Heroin, like other opiates, depresses activity in the brain centre that controls breathing. Sometimes, this effect is so profound that the drug user dies, and becomes yet another overdose casualty. Some of these victims die because they took too much of the drug. Others die following self-administration of a dose that appears much too small to be lethal, but why? This is the heroin overdose mystery, and it has been known for more than half a century.
There was a heroin crisis in New York City in the 1960s, with overdose deaths increasing each year of the decade. There were almost 1,000 overdose victims in New York City in 1969, about as many as in 2015. The then chief medical examiner of New York, Milton Helpern, together with his deputy chief, Michael Baden, investigated these deaths. They discovered that many died, not from a true pharmacological overdose, but even when, on the day prior, the victim had administered a comparable dose with no ill effects. Helpern, Baden and colleagues noted that, while it is common for several users to take drugs from the same batch, only rarely does more than one user suffer a life-threatening reaction. They examined heroin packages and used syringes found near dead addicts, and tissue surrounding the sites of fatal injections, and found that victims typically self-administered a normal, usually non-fatal dose of heroin. In 1972, Helpern concluded that ‘there does not appear to be a quantitative correlation between the acute fulminating lethal effect and the amount of heroin taken’.
It was a science journalist, Edward Brecher, who first applied the term ‘overdose mystery’ when he evaluated Helpern’s data for Consumer Reports. Brecher concluded that ‘overdose’ was a misnomer. ‘These deaths are, if anything, associated with “underdose” rather than overdose,’ he wrote.
Subsequently, independent evaluations of heroin overdoses in New York City, Washington, DC, Detroit, and various cities in Germany and Hungary all confirmed the phenomenon – addicts often die after self-administering an amount of heroin that should not kill them.
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