I am a member of Connecticut’s Overdose Fatality Review Panel. We meet on a regular basis to review selected cases of people who have died of overdose. We receive a file on each person that includes their age, gender and race, death location details and circumstances of their death, the autopsy and toxicology findings, their substance use, medical and mental health history, prescribed medications, summary of an interview with a family member or friends, their education and work history, their economic stability, neighborhood and physical environment, and an assessment of their stressors and how well or not they are integrated into their community.
The cases are soul crushing in their sadness. I have been to many overdose scenes and witnessed families’ grief. I have stood in bedrooms where a patient grew up and now died, with pictures of their younger selves in happier moments on the wall. I have also stood under bridges, the lone witness with my crew, to the end of a life. But reviewing these cases is another level of despair as we learn who the person was and hear and of their triumphs, struggles and tragedies, and their families’ love for them. They are made into people, not just another dead body or statistic. Reading the cases, you want to shout out “Danger ahead! Please someone stop the train or untie this person from the tracks!” You feel their pain in your bones. I can’t imagine the emotional toil of the death investigators as they spend their days interviewing the victims’ s families and friends as they compile the dossiers.
We hold a discussion on each case looking for missed opportunities to have saved their lives. When I review the cases, I ask myself several questions: Why did they start using drugs in the first place? Why did they continue to us and why on this fatal occasion did they overdose and die? The answers tear at your heart.
Deaths from opioid overdose are preventable. Addiction is treatable. Opportunities for successful intervention exist. The risk factors for drug use, drug use disorder, overdose and death are known. It is important to understand those factors and be vigilant against them in our families, friends, and even ourselves.
While people addicted to opioids are at a higher risk for overdose, you do not have to be addicted to opioids to accidentally overdose on them. One illicit pill can kill.
Today anyone who uses illicit opioids or pills not directly prescribed to them by a doctor is at risk for overdosing. This includes both experienced users and those who rarely use. No one is safe. This is due to the unpredictable ingredients and strength of current street drugs. There are additional risk factors that will increase a person’s chances of overdose, addiction or death.
Access to Opioids. The availability of opioids either through a prescription or through illicit sources will increase the risk of drug use and for some subsequent addiction. For people who were first exposed to opioids through prescriptions, evidence shows that risk of addiction elevates as soon as five days after beginning a prescription or use. For this reason in many states, prescribers are now limited to giving patients only a seven day supply for their initial prescription, unless they meet other requirements. The limit is five days for minors. If friends or family members are using drugs and the drugs are readily available, the danger of misuse and addiction will rise. Family members using opioids prescribed to them should keep them safe from others and dispose of any leftover pills once they have stopped taking them.
Drug Misuse and Addiction Risks
History of substance use. Those who have used other substances such as marijuana or cocaine may be less reluctant to try opioids than someone who has never used substances. There is much debate about whether or not marijuana is a gateway drug (I don’t believe it is.) What is not debatable is that persons with experience misusing prescription drugs are at a higher risk of transitioning to heroin or fentanyl, which are cheaper, stronger, and often more readily available on the black market than legitimate prescription pills — pills that may in fact be counterfeit pills containing fentanyl.
Age at first use – The earlier someone begins the use of substances, the more likely they are to develop substance use problems because young people’s brains are not fully formed. The brains are more easily rewired by opioids effects on the brain’s reward pathways because the brain is still malleable. Research published in Pediatrics in November 2015 found that, when prescribed an opioid before their senior year in high school, people with no drug use history and who strongly disapprove of others smoking marijuana have a 33 percent greater risk of engaging in harmful opioid use later in life than those who had no opioid prescription.
Adverse Childhood Experiences– People with adverse childhood experiences (ACES) are at higher risk of later substance use and addiction. These experiences include physical, emotional or sexual abuse as well as physical or emotional neglect. Additional factors include growing up in a dysfunctional household that might mean people with mental illness, a relative in jail, a mother treated violently, presence of substance abuse or history of divorce.
Mental Health– There is a link between substance use and mental health. For many, substance use may treat undiagnosed mental health issues, and encourage continued use. People with impulsivity or thrill seeking traits are also at increased risk. Nationwide, it is estimated that 25.4% of people who die of overdose have an underlying mental health concern.
Genetics– A 2023 National Institutes of Health study confirmed what researchers have long surmised, that there are certain inheritable genes that are commonly linked with both substance use and mental health issues. Having these genes does not guarantee that someone will develop addiction or substance use disorder, but the genes do increase someone’s risk when that person is exposed to other environmental factors. Some of the genes involve the brain’s dopamine or reward system, which can be hijacked by drug use, as I will explain in the chapter on addiction. Genes are not destiny, but combined with environmental influences, they can make addiction more likely in one person than another subject to the same influences. For some people a night of drinking alcohol and snorting a line of cocaine can lead to nothing more than a bad hangover, for another, it can lead to eventual homelessness and death.
Gender – Males are at higher risk of addiction than females because they are more likely to use opioids than women. Once using, there are no gender differences in who will develop addiction.
Occupation-Occupation- Those engaged in industries such as construction, extraction (mining, oil and gas extraction), and health care workers have higher proportional rates for fatal overdose than other occupations. This could be both due to the higher risk of injury from physical labor and the need to work in order to get paid.
Overdose Risks
Polydrug use. Opioids produce sedation. Combine an opioid with other sedatives like benzodiazepines and/or alcohol and there is increased risk for unconsciousness and depressed respirations. Using opioids with stimulants like cocaine or methamphetamine can also exacerbate risk. Stimulants can cause vasoconstriction, a narrowing of the body’s blood vessels, as well as an accelerated heart rate, requiring the body to use more oxygen at the same time the opioids are depressing the body’s ability to obtain oxygen, leading to hypoxia and death. In 2021, 32.3% of all fatal overdoses contained both fentanyl and a stimulant, although it is not clear the role the stimulants played in any individual death.
Injecting Opioids– Opioids can be used through several different routes. Injecting directly into the bloodstream provides the quickest and most powerful delivery. The bioavailability — the amount of drug that reaches the brain is highest with intravenous delivery. The stereotype of the drug user dying with the needle still in their arm is based in fact. The drug can hit the brain while the user is still slowly pushing the syringe plunger forward.
Abstinence/Reduced Tolerance-Years ago, I thought many of my patients were lying to me when they said things to me like: “I don’t use drugs anymore.” “I just slipped up.” “I haven’t used in months.” “I just got out of rehab.” “This is the first time in two years I have used.” When I started reading about drug use, I began to understand the truth behind many of their statements. Only a small amount of opioid may be needed to get a novice or opioid naive person high. That same person should they continue to use will soon need greater amounts of the drug to achieve the same high. People who use opioids on a regular basis develop tolerance to the opioid. This tolerance can develop in a metter of days. When tolerance develops, a higher dose of the opioid is needed to achieve the same effects. The body has adjusted to the opioid. When someone stops using opioids their tolerance drops so if a person who is used to doing “three bags“of heroin at a time, uses “three bags” when they return to using opioids after an extended absence, they will likely overdose as their body is no longer tolerant to such a dose.
Those with lowered tolerance include, patients recently discharged from treatment, those recently released from incarceration, and those who have undergone a self-imposed period of abstinence. Many prisons and drug treatment facilities now routinely give the people naloxone on their discharge. Unfortunately, this same group of people (those released from prison, people who are out of rehab and those with a self imposed period of abstinence) are likely to hide their drug use from others and will often use alone. I was sent for a welfare check on a man living in a rented room. A neighbor had complained of the smell. The supervisor left us in. A man lay dead on the floor. He’d been there for a few days. I found a box of narcan on the card table in the spartan room, along with paperwork from his prison discharge. The naloxone had instructions on how to use it. The problem was there was no one to administer it. It was far from a unique scene.
Prior non-fatal overdose. A study in Massachusetts showed that 10% of the people who received naloxone from EMS for an overdose were dead within a year. Not everyone who overdoses is going to overdose again. Nearly all opioid overdoses are accidental. Overdosing is unpleasant, and so is resuscitation with naloxone, but as long as people use illicit street drugs, the risk is going to be there. Each use is Russian Roulette.
Death Risk
Using Alone -The number one risk factor for dying of a fatal overdose is using opioids alone. According to the CDC, ninety-one percent of all fatal opioid overdoses in 2021 were unwitnessed.