How Harmful? Let's Compare!

Currently, the US conversation about opiates centers on the reported increases in recent years in the numbers of deaths of opiate users. Unfortunately, there is not sufficient comparable data to determine whether the deaths can be accurately attributed to opiates, so there's no way to know if deaths of opiate users are going up, going down, or remaining steady. First, not every dead person gets autopsied. Autopsy is expensive. The yearly total spent to investigate deaths divided by the number of dead Americans is under $3.00 per dearly-departed. Testing for opiates is expensive and without exact time of death and accurate history of use, it’s not possible to determine the size of the last dose the deceased consumed or if that amount would have been high enough to have caused that individual to die. Whether a death is counted as “overdose” (withoutspecifying any class of drug or particular drug),  or a class of drug ( “opiate”), or one of a list of drugs (and exactly what drugs may be included on that list) - depends on where it’s recorded. In the 2342 offices performing death investigationsin the US, 2/3 have no toxicology lab, 2/3 have no tissue lab, 1/3 have no x-ray equipment in house. 

“Opiate death” is a bureaucratic category, not the conclusion of a scientific investigation. In 2/3 of American jurisdictions, the legal authority to name a cause of death is in the hands of an elected coroner, most with no requirement for scientific or medical credentials.

So for a moment, let’s set aside the question of how many deaths can be attributed to opiates, and look at the potential for harm that does not cause death. Let’s compare the harm that a human body can endure from something else that Americans have the legal right to consume - tobacco. As with opiates, let’s set aside the 480,000 American deaths attributed to tobacco each year. Besides causing death, tobacco is known to cause damage other than cancer to every organ system in the human body starting with the visible vertical lines around a smoker’s mouth.

A website called Healthline has a page titled “The Effects of Smoking on the Body”, which included a helpful, cheerfully-colored cartoon of a human containing numerous organs, with short statements describing the harm tobacco can do, starting with the brain (anxiety and irritability from nicotine withdrawal), teeth (staining, increased risk of infections and inflammation), lungs (bronchitis, worsening of other lung problems, persistent cough, COPD, cancer), heart (higher risk of heart attack), blood (cholesterol: decrease good/increase bad cholesterol & increase triglycerides, increased risk blood cancers), immune system (lower ability to fight infection, more respiratory infections), reproduction (infertility, ED, early menopause, increased miscarriages, stillbirth, SIDS; baby:02 deprivation, growth problems, deformities), eyes (increased risk for glaucoma, macular degeneration, cataracts), nose (reduced smell, taste), blood vessels (constriction, GI tract (decreased appetite), skin (wrinkles, yellow fingers & nails).

I found the cartoon illustrations of organs and short paragraphs of information on the Healthline website so clear and helpful that I decided to search that website, changing one word of the above article's title to, "The Effects of Opiates on the Body." This let not to a similar cartoon style chart, but to multiple pages of links to other sites. Below the four ads at the top of each page I perused were titles such as "opiate withdrawal," "opiate abuse and addiction," "home remedies for opiate withdrawal," "coping with opiate withdrawal," "opiate and marijuana dangers," "opiate intoxication," "codeine withdrawal," "Imodium and opiate withdrawal." I saw a pattern, and it was unlike the pattern I saw in the information the site provided about tobacco.

So I did a web search using the term "organ damage caused by opiates" and I did find an illustration of a cartoon human and some organs, not as many as on the tobacco illustration.  The effects listed were: Blood (vein collapse from injection), heart (possible infection from dirty needle), brain (may cause sedation), lungs (may dangerously slow breathing), GI tract (constipation), liver (hepatitis possible from sharing needles), Nervous system (chronic use can lead to greater sensitivity to pain) and Immune system (vulnerability to infection slowing immune response.  Any damage that would persist after the opiate wears off is not from the opiate, but from incompetent injection, dirty or shared needles.  If an opiate user does the following: either refrain from injecting or use only sterilized equipment that is never shared; keep the dosage below the level that depresses breathing to a dangerously slow level, or makes sure someone is on hand to notice and address slowed respiration, and consumes fiber, there is no organ in the human body that is at risk of damage by opiates.

I know - someone is about to scream that whether an opiate user could later on have early wrinkles or COPD or a stroke or high cholesterol is irrelevant f that person can die - Today! - from consuming a sufficient dose of an opiate.

And I would ask, not at all in the spirit of being a smartass, what size dose would that be? I am sure anyone reading this will not be able to name a specific number of milligrams. Not because I expect the reader to not be an MD or nurse or PA or pharmacist. I say this for a very different reason. Unlike not only known poisons like arsenic or thallium or cyanide, or everyday household compounds such as laundry detergent or iron supplements, there is no known deadly dose for opiates. And it's not because nobody has tried looking for one. Studies funded by the US government from the 1920s to the year 2000 attempted and failed to identify an amount that will reliably kill a human.  What kills opiate users is almost never the opiate itself, as suggested when known users found dead are rarely found to have used more than their typical dose.

The danger with opiates is that if a high enough dose is consumed that it causes slowed breathing and unconsciousness, and breathing slows enough that the blood levels of 02 goes down low enough and the C)2 levels go high enough, the breathing slows, lowering O2 more and raising CO2 more. If this continues,  the brain will eventually have too little O2 to signal the lungs to breathe. This process can take 1-12 hours. Before lapsing into unconsciousness, the person will have time to pull out the needle. 

But that's assuming the person is consuming opiates alone, no other drug, and the opiates are pure.

So why do we hear about people dying so quickly that they don't have time to pull out the needle? Like the damage depicted in the cartoon, it's not the opiate itself but other things that come with the opiate. In the case of prescription medications, what comes with the opiate can be acetaminophen, which can cause rapid destruction of the liver at doses frighteningly close to an ordinary dose, with maybe two days when rescue is possible.  Acetaminophen can also cause a deadly reaction called Stevens-Johnson syndrome which can cause rapid closing of the airways.  Black market drugs may contain cutting agents that may have potential to cause harm. Some examples include procaine, which can impair breathing or cause paralysis,  allergic reaction  or irregular heartbeat or seizures; lactose can cause allergic reaction or rapid closing of airways; glucose/dextrose can cause allergic reaction or swelling of the face, tongue or throat, chloroquine can cause Stevens-Johnson syndrome, abnormal heart signals and ventricular fibrillation. Consuming any of the above mentioned cutting agents, even with no opiate, and suffering those dangerous effects are possible. But if a person takes an opiate alone, the one risk is of extremely slowed breathing, which does not occur rapidly.  Another reason for deaths of opiate users, known since at least the 1960s is injecting opiates while there's alcohol in the bloodstream, which can cause rapid death with fluid in the lungs. (This is well known in emergency rooms, which is why they ask about recent alcohol consumption before treating pain).

It's also possible to die after taking an opiate and the cause could be something other than the opiate, say, getting hit by a bus. Or the person could die from an infection or an undiagnosed disease, or poisoning (intentional or accidental). It is also not unknown for a person to have "opiate death" on the death certificate, while dying without having used any opiates. If there's no autopsy and no testing of any fluids or tissues, there is no demonstrable evidence that the death was from an opiate and not any number of other causes. 

Sources:

coroners, medical examiners, death investigation offices, labs

http://sites.nationalacademies.org/cs/groups/pgasite/documents/webpage/pga_049924.pdf

Tobacco

deaths per year: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm

cdc: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/

healthline: http://www.healthline.com/health/smoking/effects-on-body

nhs:

https://www.nhs.uk/smokefree/why-quit/smoking-health-problems

Medical examiners can easily identify dead smokers:

Diagnostic Pathology: Hospital Autopsy E-Book

https://books.google.com/books?id=yCSKCwAAQBAJ&pg=RA2-PA79&lpg=RA2-PA79&dq=signs+of+cigaret+smoking+at+autopsy+diagnostic+pathology+autopsy&source=bl&ots=f9LYcnF31b&sig=sRYw9vwLpOSupQ4_mq8EE1UBv6s&hl=en&sa=X&ved=0ahUKEwipvs6umcjTAhVW62MKHf3RAHYQ6AEIIjAA#v=onepage&q=signs%20of%20cigaret%20smoking%20at%20autopsy%20diagnostic%20pathology%20autopsy&f=false

scary list of effects of tobacco on organs with photos!

tobacco cartoon organ illustration. https://www.healthline.com/health/smoking/effects-on-body#1

Opiates

Actual Overdose symptoms

Pinpoint pupils, unconsciousness, respiratory failure http://www.who.int/substance_abuse/information-sheet/en/

Naloxone drug sheet with symptoms             https://www.drugs.com/naloxone.html

naloxone injectables insert.                              https://www.drugs.com/mmx/naloxone-hydrochloride.html

http://www.druglibrary.org/schaffer/Library/studies/cu/cu12.htm

difficulties determining opiate deaths http://content.time.com/time/health/article/0,8599,1996831,00.html

effects of opiates cartoon organ chart             https://drugabuse.com/featured/the-effects-of-opiates-on-the-body/

acetaminophen                                            https://www.drugwatch.com/2014/01/28/fda-limits-acetaminophen-liver-damage/

cutting agents                                                                   http://www.bbc.com/news/magazine-11177126

list of contemporary cutting agents                  https://www.eztestkits.com/en/drug-purity-and-cutting-agents

https://www.drugs.com/sfx/procaine-side-effects.html

https://www.drugs.com/cdi/dextrose-injection.html

https://www.webmd.com/drugs/2/drug-8751/chloroquine-injection/details/list-sideeffects