Fatal overdoses may be slightly declining in the United States, according to preliminary 2018 data, but they are not falling out of public discourse—and nor should they. Yet their prominence in daily news headlines and the 2020 presidential race typically glosses over important details. These omissions have consequences when over 70,000 people in the US and 585,000 people from around the world died “as a result of drug use” (not including alcohol or tobacco) in 2017.
International Overdose Awareness Day on August 31 is a chance to commemorate these hundreds of thousands of people who lost their lives, support their loved ones, and advocate for reforms and interventions to prevent more deaths.
It should additionally be a day to correct misconceptions, and to highlight important issues—like polydrug use and overamping—that are too often left out of the conversation.
It Has Never Been Just Opioids
The idea that North America is facing an “opioid crisis” does not accurately describe reality. Most drug-related deaths involve drug combinations, with interactions between different drugs greatly increasing risks. So the word “overdose,” which implies too much of a single drug, can be a misnomer.
Almost half of drug-related deaths (48 percent) involved two or more substances, according to 2016 Centers for Disease Control and Prevention (CDC) data. And in 2016, nearly 80 percent of all synthetic opioid-related deaths involved another drug, often alcohol or benzodiazepines. These figures may understate the prevalence of drug combinations, experts tell Filter, due to small amounts of, say, alcohol, not being recorded in autopsy reports.
“Polydrug use is the norm, not the exception.”
Dr. Kimberly Sue, the medical director of Harm Reduction Coalition, has seen the ubiquity of polydrug use amongst her patients who’ve experienced non-fatal overdoses. “When I talk to patients about why or how they overdosed, it’s often because of the addition of an extra substance (like drinking on top of regular heroin use),” she told Filter. “Polydrug use is the norm, not the exception, while the media continues to often myopically focus only on opioids.”
This focus contributes to the demonization of opioids, which sees bad policies enacted and pain patients deprived of relief. It also denies key information to people about the risks they may be taking.
While some people knowingly use one drug to amplify or balance the effects of another, others are dying from being unaware which drugs they are consuming—a situation directly attributable to drug prohibition. Illicit supplies of heroin, cocaine and methamphetamine, for example, are increasingly adulterated with synthetic opioids, particularly fentanyl.
Even when used alone, depressants can cause a fatal suppression in breathing. But when used together, drugs like opioids and benzos intensify each others’ effects, increasing the chances of death. As with polydrug use in general, benzos’ involvement in opioid-related deaths is often ignored because, in part, they “are commonly prescribed and therefore wrongly assumed not to involve risks,” as Kat Humphries of the Harm Reduction Action Center wrote for Filter. The data show that over 30 percent of opioid-related deaths also involve benzos, often sold as Valium, Xanax and Klonopin.
Combining stimulants with opioids and/or alcohol can also increase risks. The likelihood of drug-involved death has been shown to leap for people who combine cocaine and heroin, a practice commonly called “speedballing.” In New York City in 2018, nearly three-quarters (74 percent) of all cocaine-involved deaths also involved opioids, according to recently-released city Health Department data. (Although some studies also suggest that opioid-stimulant combinations could help, in some cases, to reduce harms.)
“It is easy to latch onto ‘opioid crisis’ or ‘opioid epidemic’ or ‘overdose crisis,’ and I believe that it ignores the reality of most drug use in this country,” said Dr. Sue. “Talking about polysubstance use is difficult, because we often are not trained to discuss these complexities and often don’t have the time.”
With Stimulants, It’s Not Quite an “Overdose”
Stimulants such as methamphetamine are involved in an increasing number of deaths in the United States. Like depressants, they can overwhelm the body—but their effects are markedly different. To distinguish between the two, some harm reductionists use the term “overamping,” to refer to stimulants’ intense effects. While an overdose tends to be associated with being “unresponsive,” overamping is understood to be when a stimulant user is “highly animated or agitated,” David Stuart, a London-based chemsex expert, explained to Filter.
The words overdosing and overamping are, in part, used to distinguish between their root causes. Overdose implies excessive consumption, which isn’t necessarily the case for stimulants. Stuart has seen overamping be caused by “powerful or high doses of stimulants” and being “associated with the very first minutes after ingesting or injecting the drug.” But the Harm Reduction Coalition also notes that it can hit “on the 3rd day of a run when your body is getting run down, or when you get high with some people that make you feel weird.” In short: “Overamping can happen for a lot of different reasons.”
Overamping can only be addressed through a diverse range of practices that often require case-by-case judgement.
The distinction between the two is also important, according to Stuart, because of the responses they require from other people. While overdoses demand “immediate emergency intervention,” above all naloxone, overamped people benefit from “urgent observation to keep them from harming themselves or others,” and in order to notice “more urgent symptoms developing, like breathing problems, seizures, fitting, becoming unresponsive.”
Unlike with opioid-involved overdoses, there is no overamping reversal medication. Instead, overamping can only be addressed through a diverse range of practices that often require case-by-case judgement, medical attention, or social and emotional support.
People do die from what seems to be overamping, but other harms have been more widely examined. Amphetamine-related admissions in emergency departments around the country surged by 270 percent from 2008 to 2015, and in the particularly-affected city of San Francisco, methamphetamine-induced psychosis reportedly played a major role in these hospitalizations.
World Marks International Overdose Awareness Day
International Overdose Awareness Day is bringing together survivors, friends, family, activists, and healthcare and harm reduction providers all over the world. They are turning their tragedies and successes into powerful public testimony through demonstration, education, art, music and story-telling.
On Friday August 30, for example, the Katal Center for Health, Equity and Justice, in partnership with organizations such as VOCAL-NY, is holding a rally and memorial at the New York state capitol in Albany, “in honor of the lives, spirits, and memories of all those we have lost to overdose.” This is just days after groups rallied outside Governor Andrew Cuomo’s New York City office on August 28 to demand he “stop blocking lifesaving solutions to our overdose crisis.”
On Saturday, August 31, Moms United to End the War on Drugs are holding naloxone training and overdose prevention clinics in San Diego and Los Angeles, California. Their broader network of partners and allies are also screening films, holding candlelight vigils, marching, holding prayers, ringing bells, and discussing drug police all over the country in Michigan, Florida, Tennessee, Pennsylvania, Georgia, and Washington, DC. Moms Stop the Harm, a partner organization in Canada, is holding a harm reduction workers’ support group in Victoria on Thursday.
Harm reductionists are also gathering in Indonesia, India and Afghanistan; in Ireland, Italy and Germany; and as far south as Australia, to name only some. In Russia, where harm reduction is highly stigmatized and criminalized, a Moscow photographer is presenting a series of pictures of people who died.
A Range of Successful Responses
Despite slow progress on drug policy reforms at the national levels, grassroots activists are leading the way in developing effective harm reduction interventions to prevent drug-related deaths. Some of these tactics are technically illegal and take place underground. Others are implemented by city and state governments, ususally thanks to pressure exerted by people who use drugs and their activist allies.
Over the past year, Filter has reported on many such interventions and campaigns in the US and around the world. Some examples of these include:
* An unauthorized safe consumption site (SCS) in an undisclosed location in the United States. This site prevents the majority of its users from injecting in public and has reversed 26 overdoses with naloxone. This article additionally describes efforts to prescribe safe supply and implement heroin buyers clubs.
* The ongoing battle to open the first legal SCS in the US, in Philadelphia, which is being opposed by the federal government.
* Three unauthorized SCS operating underground in Seattle. Operated by people who use drugs, they utilize different modeals attract different demographics, but all monitor safety and observe strict privacy and secrecy.
* Government-sanctioned SCS in Sydney and Melbourne in Australia.
* Efforts by a group call Next Harm Reduction to make naloxone available online in the US to everyone who needs it.
* Harm reduction groups and drug users themselves engaging with people who sell drugs. This includes sharing sterile syringes, drug checking kits, or fentanyl testing strips so sellers are better informed about the quality of their supply.
* People who use drugs taking the lead to educate their peers about fentanyl in Baltimore, Maryland. Bmore POWER activists partnered with a public health organization and the local university to take harm reduction education directly into their communities.
* The first mobile SCS van in Lisbon, Portugal. The van is stocked with safe injection supplies and two injection stations, and brings harm reduction directly to those who need it.
* New York City expanding its rates of syringe exchange 127 percent over 10 years. In 2018 it distributed 4.5 million sterile syringes, or more than one syringe for every two New Yorkers.
* The Netherlands hosting a government-funded drug checking service, capable of issuing national “red alerts” about contaminated drug supplies.
* A range of harm reduction services offered by different groups to people attending music festivals.
* An addiction-treatment provider in Phoenix, Arizona which opened the nation’s first 24/7 methadone clinic.
* An engineer in Boston who designed a motion detector to be placed in public bathrooms that alerts staff if someone overdoses and falls to the floor.