5 Drugs Not to Mix With Your Heroin

Some 46,000 people died of drug overdoses in 2013, 50% more than died in traffic accidents that same year. Most of them were due to legal prescription drugs, not illegal ones, but the number of fatal overdoses attributed to heroin—some 8,200—made up an increasing proportion of overdose deaths 

Media accounts tend to just blame them on heroin. The concept is simple: Heroin is a central nervous system depressant, so if you take too much, you eventually stop breathing and die.

The problem with this formulation is that it's rather hard to overdose on simple heroin, particularly if you are an experienced user. Deeply addicted people are able to consume monstrous amounts of heroin because they have built up tolerance to the drug. And you just don't drop dead. To actually die of a heroin overdose typically takes several hours, with the user slipping from consciousness to unconsciousness to coma and then to the cessation of breathing and death. (That process can be stopped in its tracks by treatment with an opioid antagonist such as Narcan, which is why first responders and law enforcement are increasingly carrying the stuff.)

The other problem with the simple "heroin kills" formulation is that it's not typically first-time or naïve users who are dying (although there is a not insignificant number of people who die upon using again after quitting or upon being released from jail or prison.) Most people who die on heroin are in fact older, long-term addicts.

So what's going on? It's not so simple, and there are important harm reduction lessons to be learned here. Most heroin deaths, it turns out, are not single-drug overdoses, but are the result of polydrug interactions. When mixed with other central nervous system depressants, the effects tend to be not linear, but synergistic.

We need only look at a couple of celebrity drug deaths to get the point. Actor Heath Ledger was taking prescription opiates, but also benzodiazepines, and an anti-insomnia drug, when he died in 2008. Similarly, Phillip Seymour Hoffman died after taking two central nervous depressants and two stimulants at the same time.  

As addiction scientists Shane Darke and Michael Farrell write told The Conversation US:

"What does kill heroin users is polydrug use. More specifically, the use of heroin with other central nervous system depressants. Death is due to respiratory depression, from the combined effects of these substances. While one of these may not kill if taken alone, together they are toxic. That’s why we see a large number of deaths with low morphine concentrations."

In the interest of keeping heroin users alive, here are five drugs not to take alongside it:

  1. Alcohol. Another central nervous system depressant, booze is associated with roughly half of all heroin deaths. One shot of heroin and one beer may come on like a lot of heroin, plus a pint of hard alcohol. If you're on smack, put down that drink.
  2. Benzodiazepines. You know them as tranquilizers, such as Valium, Librium, Ativan, and Xanax. These are some of the most commonly prescribed drugs in the United States, but their synergistic interactions with heroin and other opiates can leave you in the boneyard.  And these central nervous system sedatives can kill you all by themselves. No need to mix and match here.
  3. Cocaine. It seems paradoxical, but it isn't a good idea to mix heroin and stimulants, such as cocaine. Like other drug interactions, the famous "speedball" mixture of cocaine and heroin heightens the effects of both, increasing the risk of overdose, but equally important, cocaine wears off much faster than heroin, so your creeping heroin overdose is masked by the cocaine until it starts fading out, and then you die. Phillip Seymour Hoffman did a variant of this, speedballing with heroin, two stimulants, and two antidepressants. You see what that got him.
  4. Prescription Opiates. Duh. If you're already using one opioid central nervous system depressant—heroin—adding on Oxycontin or hydrocodone or morphine is likely to be too much of a good thing. Prescription opiates are already implicated in more than two-thirds of all prescription drug deaths and are found in many heroin deaths as well. If you insist on using opiates, stick to one at a time.
  5. Tricyclic Antidepressants. These old-school antidepressants, including Elavil, Tofinil, and Silenor, have largely been replaced by newer ones because of their undesirable side effects, but are still in use. By themselves, these drugs are responsible for numerous overdose deaths derived from cardiac arrhythmias, seizures, and apnea. Add them to your heroin and you may never be depressed—or anything else--again.

Finally, if you're using heroin or prescription opiates, having the overdose reversal drug naloxone (Narcan) on hand is the ultimate harm reduction measure. More and more states and localities are passing laws to ease access to this life-saver for drug users, friends, and family members, as well as cops and EMTs. Find out what the law is where you live, and get that stuff if you can. 


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