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One of the biggest causes of overdose is mixing drugs.

Taking depressant drugs together, such as:

• alcohol and heroin; or
   
• heroin and benzos

means that they work together in the body to create a stronger sedative effect.

Most ‘heroin overdose’ deaths are actually heroin + alcohol overdoses.

[heroin] + [alcohol] = [overdose]

Taking depressants and stimulants together, particularly combinations of heroin and cocaine or cocaine and alcohol can also lead to overdose.

Remember: drugs [particularly alcohol and benzos] can still be in your system and can contribute to overdose hours after you have taken them.

In Queensland, for further information on safer drug use contact the Alcohol and Drug Information Service on (07) 3236 2414 or regional freecall on 1800 177 833.

Below is the information the briefing paper gives to pharmacists to support the text on the calendar card.
It will hopefully be of interest both to professionals and injecting drug users.

Depressant + Depressant
The key messages that we want IDUs to take from this month’s card are that mixing depressant drugs is the main cause of overdose and that the combination of mixing depressants such as alcohol and heroin or benzodiazepines and heroin, leads to the majority of drug related deaths.

Many injectors do not realise that depressant drugs have a potentiating effect, and this is why we have developed the 2+2=7 logo.

Anything you can do to reinforce and explain this message will help reduce the risk of overdose.

Depressant + Stimulant
Using depressants such as alcohol, with stimulants such as amphetamine, cocaine or ecstasy can often lead individuals to a higher level of alcohol consumption as the effects of the alcohol may not be felt because of the stimulants in the system. However, this does not reduce the toxic effects of alcohol on the body.

A particular risk factor with ‘speedballing’ heroin and cocaine together is that the stimulant effect of cocaine allows people to tolerate a much higher dose of heroin; but because the effect of cocaine wears off more quickly than the effect of heroin, people can overdose as the levels of stimulant fall.

Stimulant + Stimulant
Stimulant overdose is less common but is more likely if combinations or high doses of stimulants are used. Stimulant overdose can cause faster, irregular or weak heartbeat, very high fever, and fitting. This can cause death through heart attack, stroke or, in the case of fitting, anoxia.

Myths
Factors like ‘high purity heroin’ and ‘contaminants’ are media myths that serve to distract attention from the main cause of death - mixing alcohol and heroin or mixing benzodiazepines and heroin (particularly injected heroin).

Key intervention points:
One of the main tasks is to get injectors to recognise their own overdose risk. If you can engage someone in conversation on this topic, gently asking about their personal history of overdoses with questions like:

“have you ever overdosed?”

“how long ago was that?”

“has it happened lots of times?”

could heighten awareness of the risks.

This can be useful because frequency of recent non-fatal overdose is one of the strongest predictors of fatal overdose.

You might also be able to point to the risks raised on this card by pointing out the connection between alcohol and heroin or benzodiazepines and heroin, in their past overdoses (many drug users underplay the role of alcohol in their past overdoses).

Further reading
Commonwealth Department of Health and Aged Care. (2001). National Heroin Overdose Strategy. Canberra: Commonwealth of Australia.

Manly Drug Education & Counselling Centre. (2001). Chemical Reaction. Sydney: MDECC.

Preston, A., Hardacre, P., Hunt, N. & Derricott, J. (2001). Preventing Overdose (Second Edition). www.exchangesupplies.org.

Warner-Smith M, Lynskey M, Darke S, Hall W. (2000). Heroin overdose: prevalence, correlates, consequences and interventions Monograph No. 46. National Drug and Alcohol Research Centre, University of New South Wales.

Zador D, Sunjic S, Darke S. (1996). Heroin-related deaths in New South Wales, 1992: toxicological findings and circumstances. Medical Journal of Australia 164: 204-207.

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