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I. Drug Overdose
Tom Petty died from, according to the New York Times headline, an "Accidental Drug Overdose."
Here's the coroner's list of the drugs found in Petty's system: fentanyl, oxycodone, temazepam, alprazolam, citalopram, acetyl fentanyl and despropionyl fentanyl.
Petty's death is not accurately classified as an overdose. He died due to a dangerous mixture of opioid drugs. Such drug intake, often classified as "chaotic" drug use, is the source of over 90% of deaths involving drugs, so much so that the CDC now classifies these deaths as "drug poisonings" rather than as "overdoses."
I have been making this case for a few decades (see "The Persistent, Dangerous Myth of Heroin Overdose"). The main case against the overdose myth was made initially by the New York Medical Examiner, as presented by Edward Brecher in his remarkable Consumer Reports volume, "Licit and Illicit Drugs.”
Among the data Brecher and the New York ME present that should have forever jettisoned the overdose concept:
- Drug overdoses became a "thing" in the 1960s as street use became popular in New York City and drug supplies were regularly adulterated with whatever came to hand.
- Pioneering heroin researchers at Jefferson Medical College early in the last century, Light and Torrance, administered pharmaceutical heroin orders of magnitude more concentrated than addicts' usual doses, without the addicts even noticing the change in the purity of the drug in their systems.
- Dead heroin users examined by the NYME showed no differences in the presence of narcotics than did fellow users taking the same drug at the same time who walked away.
Of course, the myth persists, amplified by popular media. Writing for the National Review in 1994 about the front page New York Times too-pure heroin hysteria story of China Cat, I pointed out that the Times, in articles buried ever deeper in the newspaper, was forced to slowly retract the story, since among the claimed victims of "Cat,"
- a majority hadn't consumed heroin at all
- more had consumed cocaine
- but, in general, the dead men were characterized by multiple drug and alcohol use
Why it matters. People often balance their heroin use with other drugs (including now often benzodiazepines) — exactly the wrong approach to using drugs. If Petty had a reliable adviser (one who might have also saved the 12-step acolyte, Carrie Fisher), the helper would say, "You can take whatever drugs you wish—one at a time."
II. The Prescribed Drug Addict/Overdose Victim
A media colleague of mine wrote me, apropos of Petty: "If a guy with this much cash can't manage to have a doctor who gets it straight, what about everyone else?"
I replied, "In defense of doctors, I believe he was out fishing for drugs through personal connections. NO doctor would prescribe this list for a patient — if only because they'd remove his license inside a month (the days of Elvis, like Elvis himself, are dead)."
(In particular, the drug acetyl fentanyl in Petty's system is made by street chemists, never prescribed by doctors.)
Where is this fable of unscrupulous, ignorant doctor prescribers going? When Chris Christie left the governorship of New Jersey this month, deeply unpopular, his successor, Democrat Phil Murphy, picked up for approval only one part of the Christie platform — Christie's ubiquitous Reach NJ program encouraging people to seek treatment for their disease of drug addiction.
Here's how the media described the imperative that Murphy adopt the Christie project:
Christie made the opioids crisis the hallmark of his final year in office, and it will now be up to Murphy to follow through on state efforts to tackle it.
Murphy praised Christie's efforts during his inaugural address, and has vowed to continue the fight, which included more money for treatment and an effort by the state attorney general's office to sue drug dealers and pharmaceutical companies, and charge doctors for unscrupulous overprescription of the addictive drugs.
The problems with the second part of this policy attacking "unscrupulous overprescription of the addictive drugs" include these:
- opioid prescriptions have been declining for years
- during this same period, in New Jersey and elsewhere, drug deaths have risen precipitously (a 50% rise in 2016 over 2015, a trend that is seemingly continuing)
Why it matters. The narrative that best fits these data is that users, forced off their prescriptions by new medical restrictions, are increasingly turning to the street for their drugs. And such unregulated drug use is the fundamental cause of increasing drug deaths.
III. Drug Use = Addiction, Death
The basis for the idea that people taking painkillers long term inevitably leads many to become addicted, and some proportion to die, is based on the fundamental addiction myth: narcotic drugs = addiction.
Of course, the very prevalence of opioid painkillers in the American experience makes clear that this concept is a myth: in 2015, the latest year for which data were available, 93 million Americans — 38% of the adult population — took a painkiller.
How many became addicted? Fewer than 1%. A recent study of insurance records found that, among people taking prescribed opiates,
- 0.6% of the entire sample wound up “misusing” opioids — meaning they became dependent on the drugs, abused them, or had an overdose
- rates of misuse increased over the course of the study, but were still virtually nil (from 183 cases for every 100,000 person-years in 2009 to 269 cases per 100,000 person-years in 2016)
- the prescription rate for opioids declined over the course of the study — over the years, doctors prescribed lower doses of painkillers and longer periods between administration
Why this matters. The narrative fitting these data is that constraining the use of prescribed opiates led to greater rates of misuse of the drugs and deaths, even only including their legal use, let alone those turning to outside sources to supplement their diminished supplies. That is, the policy recommended by all parties in New Jersey and across the U.S. has been shown empirically to create more, rather than fewer, problems.
IV. Treatment Will Solve the Problem
New Jersey now budgets $1 billion in public funds for addiction treatment. This doesn't include private treatment, which entails multiple times the expenditures of public funds. And how well is this going?
The simple equation is that greater expenditure on treatment has accompanied precipitous rises in drug problems, up to and including death, even as there are no clear signs that drug use and addiction themselves are increasing.
How is this possible? One narrative to account for this is the case of Delray Beach*, Florida, a haven for drug treatment in which many rehab graduates choose to remain as they cycle in and out of treatment. But their relapses (which are readily explained by the rehabs as being due to the incurable nature of their disease) aren't a problem for providers.
Rather, drug testing, relapses and "overdoses," are accepted and billed at extravagant costs to insurers, who are increasingly required to pay for them by law (including Obamacare). In other words, providers make out like bandits, even if — especially if — treatment fails.
*"Unlike other places in the United States that have been clobbered by the opioid crisis, most of the young people who overdose in Delray Beach are not from here. They are visitors, mostly from the Northeast and Midwest, and they come for opioid addiction treatment and recovery help to a town that has long been hailed as a lifeline for substance abusers. But what many of these addicts find here today is a crippled and dangerous system, fueled in the past three years by insurance fraud, abuse, minimal oversight and lax laws. The result in Palm Beach County has been the rapid proliferation of troubled treatment centers, labs and group homes where unknowing addicts, exploited for insurance money, fall deeper into addiction."
Why this matters. The addiction myth that drug use per se causes addiction, and not the situations faced by users, has resulted in a major shift of government money to funding treatment, without demonstrated efficacy, and away from funding such social fabric matters as education, general health care, housing, et al. Meanwhile private treatment is an industry largely unshackled by the requirement of proving its efficacy.
V. The New Drug Policy Reform
Drug policy reform has increasingly advocated for the use of narcotic substitute drugs (suboxone, methadone, buprenorphine). And data do show that treatment graduates placed on these drugs are less likely to encounter problems, up to an including death.
Advocates for this approach, such as Maia Szalavitz, argue that MAT (medicine-assisted treatment) is a proven treatment method for addiction. But, while providing substitute narcotics for people makes it less likely that they will seek dangerous street drugs, it in no way weans them from their addictions. If anything, MAT convinces people that they suffer from a disease they can never remedy. And, if and when they should ever desist their reliance on a prescribed substitute narcotic medication, what happens then?
Many will return to unregulated street use. How else to explain this strange phenomenon: while MAT has increased dramatically, even in those places where it is most systematically administered (like New York), drug deaths have continued to rise, often dramatically.
Why this matters. Ironically, it may seem, drug policy reformers have now adopted policies and treatment approaches fully in line with the disease model provided by the National Institute on Drug Abuse, against whose policies reform organizations were once adamantly opposed. Now, as I describe in this podcast, such organizations are in danger of becoming policy adjuncts to the most reactionary and repressive drug regimes.
Summary
The United States, from reactionary anti-drug forces like Chris Christie and the Trump administration, to radical reform organizations that favor drug decriminalization, are all aboard for the same disease model of addiction and its treatment. And all remain smugly content with their wisdom in this transition.
With only one problem. We can't seemingly stem the tide of drug-related deaths. The actual lesson yielded by the limited efficacy of providing narcotic substitutes is to reaffirm that providing drug users reliable, guaranteed supplies of narcotics (as they are by heroin maintenance or injection sites throughout Europe, and which are now being considered in the U.S. from Seattle to Philadelphia) is the safest support plan for drug users.
There is nothing magical about drugs and addiction. All of the same common-sense dictates that are at work in human behavior and that make sense in social policy apply to drug use and addiction. In contrast, the truisms of drug addiction that are widely propagated and universally accepted throughout our society, on all sides of the political spectrum, have coincided with our unprecedented descent into drug death hell.
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An Education in OD from PT Readers
Anthony
I have also noticed here, in Canada, a woman was all over the news claiming she had started on heroin after a knee surgery in which she was tapered down to a small dose.
I googled her name and found her in another article where she said naloxone saved her life.
Predating that by 3 yrs I found another article where the same woman was recognized as a long time drug user, drug type not specified.
Marion Ambler
I have seen one other article and person notice the two illegal fentanyls in the toxicology report. David Kroll, who is a former academic pharmacologist, wrote an article in Forbes. I will just give the title and you can google since I don't know if a link will work.
"Heartbreaker: Tom Petty Died From An Accidental Overdose Of Opioids And Benzodiazepines"
"But what concerns me even more are the last two drugs: acetyl fentanyl and despropionyl fentanyl. These are nonprescription, synthetic opioid relatives of fentanyl that are not used medically. Both of these fentanyl relatives are on Schedule I of the U.S. Controlled Substances Act.
Despropionyl fentanyl is better known by its acronym, ANPP or 4-ANPP, for 4-anilino-N-phenethyl-4-piperidine; it's more often seen as an illicit chemical precursor in the synthesis of other designer fentanyls and, according to Cayman Chemical, is sometimes found as an unreacted impurity in illicit fentanyl preparations.
How Petty might have been exposed to these two compounds on top of the prescription opioids is concerning, and is reminiscent of Prince, who died of a combination of prescription fentanyl and the nonprescription synthetic opioid, U-47,700."
Trish
One thing few people know about American death statistics is that "opiate death" is not a scientific conclusion, but a bureaucratic category. The medical examiner or coroner has legal authority to categorize a death. Only 1/3 of Americans live in communities that have medical examiners, 2/3 have elected coroners, often with no required medical or scientific credentials. In 2007, a coroner was elected and serving in Indiana while in high school. One South Carolina coroner has a full time contracting job. Many morgues no in house toxicology lab. Many have no in house histology lab. What specific drugs wind up in the death statistics differ over jurisdictions and over time, so there's no way to be able to say whether a specific drug is associated with increasing or decreasing numbers of deaths. According to Vincent DiMaio, long a Bexar County, TX medical examiner, if the money spent on death investigations is divided by the number of deceased, it comes to about $2.50 per corpse. and testing for opiates is expensive. Currently there's a narrative of increasing opiate deaths, so things like relatives mentioning use or a prescription or a pill bottle at the death scene are read as clues to justify an "opiate death" notation.
US funded studies from the 1920s to 2000, haven't found a reliable deadly dose (as most substances, from acetaminophen to laundry detergent). In the 1940s it was found heroin cut with quinine could kill. In the 1960s Dr Michael Baden found a reaction to the quinine and sugar used to cut heroin can kill. Many substances used to cut heroin today can cause sudden death from anaphylaxis or Stevens Johnson syndrome (both can cause rapid swelling of airways). Some street heroin is cut with acetaminophen, and prescription opiates often contain it, too. Acetaminophen can cause sudden liver failure.
In Dec. 2016, the CDC issued a report discussing 59 deaths in Minnesota between 2006 and 2015, where the people had both pneumonia and opiate prescriptions at the time they died. The CDC was making a case that such deaths should be classified not pneumonia, as they had been, but as opiate deaths. If a country is in the midst of an actual epidemic, would public health authorities really need to scrape up a few dozen deaths from years ago to pump up the numbers? On the other hand, if authorities wanted to generate or magnify a moral panic, adding any numbers they could find might seem an attractive option.
Trish wrote further:
Just for fun, I looked at the IMDB for listings for every episode of Forensic Files. Of 800+ episodes, not one involved a claim of poisoning via opiates. There were other poisons, like ricin, antifreeze and arsenic.
Consider this comment from Dr Robert Anderson of Glasgow University's Forensic Toxicology Department:
'Sometimes there is no trace of a poison in the blood because it killed the person too quickly. A heroin addict found dead with a needle sticking out of his arm is an example - sometimes there's no trace of the drug at post-mortem. However, if the person lived long enough [after the morphine was administered] for the blood to get into circulation, it should be present.'I found the above quote remarkable. How could a substance stop the brain or the heart or the lungs if none of the substance is in the bloodstream?
