Mixture of pills

Reports show most Pennsylvania overdose deaths involve multiple drugs

“FACT: Risk for OD & death increases when Rx opioids are combined with alcohol or other drugs,” tweeted NIDA earlier this month. A new DEA report on Pennsylvania’s overdose deaths underlines, italicizes, and exclamation-points this statement. Of 2,500 recorded drug-related deaths in Pennsylvania in 2014, 81% involved two or more drugs.

There are major limitations to the DEA report, but it clobbers us with a few facts.

1) “Heroin abuse is truly ubiquitous” is one of the key findings. Almost every single one of Pennsylvania’s 67 counties recorded a heroin-related death in 2014. There’s no geographic space, rural or urban, that has avoided the harms of heroin use.

2) The two types of drugs that are contributing most often to overdose deaths are opiates (both heroin and prescription painkillers) and benzodiazepines. Heroin was present in 51% of the recorded overdose deaths, any type of prescription opioid was present 60% of the time, and a benzodiazepine was present about 50% of the time.

3) And finally, the vast majority of overdose deaths involve more than one drug.

Has our message about drug combinations been loud and clear enough?

You can read the full report here.

There are all sorts of questions that are not answered by this analysis. For example, the report does not look at the presence of alcohol, over-the-counter drugs, or synthetic marijuana. It gives no information whatsoever about where the prescription drugs came from: were the painkillers and benzos prescribed by a doctor or purchased illegally? It tell us nothing about how the drugs were administered or how much of each drug was in the person’s system. Frankly, it leaves a lot to be desired.

But it’s a nightmare trying to collect all of this data. Pennsylvania’s reporting system is a complete free-for-all: each county has its own process for analyzing toxicology reports and determining causes of death. And some refuse to share their data (even at the behest of the DEA). This total lack of uniformity compromises the accuracy of our overdose statistics. Given the circumstances, the DEA’s report is intended to serve as an imperfect baseline measure of where we stand in 2014.

Earlier this year, the Pennsylvania State Coroners Association (PSCA) compiled data on 2014 Pennsylvania overdose deaths that offers a few more tidbits of information. According to the PSCA report, alcohol, antihistamines, and muscle relaxers are present in a significant number of overdose deaths. Nearly 20% of the toxicology reports showed the presence of alcohol. Antihistamines showed up in about one in ten cases. And muscle relaxers were present about 5% of the time.

The trouble, of course, is that epidemiological data are better at painting a picture than explaining why it looks that way or what to do about it. So what can we make of these statistics?


Click on the image for a larger version

It’s very common for people to mix drugs

Anecdotally, mixing multiple drugs seems to becoming more popular.

“I think that the cocktail’s a more common thing than heroin is now, or most people that take heroin take the cocktail as well.” That’s a Boston-area heroin user commenting on statistics that show the majority of Massachusetts overdoses result from multiple drugs.

Heroin is the real wild card in these drug cocktails.

“The potency now is so inconsistent, you don’t know what to expect. So you’ll eat a bunch of Klonopins and do a shot of heroin and then you’re dead,” says another heroin user from Boston.

Read more of Boston-area drug users’ thoughts in the illuminating article “It’s Not Just Heroin: Drug Cocktails Are Fueling the Overdose Crisis.”

A 2012 study of high school seniors who report using prescription opioids non-medically showed an astounding seven out of ten use them in combination with other drugs. And of those who do mix opioids with other drugs, 27% mix opioids with three or more drugs. One of researchers behind the study called these findings “staggering.”


In conclusion, a question

Much has been made of the importance of educating physicians and citizens about the risks of prescription opioids. But has our message about drug combinations been loud and clear enough?

Most people who die of a drug overdose die from more than one drug. Do young people understand that experimenting with multiple drugs can be much more dangerous that experimenting with one at a time? Do physicians who prescribe opioids for pain clearly articulate the importance of avoiding alcohol and benzodiazepines? Do human service providers whose clients are known drug users convey the message that a mixture of drugs–particularly one that includes an opiate or opioid–can easily lead to overdose death?


Recommended Resources

Infographic: Benzodiazepines and Medication-Assisted Treatment

Problem Behaviors Can Signal Risk in Prescribing Opioids to Teens

PaStop.org, the Commonwealth Prevention Alliance Stop Opiate Abuse Campaign

Online course: The Prevalence of Prescription Opioid Misuse: Doctor Shopping, Co-ingestion, and Exposure