I’ve looked into the drug poisoning data and the drug use
surveys in enormous detail. What jumps out at me is that there are certain risk
factors that make an overdose death much more likely. Given this, our policy of
general drug prohibition is a mistake. We should instead issue *specific*
warnings to people with risk factors, and we should warn against specific risky
behaviors.
Age and Health
Age and health are both huge risk-factors in an overdose
death. As I mentioned in this previous post (here), older people appear to be dying of drug overdoses *way* out of proportion to
their use rates. And the opposite is true of young people; the young, while
certainly not immune to drug poisonings, are far more resistant than the older
users. There is an alternative explanation for these data, which I explore in
the link. It’s possible that many of these “overdose deaths” are misclassified,
where the decedent dies of a different cause. It’s just that people with drugs
in their system are overwhelmingly labeled “drug poisonings,” even when another
cause is responsible. The apparent age-disparity is driven by the higher
mortality of older age groups. I think there is something to this alternative
explanation, but 1) it implies that there are far fewer drug poisonings than we
thought and 2) it stands to reason that as people get older and more infirm
they’d be more susceptible to something that would not have killed their
younger self. General warnings against drug use (“Just say no!”) are not
effective and not informative; specific warnings (“Just because your heart
could take it at 20 doesn’t mean your heart can take it at 40!”) might actually
prevent some deaths.
In looking at the individual records on these poisoning
deaths, it really jumps out at you how unhealthy these people are. It seems
like every other record has some non-drug related health issue attached. (See
my analysis here.) Sleep apnea and obesity are very commonly represented among these drug
poisoning deaths. It’s easy to imagine that someone who has trouble breathing
is more susceptible to an overdose from drugs like opioids, benzodiazepines, and
alcohol, which all can make you sleepy and suppress respiration. Also, heart
conditions are fairly commonly listed on the death records. It’s fair to ask if
these people would have died if they’d been in better physical health. Once
again, a general warning against drug use misses the point. A specific warning
to people in poor health might be more helpful. Very specific drug-illness
interactions would be even more helpful. “Don’t use cocaine if you have a heart
condition.” “Don’t use more opioids than prescribed if you have sleep apnea.”
Etcetera. We could still even issue the general warning, so long as it’s
followed up with one of these “especially if…” provisions.
Multi-Drug
Interactions
Overwhelmingly, these drug poisonings are multi-drug
interactions. I thoroughly explored the interaction issue in this post. For every major category of potentially lethal drug, the vast majority of
deaths involve multiple substances. Some of these interactions are well
understood. Benzodiazepines, opioids, and alcohol interact to suppress
respiration. If someone takes a non-toxic dose of several of these substances,
the combination can be deadly even though each substance alone would not have
been. Once again, a specific warning not to combine certain drugs would be
extremely helpful and could save a lot of these lives. A ham-fisted “Drugs are
bad. Don’t do drugs” doesn’t accomplish much. The problem is that people start
ignoring such warnings as soon as they survive an encounter with drugs. They
might start assuming that everything the government tells them is a lie, and
then they won’t believe anything else they hear. Well, here’s a quantifiable
risk, with easy-to-cite data sources. We don’t even have to wait for a big
policy change to implement this warning. People can unilaterally change their
behavior once they know the *specific* risks of drug use. Such a behavior
change doesn’t require a big congressional battle over drug policy, just
accurate information about risks.
One caveat here is that sometimes there are combinations of
drugs on the death record that don’t seem to have a dangerous pharmacological
interaction. To name a couple of dubious combinations: Does cocaine really
negatively interact with benzodiazepines? Do opioids interact dangerously with
cannabis? (For that matter, did cannabis actually *cause* any of the deaths in
which it’s listed on the certificate?) Or are the medical examiners
promiscuously listing everything they find on the toxicology screening? It’s
possible that some of these truly are single-drug poisonings and irrelevant
factors are listed on the death certificate. But if we admit that irrelevant
factors are listed on the death certificate, that once again opens up the possibility
that many of these deaths aren’t really drug poisonings in the first place. I
suspect that the opioid-benzodiazepine-alcohol interactions are real and really
are driving some of these death numbers. A specific warning against using any
of these in combination would spare us a large fraction of the total drug
poisonings.
The really sad thing here is that we’re missing an
opportunity to meaningfully inform people of risks. We’re missing a chance to
save lives. And it’s all because the US government has insisted on a
puritanical “thou shalt not” policy regarding all questionable substances.
Someone else came to a similar conclusion after doing their
own research. See this excellent article, including the comments section (Less
Wrong tends to have excellent comments):
The very first comment makes the following point:
“Even the worst drugs that legitimately screw people up do so
because those people are taking them in ridiculously stupid ways. These drugs
can often be useful tools to have when used responsibly.”
This is consistent with what I’ve seen in the CDC data.
Infirm people, often using multiple substances, are driving the death counts.
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