The Canberra Christmas Overdoses Mystery

Abstract

Our investigation of a cluster of three fatal overdoses casts doubt on the conventional wisdom that overdoses result from unregulated changes in the purity of street heroin. Use of alcohol or other sedatives can make an otherwise safe dose of heroin (or other opioids) lethal. In addition users can knowingly increase their dose, usually as an indulgence. Some media reporting of this cluster of deaths was accurate, but there was also sensationalization, perpetuating stereotypes about the drug market that may be untrue. Information flow within the using community was relatively accurate, but slow, possibly because it was the holiday season. Larger studies to substantiate our findings are needed. In addition, introduction of a user-organization-based epidemiological monitoring system for overdoses would be a valuable public health measure.

Introduction

It is commonly accepted that heroin-related overdoses result from unregulated changes in the purity of the street drug. This view was challenged by Brecher and others in 1972 [1], but has persisted. Indeed, overdoses can result from a number of causes. In particular, overdoses can occur when a person's tolerance is reduced (for example, if they stop using for some time) and if that person does not correspondingly reduce the amount injected. Use of heroin in conjunction with other drugs which depress respiration, such as alcohol, can also be fatal [2, 3]. In addition some people knowingly use doses which are much higher than usual, although they may not be aware of the potentially fatal consequences.

The latest Australian figures (1990) report that an estimated 457 people died from causes related to the use of opiates; 72 deaths were attributed to "accidental poisoning", 63 to suicide and 45 to "poisoning, cause uncertain" [4]. Concern about overdoses increases when there is a cluster of deaths. We investigated one such cluster which occurred between Christmas and New Year in 1992. As well as following up the Coroner's reports on the deaths, we examined the media reporting and the information about them in the illicit drug-using community.

The Coroner's Reports

The Coroner's inquest was held in March 1993 and found that only one of these deaths was linked to heroin alone. The second person had high levels of both heroin metabolites and alcohol in their blood and the death can be attributed to the combination of drugs, although the heroin dose alone might have been fatal. The third person probably died from a combination of methadone and benzodiazepines, neither of which alone would have been fatal. Thus heroin was implicated in only two of the three deaths and in one of them it is not dear if the dose of heroin alone was fatal or if death occurred because of the effects of heroin and alcohol used together.

The Media Reports

News of the deaths was made public by a police press release issued on January 1. In part the press release stated "While investigators are still awaiting analysis results to establish the exact contents of the drug which may have been responsible for the deaths. They are very concerned that the deaths could have been as a result of contaminated or concentrated heroin" [sic]. The release ended with a request for drug users who thought they might have used or been sold contaminated heroin to contact police.

We examined the reporting of the story by The Canberra Times and The Australian. The original story by The Canberra Times reflected the press release reasonably accurately. The story appearing in The Australian was more embellished. There the deaths were linked to a batch of concentrated or contaminated heroin which could be "circulating" [sic] throughout the country. The police were said to believe that "all three died as a result of taking heroin from the same batch". By 6 January, The Australian was reporting that the police were linking deaths in Melbourne, Canberra and Newcastle to "[d]eadly batches of highly concentrated or contaminated heroin". The Canberra Times was more circumspect, reporting that laboratory tests might help determine if deaths in Canberra and Melbourne were linked, but that police did not believe that the deaths were related. By 23 January, however, The Canberra Times was also linking the deaths. Police were reported to be warning that "High grade heroin believed responsible for a spate of recent overdoses in the ACT, NSW and Melbourne might be available across the country". None of the press stories suggested that overdoses could have causes other than highly concentrated or contaminated heroin.

Information from the Canberra Using Community

On 4 January, the ACT Intravenous Drug Users League (ACTIV) told us that users "would be jumping up and down now" if the heroin available was of exceptionally high purity or contaminated, and because this was not happening doubted the press reports. On 6 January, ACTIV issued a press release, headed "No easy answer to junkie deaths", in which they stated that "The recent overdoses could be caused by many circumstances. It could be that people are buying concentrated or contaminated heroin or it may be that over the Christmas-New Year period people are simply overdoing things, taking too much heroin or mixing it with other depressants like alcohol". The media did not report on this press release. On 13 January the League issued a poster warning people not to use alone, so that if they overdosed someone could get help for them.

At the time of the overdoses we were in the middle of another project relating to the drug market which involved periodic interviews with eight illicit drug users. We used these contacts to monitor the flow of information about the overdoses in the illicit drug using community. They were also of the view that "killer dope" was unlikely to have caused the deaths. However, the accuracy of their information concerning the individual cases was mixed. The flow of information also seemed to be relatively slow which may have arisen because a number of them had not been in Canberra over the Christmas period. We obtained accurate information about one of the deaths on 5 January from someone who knew the deceased. This person had died from heroin alone and was thought to have knowingly used twice as much as usual, although the motives for this are unknown. It is possible that it was "indulgence" rather than planned suicide. We were given information about another death which was inconsistent with the Coroner's eventual findings and it was not until 18 January that we heard that this death had not been related to heroin at all. No one seemed to have any close familiarity with the third case.

Conclusions

Although this is a small cluster, it does suggest that the current wisdom about the causes of overdoses should be scrutinized and that larger studies of fatal overdoses are warranted. A recent study of six fatal overdoses from Sweden [5] also found that purity was not the key factor in the overdoses; instead, the deaths were variously related to user inexperience with heroin, return to use after abstinence and use in combination with alcohol.

If these suggestions are substantiated by further investigation, the media needs to be made aware of the findings. Both users and the community at large need to be accurately informed of the causes of overdoses. Not only does some media reporting sensationalize meagre facts, but it also reinforces stereotypes of the illicit drug market which may not be accurate. The connections between the deaths in different cities drawn by the media suggest some high-up central distribution point in the illicit market, which is inconsistent with information we obtained about the structure of the heroin market [6].

The role of the police in publicizing these deaths is an interesting one. The ACT Drug Squad reported that, as a matter of routine, whenever two or three deaths occur together, police send out a press release to warn users of possible dangers. This is a public health measure which should be applauded. Many of the media reports claim to have relied on information from the police, although we have no way of knowing how accurately the media reflected the information given to them. The ACT Drug Squad did however tell us that the media "was taking a fair bit of journalistic licence", especially in linking the overdoses in different cities. The police also seem to use such occasions for furthering their intelligence gathering. There was an emphasis in their press release in requesting information about the state of the market. Both ACTIV and some of our interviewees from the user community reported that the police were "hassling" people who might have information about the deaths.

The primary law enforcement role of police sits uncomfortably with their potential public health value in warning and educating about overdoses. Organizations which act as advocates for illicit drug users would be better able to rapidly collect and disseminate information about the causes of clusters of overdoses. There may be value in providing workers from such organizations with epidemiological training and back-up, so that they can investigate 'outbreaks' of fatal and non-fatal overdoses.

Acknowledgements

We are grateful to our contacts in the illicit drug-using community, as well as to Ms. Tarquin McPartlan from ACTIV, Ms. Marion Watson from Assisting Drug Dependents Inc, Detective Superintendent Ted Foster, ACT Drug Squad and Mr. PR Thompson of the ACT Magistrate's Court. Financial support came from The Australian National University's Strategic Development Fund.

References

[11 Brecher EM, Editors of Consumer Reports. Licit and illicit drugs. The consumers union report on narcotics, stimulants, depressants, inhalants, hallucinogens, and marijuana-including caffeine, nicotine, and alcohol. Boston: Little, Brown and Company, 1972.

[2] Ruttenber AJ, Luke JL. "Heroin-related deaths: new epidemiologic insights." Science 1984;226:14-20.

[3] Darke S, Ross J, Cohen J, Hall W. "Context and correlates of non-fatal overdose among heroin users in Sydney." NDARC Monograph No. 20. University of New South Wales: National Drug and Alcohol Research Centre, 1994.

[4] Department of Health, Housing and Community Services. Statistics on Drug Abuse in Australia 1992. Canberra: Australian Government Publishing Service, 1992.

[5] Fugelstad A. "Heroin deaths in Stockholm 1986-1991." Paper presented at the 5th International Conference on the Reduction of Drug-related Harm, Toronto, March 1994.

[6) Bammer G, Sengoz A."How would the controlled availability of heroin affect the illicit market in the Australian Capital Territory?" An examination of the structure of the illicit heroin market and methods to measure changes in price, purity and availability, including heroin-related overdoses. Feasibility Research into the Controlled Availability of Opioids Stage 2 Working Papers Number 10 Canberra, ACT: National Centre for Epidemiology and Population Health, 1994.