What opioid hysteria leaves out: most overdoses involve a mix of drugs

Drug overdose is now the leading cause of accidental death in the United States, with opioid-related deaths driving the much of the increase. This alarming statistic has gained widespread attention and led to a national conversation demonizing opioids and the people who use them. But a critical predictor of overdose has remained absent from this conversation: opioid-related overdoses, both fatal and non, almost always involve at least one other drug.

Mixing drugs is generally much more dangerous than single-substance use, and certain combinations are particularly lethal. Taking opioids with alcohol, for instance, or benzodiazepines, dramatically increases the potential for fatal respiratory depression, as all three drugs depress the central nervous system. A person’s blood-morphine concentration needs to be significantly higher to cause death in an opioid-only overdose than in an overdose where alcohol or benzodiazepines are present. These drugs are frequently noted in autopsy reports for opioid-related overdoses.

But autopsy reports and death certificates do not always capture the true reasons behind a person’s death, especially when drug use is a factor. Kenneth Anderson, CEO of the Hams Harm Reduction Network, scoured death certificate data on opioid overdoses, and found stark state-by-state differences in regards to drug mixing. While there are surely some differences between individual communities, the more likely explanation for this variation is the subjectivity of individual physicians, medical examiners and coroners.

One coroner might attribute an opioid-related overdose death to heroin alone when in fact the death resulted from a combination of heroin and a legally prescribed, low-dose benzodiazepine. Another could attribute the death of a known drug user to overdose, when in fact the death resulted from dehydration, pneumonia or another health condition. Researchers have pointed to this and called for more thorough reporting of drug-related overdose in death certificates, as they provide the basis for our understanding of public health trends and consequently shape research and public policy.

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