If the drugs (including alcohol) build up in the body faster than the body can metabolize them, this can lead to overdose. Especially in the cases of cocaine and long-lasting benzodiazepines, it is tempting to re-dose before the body is ready because the high often wears off before the drug is sufficiently cleared from the body.
Past Overdose Events
Recent research has shown that people who have overdosed in the past are at much greater risk of future overdose. One study among 772 heroin, crack, and cocaine users in New York City found that respondents who had overdosed in the six months before the study were 28 times more likely to have had one or more earlier overdose experiences. If you have overdosed in the past, know that you may be at greater risk in the future. Stay well informed about prevention measures.
Weakness due to recent illness, dehydration, or under-nutrition will likely make the body unable to handle the same dose as a healthy body. Overdose is more likely if the liver and/or kidneys are not working well. In the case of poor health, a smaller dose will likely produce a significant high, and a normal dose may cause overdose.
Using Street Drugs While on Methadone or Buprenorphine
If prescribed the appropriate dose of methadone or buprenorphine by a doctor, patients in medication assisted drug treatment should not feel symptoms of withdrawal or extreme craving for street drugs. However, while using only the prescribed dose of methadone or buprenorphine, the patient is unlikely to experience a high. The use of street drugs or alcohol on top of methadone or buprenorphine increases overdose risk, especially with methadone. Methadone is a relatively long lasting and potent opiate. Adding other depressants can greatly impede the body’s ability to breathe.
Inconsistent Drug Quality and Potency
There is no “quality control” for street drugs, so it is hard to tell what you are getting. Especially in areas where the drug scene is heavily policed or drug supply is inconsistent, it is likely that the strength and quality of the drugs available varies greatly from day to day. A person’s regular amount may lead to overdose if the drugs are unexpectedly strong. Every time there is a new dealer or a new batch of drugs on the scene, the drug’s strength can change.
Using alone does not cause an overdose, but it does increase the chance that if a person does overdose, she will die because no one is around to help. There are many reasons people use alone: fear of the police, hiding use from family and friends, or just wanting or needing to use when no one else happens to be around. However, it is strongly recommended that drug use be conducted in a safe space with people you know and trust, and that an overdose plan be discussed in advance of any drug use.
Route of Administration
The route of drug administration determines how quickly the drug takes effect. Intravenous injection will affect the body more quickly and intensely than snorting, smoking, or “skin popping” (subcutaneous injecting) the same amount. Switching to injection from snorting or smoking can increase overdose risk. Also, “slamming” (pushing in the entire shot quickly and at once) is more likely to cause overdose than a slower injection technique.
Overdose Risk of Specific Opioids
An overdose of heroin (or any opioid), can cause respiratory failure and lead to death if not properly treated. The main factors that contribute to the overdose risk associated with heroin are: (1) the variability of the quality and potency of the product available (a “safe shot” might not be safe if the batch is unexpectedly strong); (2) a user’s decreased tolerance due to ill health or a break from use (including after a stint in detox or jail/prison); (3) switching to a more direct administration route without decreasing dose (for example: switching from sniffing to intravenous injection); and (4) mixing heroin with other drugs, especially downers (including alcohol), but also stimulants.
Methadone is an opioid most commonly used in a medical setting and prescribed by doctors as part of drug treatment for people dependent on heroin or other opioids, or for pain management. It is used in drug treatment in many countries, methadone is a strong opioid that stays in the body for a long period of time. Because methadone does not leave the body as quickly as some other opioids, like heroin or oxycodone, using other depressant drugs or drinking alcohol even many hours after taking methadone can cause overdose. A main overdose risk with methadone comes from mixing it with other drugs and/or alcohol. If given the appropriate dose by a medical provider, a person receiving methadone usually will not experience a “high,” and should not experience withdrawal symptoms or cravings. For this reason, methadone (as well as buprenorphine) treatment are also strongly associated with decreased risk of overdose. However, “topping off” with something else to achieve a high may lead to overdose. Injecting methadone (instead of taking a dose orally) may greatly increase overdose risk because significantly more of the drug is absorbed, and much more quickly.
Opiate Prescription Medication
The main cause of death resulting from overdoses of prescription opiate type drugs such as morphine, oxycodone, hydrocodone or codeine is ‘depressed’ breathing (slow, shallow breathing which can potentially lead to unconsciousness and subsequent death) which is caused by a lack of oxygen reaching the body. Opioids suppress activity in the brain causing the body to lose its ability to react to the chemical changes (such as harmful levels of carbon dioxide) which would usually trigger the mechanisms responsible for breathing. Depressed breathing can also cause excess fluid in the lungs which is called pulmonary edema. This can happen either gradually or else so quickly that this in itself can be a direct cause of death.
If someone has taken an overdose of an opiate drug, it is probable that the pupils of their eyes will contract and become like pinpoints and that they will be displaying extreme lethargy if not already in a coma. Prolonged depressed breathing may result in extremely low blood pressure and dilated (enlarged) pupils. Quickly restoring their ability to breathe properly is the key to their resuscitation and ultimately their survival. It is for this reason that it is particularly dangerous when a person is alone as there is no-one there to summon help on their behalf when they fall into a state of unconsciousness.
Like methadone, buprenorphine is a medication used in treatment of opiate dependency, as well as in pain management. Unlike methadone, buprenorphine is a “partial antagonist”—that is, it has chemical properties like other opioids, but it also has “antagonist” effects which block the ability of other opiods to bind to the brain. Because of this, the respiratory depressant effects common to all opioids have a “ceiling” (a limit) with buprenorphine, making it extremely difficult to overdose on the medication alone. The one exception to this involves use of benzodiazepines, which appear to destroy the ceiling effect of buprenorphine and make overdose more likely. People using buprenorphine should therefore avoid using benzodiazepines.
Tramadol is a synthetic quasi-narcotic painkiller that is prescribed for the treatment of moderate pain, and its effects are similar to those of codeine. In recent years, tramadol has gained popularity as a street drug. Pills are taken either orally or crushed, mixed into a solution and injected. Like other opioids, there is a risk of respiratory failure with high doses of tramadol. There is a serious overdose risk associated with tramadol when it is used in combination with alcohol or other downers. However, on its own the overdose risk from tramadol is low. People taking SSRI antidepressants (such as Prozac, Paxil, Zoloft, etc.) should not take tramadol due to the possibility of severe adverse reactions.
Benzodiazepines (benzos) are tranquilizers that have various hypnotic, sedative, and muscle relaxing qualities. They also slow the central nervous system. Stimulant users often use benzos to counteract the negative symptoms of “coming down” from stimulants, and some opiate users “top off” with benzos, especially if they have a high tolerance to opiates. Benzos are divided into short-acting (less than 12 hours), medium-acting (12–24 hours), and long-acting (24+ hours) categories. Long-acting benzos have a greater likelihood of accumulating in the body without the user’s knowledge and contributing to overdose risk when combined with other depressants, especially alcohol or opiates. It is important to understand the specific benzo a person is using and how long it will stay in the body. Using benzos alone rarely causes overdose, though it may result in very heavy sedation that lasts a long time. A major risk of respiratory failure from benzos is due to the combined effects of the pills with other depressants like alcohol and heroin (or other opioids). In the case of an opiate/benzo combined overdose, rescue breathing, naloxone, and monitoring of the person overdosing should be enough to bring the person out of the overdose. Overdose risk is increased by injecting benzos and opiates together. Instead, it is safer to consume benzos orally in pill form before taking an opiate shot: benzo pills are slower to take effect than an opiate injection, so the user can first take the benzos and then moderate her heroin dose based on how she is feeling.
Overdose Risk of Specific Stimulants
Methamphetamine is a strong physical and mental stimulant that is available both by prescription and on the street for recreational use. It causes the release of large quantities of neurotransmitters, especially dopamine. Methamphetamine use generally increases heart rate, body temperature, and breathing rate. Homemade/ street methamphetamine recipes often use ephedrine-based cold medicines as the main ingredient, as ephedrine can be reduced to methamphetamine by various methods. Meth users tend to re-dose every 3-8 hours to maintain the euphoria and avoid the “crash” and resultant depression of coming down. The longer the session, the larger the dose needed to produce the desired effects. Although rare, repeated use in this way may result in overdose as the body becomes overheated and dehydrated and intense stimulation results in seizures, heart attack, or stroke. Behavioral problems, including extreme agitation, paranoia, anxiety, or repetitive behavior are the more common results of heavy methamphetamine use in a short period of time.
Ecstasy is a psychoactive drug that is closely related to amphetamines. Ecstasy usually takes 30–60 minutes to take effect, with an intense launch period toward the peak lasting three to four hours. The overdose risk associated with ecstasy alone is low, but people should avoid using ecstasy in combination with other stimulant drugs or if they are taking MAOI anti-depressant medications. HIV-positive people who take the protease inhibitor Ritonavir should not take ecstasy because of a potentially life threatening interaction. Ecstasy is rarely pure and often cut with other stimulants and drugs of other classes. If someone taking ecstasy experiences negative effects or appears to be overdosing, respondents should react based on the person’s symptoms, even if they are not characteristic to ecstasy use.
Snorting cocaine usually produces effects within a minute. Injecting or smoking produces effects within a few seconds. The effects of cocaine are quite brief, with the high usually lasting only 20–40 minutes. Because the euphoric feelings produced by cocaine wear off before the entire dose is eliminated from the body, repeated doses, especially in combination with other drugs and alcohol, increase overdose risk because cocaine may accumulate in the body without a person realizing it. Repeated doses should therefore be spaced out as much as possible. Unlike methamphetamine, cocaine also has direct toxic effects on the heart and circulatory system that make it, in comparison to other stimulants, more dangerous in terms of overdose risk.
Speedballing is a slang term for taking stimulants and opiates (usually cocaine and heroin, but often other drugs) at the same time. In general, someone taking a speedball faces the overdose risks associated with each drug. Although not well understood by science, it also appears that overall overdose risks increased, and in places where speedballing is more common, overdose death statistics usually include a significant number of people who had both heroin and cocaine or other stimulants in their system.
Mixing multiple drugs or drugs and alcohol is more often associated with overdose than single drug use. When using drugs in combination, the user should be clear about the effects of each drug before she uses it and the likelihood of an intense combined effect. When using multiple drugs at once, the dose of each drug should be significantly reduced to account for the intensity of the combination.