Difficulties with Numbers in A Time of Prohibition
I would like to discuss some numbers I encountered recently in the context of two publications that were supporting the narrative that opiates are a desperately urgent issue for the general American Public. For the first part of this exploration, we will take the reported numbers at face value, momentarily setting aside circumstances that would make difficult the gathering of accurate data.
The first use of numbers we’ll explore is a 3/12/18 Boston Globe article titled, “One-quarter of Mass. residents know someone who died from opioids, survey suggests.” This title is not entirely clickbait, in that the body of the article concerns the deaths of approximately 2,000 MA residents attributed to opiates in 2016. Adding a little research outside of the article, and a bit of arithmetic, I discovered that Massachusetts’ population in 2016 was 6,811,779, meaning that each of those 2,000 decedents would have to have had something like 851 acquaintances (not counting out-of-state friends and relatives) for those 2,000 deaths to have touched 1,702,945 residents of MA. Those 2,000 people were 0.02% of the total population, and 5.9% of the 33,953 deaths in MA in 2016.
I am hoping each number I located – or calculated – outside the Globe article made the 2,000 total sound much less impressive.
A second publication I encountered recently was “Poison Statistics National Data 2016: Reports to US Poison Control Centers.” This report had quite a few numbers and charts mostly in reference to calls to poison emergency numbers, with most of those calls not resulting in a death (some may even not entail actual consumption of a substance, just a “what if” question). Toward the bottom of the webpage were cited some numbers regarding opiates users.
The Poison Control report cites a total of 15,000 deaths attributed to opiate medications in 2008. Then it cites some more numbers in relation to that 15,000 total. For each of those 15,000 individuals, the report cites: 10 admissions to rehab, 32 ER visits for misuse/abuse, 132 individuals abusing or dependent on opiates, and 825 non-medical users. These numbers could be stacked into a pyramid of problems. Or maybe an iceberg.
But then I did a little more arithmetic. If, for each of the 15,000 deaths in 2008 attributed to opiate medications there were 10 people admitted to rehab, that’s 150,000 total, in a nation whose 2008 population was approximately 304,090,000 million, or 0.049% of the total. The number of individuals reported to have visited an ER for misuse or abuse of opiates were 480,000, or 0.16% of Americans. The 130 individuals identified as misusing or dependent on opiates comes to 1,950,000, 0.6% of Americans, and the 825 non-medical opiate users comes to 12,375,000. The total of US deaths in 2008 was 2,471,984, making 15,000 deaths 0.6% of all deaths in the US in that year. The 12,375,000 non-medical users of opiates were 4% of the population. If we subtract the 1.9 million people identified as abusing or dependent on opiates from the 12,375,000 identified non-medical users, we have 10,425,000 people using opiates without developing dependency 3.4% of Americans, 6 times as many individuals counted as making non-medical use compared to the numbers identified as dependent on opiates.
On top of making sure to examine carefully numbers publicized by advocates of any social policy or legislative agenda – or even just noticing that one or a very small group of numbers is being used to make a very sweeping point – it’s also important to understand any context that would make difficult obtaining accurate data. Asking people to report use of black market products is likely to result in under-reporting, especially when the punishments inflicted on users who are caught are very severe (loss of student aid, loss of job, criminal record, incarceration, forced rehab, zero tolerance/tough love practices, civil forfeiture). Meanwhile estimates produced by government agencies whose employees’ jobs depend on the public willingness to fund ongoing interdiction efforts, rehab facilities and prisons, might be over-estimates. The combination of these two issues complicating data collection and reporting means that the public’s picture of drug users is skewed to under-report people whose use pattern mirrors legal alcohol drinkers (not consuming daily, not creating trouble at work or home, not committing crimes such as assault, stealing, fraud, embezzlement, not purchasing any when one can’t afford it), and to over-represent people who are in trouble for other reasons but find blaming drugs to be convenient.
While the total number of deaths in a state or in the whole US are likely to be pretty close to accurate, since very few murder victims’ bodies remain un-found, and very few people die accidentally alone and in a remote location to remain undiscovered and un-missed, attributions of specific cause-of-death are another matter, because **the vast majority of people who die in the US are not autopsied.**
Here’s a number to shock you, Dr. Vincent DiMaio, long-serving medical examiner in Bexar County, TX, says that if the amount spent for death investigations in the US per year is divided by the number of deceased individuals, it comes to $2.50 per individual.
Totals for various causes of death are reported each year as national figures, as if there were a standardized list of potential causes of death used across the entire nation. But this is not even close to true. Different jurisdictions tabulate causes of death very differently. Some will only report a total of “overdose deaths” without specifying which drug or drugs are involved, others may have a list of a certain number of drugs, and what drugs are or are not on the list vary by state or local jurisdiction, or from year to year. A death may be legally recorded as an “opiate death” while there are 4 other drugs in the individual’s system at time of death. And remember, most people who die in the US, including most people whose deaths are attributed to drugs, are NOT autopsied.
There are a total of 2,342 separate death investigation systems in the US. Of those, 2/3 give the authority to determine cause-of-death to elected coroners, most of whom are not required to have any medical or scientific credentials. Of the offices investigating deaths in the US, 2/3 have no in-house toxicology lab, 2/3 have no in-house histology (tissue) lab, and 1/3 have no x-ray machine. In jurisdictions served by both coroners and medical examiners, there are chronic personnel shortages.
Interestingly, a 2011 episode of Frontline had a segment titled: “Massachusetts: An Office in Turmoil”. As of 2015, the entire state of Massachusetts, which does have medical examiners, had a total of 9 full time and 2 part time investigators for the entire state.
Even in instances where an autopsy is performed, and toxicology samples are collected, different death investigation offices test for different things. But even if the samples are taken from the decedent and sent to a toxicology lab and opiate is detected, that doesn’t mean the individual died from the opiate. Without an accurate time of death, postmortem redistribution can cause tests to show a quantity of opiate incompatible with the person’s final dose, and even if there is an accurate reading and a high dose, the amount of the final dose alone cannot prove that the opiate is the mechanism of death. Every government-funded attempt to determine a reliable deadly dose of opiates from the 1920s-2000 has had subjects not only survive but show no ill effects from amounts the researchers expected to be deadly.
Actual death from an opiate overdose is not the sudden, needle-in-the-arm demise we in the US have been habituated to think of as the norm. The actual process of dying from an overdose of opiates is a 1-12 hour process, entailing a feedback loop of slowed breathing, leading to lower blood oxygen levels, leading to decreasing frequency in signals from the brain to the lungs to breathe. If this process is interrupted, with naloxone, the individual suffers no permanent damage to any part of the body.
But if opiates didn’t kill a clearly-deceased opiate user, then what could be the actual cause of death? Injection can cause endocarditis, hepatitis and other infections, or if injected into a bloodstream already containing alcohol, cause rapid pulmonary edema. Beginning in the 1940s, heroin began to be cut with quinine, which could cause the kind of rapid needle-in-the-arm deaths that have been in recent decades associated in the public mind with opiate overdose death. In recent times, there have been many different substances used to cut heroin, including acetaminophen, which is also an ingredient in numerous prescription opiate medications and can cause rapid death due to anaphylaxis or Stevens-Johnson Syndrome, both of which cause extremely rapid closing of the airways. Other cutting agents that can cause sudden death include: procaine (seizures, respiratory impairment, paralysis, anaphylaxis), lactose (anaphylaxis, hives, swelling in throat, difficult breathing), chloroquine (anaphylaxis, abnormal heart electric signals, hives, Stevens-Johnson, seizures, ventricular fibrillation).
The main thing to remember, when examining the topic of ANY “drug death” is that any individual in the US whose death is attributed to a drug was likely not autopsied, and the determination that the death was caused by a drug (or drugs) was more likely than not made by someone with no scientific or medical training, who is exposed to the same Drug Death Panic style reporting and 12-steps influenced TV shows and movies (Hollywood being under the influence of DC Drug Warriors to include such plot points in their productions) as the rest of the public, and is using clues like the presence of a prescription bottle or a relative mentioning use of a particular drug to count a death as having a drug cause.
It is not only entirely possible for someone to have a legal cause-of-death be “overdose” with absolutely no drug in the body at the time of death. Here’s two pieces of evidence that this can and has happened:
In January 2009, 43-year old Cayne Miceli died in a New Orleans jail, and the medical examiner citing fresh needle marks, recorded the death as a drug overdose (no drug specified). However, before winding up in jail, Cayne had been under medical care. Doctors who had treated her encouraged her father to investigate further, and he had her body flown to Montgomery, AL, for a second autopsy. That autopsy concluded the puncture marks were caused by medical personnel drawing blood and inserting an IV. A toxicology screen showed no drugs or alcohol in Cayne’s body. The medical condition she had been treated for was asthma. She had gone to the hospital for treatment of an attack, and when she felt they were discharging her too soon and resisted being released, she was arrested, and brought to the jail where she was restrained in a way that, combined with the asthma, caused her death.
I will leave you with a quote from Dr. Robert Anderson, of Glasgow University’s forensic toxicology department, which I found remarkable. I sincerely hope that each reader of this essay will take a moment to ponder the implications of Dr. Anderson’s words, “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.”
Sources
Boston globe 1 in 4
https://www.bostonglobe.com/metro/2018/03/12/one-quarter-state-residents-know-someone-who-died-from-opioids-new-survey-suggests/NZFecBcUaVMbVXSsfvt2WM/story.html
population MA 2010-2016
https://www.mass.gov/service-details/population-information
total US Deaths 2016
2,744,248
https://www.cdc.gov/nchs/products/databriefs/db293.htm
total US deaths 2008 2,471,984
https://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_10.pdf
2016 MA Deaths total – 33,953
http://www.worldlifeexpectancy.com/massachusetts-cause-of-death-by-age-and-gender
us coroners, ME
http://sites.nationalacademies.org/cs/groups/pgasite/documents/webpage/pga_049924.pdf
Opiate death #s can’t be accurate according to CDC!
Some places just list type of drug, in 2013-2014, 22% & 19% just OD not specific drug
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm
postmortem redistribution, determining opiates levels in the dead
http://content.time.com/time/health/article/0,8599,1996831,00.html
attempts to determine deadly dose
http://www.druglibrary.org/schaffer/Library/studies/cu/cu12.htm
most deaths not investigated or autopsied
https://www.cincinnati.com/story/news/2015/01/24/cost-death-morgue-budget-problem/22242687/
DiMaio quoted: $2.50/deceased
MA medical examiner office in turmoil
OD death without no drugs
https://www.pbs.org/wgbh/pages/frontline/post-mortem/real-csi/
most corpses not autopsied/MA particular shortage
https://www.cbsnews.com/news/families-suffer-due-to-medical-examiner-shortage/. (mass, 2015
opiate OD death is a long process/naloxone no harm
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 nasal spray package insert
https://druginserts.com/lib/rx/meds/narcan/
naloxone injectables package insert
https://www.drugs.com/mmx/naloxone-hydrochloride.html
causes of opiate users’ deaths
http://www.druglibrary.org/schaffer/Library/studies/cu/cu12.htm
acetaminophen
https://www.drugs.com/drug-interactions/acetaminophen-diphenhydramine,tylenol-severe-allergy.html
cutting agents
list of contemporary cutting agents
https://www.eztestkits.com/en/drug-purity-and-cutting-agents
Procaine* (aka novacaine)- allergic reactions, cardiovascular, apnea, tremor, seizure, breathing/respiratory impairment, paralysis
https://www.bing.com/search?q=procaine+injection+side+effects&FORM=SBRS01
Lactose* allergic reaction, hives, swelling of throat, difficulty breathing
https://www.rxlist.com/lactated-ringers-side-effects-drug-center.htm
Chloroquine* – https://www.webmd.com/drugs/2/drug-8751/chloroquine-injection/details/list-sideeffects
some examples – allergic, abnormal heart electrical signals, low BP, hives, mood changes, muscle weakness, psychosis, Stevens Johnson syndrome (deadly, swell tongue, throat mouth), seizures, suicidal, ventricular fibrillation, very rapid heart rate
needle-in-the-arm deaths
https://www.theguardian.com/uk/2000/jan/31/shipman.health4