Drug overdose is now the leading cause of accidental death in the United States, with opioid-related deaths driving the much of the increase. This alarming statistic has gained widespread attention and led to a national conversation demonizing opioids and the people who use them. But a critical predictor of overdose has remained absent from this conversation: opioid-related overdoses, both fatal and non, almost always involve at least one other drug.



Mixing drugs is generally much more dangerous than single-substance use, and certain combinations are particularly lethal. Taking opioids with alcohol, for instance, or benzodiazepines, dramatically increases the potential for fatal respiratory depression, as all three drugs depress the central nervous system. A person’s blood-morphine concentration needs to be significantly higher to cause death in an opioid-only overdose than in an overdose where alcohol or benzodiazepines are present. These drugs are frequently noted in autopsy reports for opioid-related overdoses.

Addictions are harder to kick when you're poor. Here's why | Maia Szalavitz Read more

But autopsy reports and death certificates do not always capture the true reasons behind a person’s death, especially when drug use is a factor. Kenneth Anderson, CEO of the Hams Harm Reduction Network, scoured death certificate data on opioid overdoses, and found stark state-by-state differences in regards to drug mixing. While there are surely some differences between individual communities, the more likely explanation for this variation is the subjectivity of individual physicians, medical examiners and coroners.

One coroner might attribute an opioid-related overdose death to heroin alone when in fact the death resulted from a combination of heroin and a legally prescribed, low-dose benzodiazepine. Another could attribute the death of a known drug user to overdose, when in fact the death resulted from dehydration, pneumonia or another health condition. Researchers have pointed to this and called for more thorough reporting of drug-related overdose in death certificates, as they provide the basis for our understanding of public health trends and consequently shape research and public policy.

Our current obsession with opioids is just the latest trend in a long history of scapegoating single drugs: alcohol in 1830s and 40s, opium in 1870s, marijuana in the 1950s and 60s, crack cocaine in the 1980s and 90s, methamphetamine in the 1990s and early 2000s and now, opioids like heroin, Oxycontin and Fentanyl. The problem of multiple-substance use has remained absent from much of this conversation – and from the education of users and health practitioners – despite the fact that drug mixing is both dangerous and pervasive.

The vast majority of opioid-related overdose death is accidental – and entirely preventable. Drug mixing and tolerance changes are the primary predictors of overdose. Graduates of 28-day abstinence-based rehabs are over 30 times more likely to die of a heroin overdose than untreated addicts using on the streets. These programs should be held legally responsible if they choose not to distribute overdose antidote naloxone, and they should be required to run regular trainings on tolerance, drug mixing and safe-use practices.

In order to continue receiving federal funding, public schools and universities should be required to implement a standardized drug education and overdose prevention program covering the dangers of drug mixing.

A deadly crisis: mapping the spread of America's drug overdose epidemic Read more

Amid mounting concerns around heroin, intravenous drug use and the spread of infectious diseases, the cultural tide seems to finally be shifting in favor of harm reduction services that have been proven to work. The federal government has called for more access to medication-assisted treatment programs and lifted the nearly 30-year ban on allocating funding to needle exchange programs.

Many states have passed good samaritan laws and made naloxone available without a prescription. Some have proposed bills that would establish safe-injection sites and others have decriminalized marijuana. But none of these measures will prove effective if we cannot keep users – be they addicted, dependent or dabbling – alive.

By fixating on fearing opioids, we are missing the more culpable factors that lead some people to keep using drugs despite negative consequences. Opioid use on its own is not dangerous, and it’s time we stop demonizing it. Instead, we must implement a national overdose education strategy targeting the immediate factors of opioid-related overdose: drug mixing and tolerance changes.