Overdosing to Die

By Brian Whitney 05/18/16

How do we determine whether drug overdoses are accidental or intentional?

Overdosing to Die

By anyone’s standards, I have used enormous amounts of drugs and alcohol over my life. There are not many drugs I have not tried or used frequently. And, although I have never done it myself, I have had many close friends over the years who got involved with heroin. For a few months, I had a girlfriend who was a heroin addict who ended up crashing with me at my apartment. She would use in my presence, cooking up in my kitchen while I watched. I would often pull lit cigarettes out of her fingers while she nodded out next to me on the couch. While she never actively tried to get me to use—heroin addicts don’t usually look for people to give their stuff to—she would often speak of what nice veins I had, and the opportunity was there for me to take if I wished. 

I hated myself at the time. I wanted to blow things up. I wanted my life to be insane. But still, as little as I cared about myself, I never did use. And after a while, she moved away to another state where she eventually was imprisoned for robbing a bank. But that is another story for another time.

I never used for one reason and one reason only: I was concerned that I was going to die. It wasn’t that I was afraid of dying, really. It isn’t that I am afraid of my mortality—I am pretty much a nihilist—it is more that I never saw the reason to do something that could kill me. As unimportant as my life was, it still just did not seem to make sense to risk my life for whatever that feeling was that came with shooting up. Even for someone like me, who is diagnosed with impulse control disorder, the risk did not seem worth the reward.

The thing is that all of us that have been heavily involved with heroin, or have had someone close to us who has, know that sometimes people who use heroin die. It comes with the territory. There is no avoiding the possibility that when you shoot up, there is a chance it will be the last thing you do.

So when that happens, when someone shoots up and dies, was it at least in some way intentional? Was what seemed like someone's attempt at getting ridiculously high in actuality a suicide? Is something an accident if you know that it might happen before you attempt it?

Ian Rockett is a professor at West Virginia University and one of the world's leading experts in the field of overdose deaths. In 2014, he published a study that came to the conclusion that suicide is severely undercounted in the cause of death when it comes to ingestion of prescription drugs and opiates, and that “public health and research needs would be better satisfied by considering most of these deaths a result of self-intoxication.”

He took that a step further in a 2015 study, in which he claims that the epidemic of drug-intoxication deaths has caused an increase in undercounted suicides. In his view, suicides due to drug intoxication are quite often misclassified as an accident or as undetermined. 

In a phone conversation, Rockett told The Fix that he has “been pursuing the topic of suicide undercounting for some time now,” and that he feels that “drug intoxication suicides are being undercounted by a large margin.” According to his paper, many states, in particular ones that have been overwhelmed by overdose deaths, simply lack the resources and the inclination to research the death enough to make the correct assessment. 

In some ways, of course, this makes sense. Why would a coroner spend a lot of time ascertaining whether an overdose was an accident or on purpose, in particular when the result might just cause the loved ones of the deceased more pain? Best to just say it was an overdose and move on.

I once asked underground author and heroin user Shane Levene if he cared if he died. He said, “Of course I care if I die. I began using heroin (as most do) to make life more acceptable. It’s another myth (often perpetuated by addicts themselves) that heroin users are self-destructive and suicidal. In fact, it’s the opposite: we use to make life more bearable because we want to live.”

As to whether or not a fair amount of overdoses are misclassified, Levene agrees, but he thinks it is the other way around. He recently told me that, “Most times a post-mortem isn't even carried out, as they have already concluded the cause of death. So I think it's more the inverse, that a lot of accidental deaths, even non-overdose deaths, are put down as suicide rather than the other way around. And it's very easy for the authorities to justify their decision as (as we know) many users are already suffering from depression or some form of mental illness. For them, it's case closed. Another body out of the way, another good statistic to further stigmatize heroin, the minimal amount of paperwork to be done and one less stiff for the coroner to have to slice up and sniff through.”

There are other academics out there who are not studying overdose rates, but instead are examining the correlation between suicide attempts and the use of substances. One recent study followed numerous men and women around the U.S. who had either previously attempted suicide or were having suicidal thoughts at the time of a visit to an emergency room. According to the study, those who used cocaine and alcohol in combination were far more likely to try suicide than those who used any other drugs individually or in combination.

Of course, this is the classic chicken-or-the-egg situation. Is it that those that use alcohol and cocaine in combination are more likely to be suicidal? Or does using that combination make people suicidal that would not be otherwise?

One of the authors of the study, Sarah Arias, assistant professor of psychiatry and human behavior at Brown University, told me via email that “our main goal was to better understand the association between substance use and future suicide attempts. In our study population we found that individuals reporting both alcohol and cocaine use were more likely to report a suicide attempt in the 12 months after their initial emergency department visit, when compared to other substance users. In regard to suicide risk assessments, the current study suggests that not all groups are equally affected by the same risk factors (e.g., substance use).”

Or course, the connection between addiction and suicide in nothing new. Susan Kozak, LMSW, CAADC, and the Executive Director of Community Care Services told me that, "There is a lot of evidence of a strong link between active addiction/substance abuse and suicide. Substance use alters thinking and emotions. Alcohol, specifically as a depressant, can increase negative feelings and hopelessness. Feelings of hopelessness can lead to total apathy toward life and living. When substances are added to the mix, ending one's life seems like a logical choice. Substance use always increases the risk of suicide in an already depressed individual."

Which really brings us back to square one. When you have 12 vodka tonics at the bar and then get in your car and drive home, or when you shoot a potent dose of heroin into your arm, are you trying to die? Do you want to be dead? Or, as Shane Levene claims, are you doing it in order to make life more bearable?

Or is it that you just don’t care? Getting home safe and waking up in the morning would be fine, but if that doesn’t happen, if you never wake up again, do you care all that much?

How many substance abusers who passed away from overdoses, drunk driving accidents or suicides truly wanted to live, and how many wanted to die? None of us will ever really know for sure, except for the person who has passed away.

Brian Whitney is a pseudonym for an author and ghostwriter, his book Raping the Gods came out last year. He last wrote about harm reduction at raves and about Melissa Hartwig's Whole30.

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