Wednesday, September 21, 2011

Cocaine, Speed, and “Overdose”: What Should We Be Doing?

By Eliza Wheeler, DOPE Project, Harm Reduction Coalition, San Francisco
This is going to be a two-part post about cocaine and stimulant-related deaths and what harm reductionists can start doing about it. The first part is a rant, the second part is some harm reduction information about stimulants and “overdose” (not the right word, but we’ll get to that), created from a meeting with some folks from the Speed Project here in San Francisco.

The Rant
So, the good news is that we have over 200 places in the U.S. where someone can get naloxone and overdose prevention education, and more are popping up every day. This is a great thing, because we know that opioid-related overdoses (pharmaceuticals and heroin) make up the bulk of overdose deaths in the US. However, according to the CDC’s most recent report, there were 27,658 unintentional drug overdose deaths in the US in 2007 and the second most common drug involved in those deaths, before heroin, was cocaine. According to this report, there were about 12,000 opioid-related deaths and 1,900 heroin deaths—making up the majority. However, there were 5,000 cocaine-related deaths.  I’m sorry, but that’s 5,000 people who died (at least), and I personally think that’s a lot of people.
According to the most recent DAWN report (PDF), here in San Francisco, there were 103 cocaine-related deaths in 2008 and 65 stimulant-related deaths. There were 221 opioid-related deaths. The San Francisco Medical Examiner’s report shows the same thing—the majority of deaths are opioid-related, but following in close second is cocaine. However, cocaine is the most frequently found drug (after alcohol) in people’s system when the Medical Examiner does post-mortem toxicology.  Deaths are not the only issue, however. Stimulants like amphetamine and methamphetamine don’t contribute to a very high number of fatalities on their own, but are mentioned frequently in emergency room admissions and other types of deaths, including homicides, suicides, traumas, vehicular deaths. According to DAWN data, in 2008, cocaine was involved in 482,000 Emergency Department visits—48% of all visits involving illicit drugs. Stimulants, including amphetamines and methamphetamine, were involved in 91,939 ED visits, or 9.3 percent.

My point with the data (and believe me, I know data is flawed and incomplete and never tells the whole story) is that although opioids surely cause the majority of deaths, we have systematically ignored the fact that the second largest number of deaths is attributed to cocaine, not to mention other harms that come from cocaine and stimulant use that land people in the emergency room. By we, I mean harm reduction programs, overdose prevention projects, public health departments—you name it, we’ve done a bad job at addressing cocaine and stimulant-related death and injury.
I have many thoughts on why this is. Part of it is because it’s a more complex issue than opioid overdoses, and there’s no magic bullet like naloxone so people avoid talking about it. Also, cocaine and speed are different, and have different effects on the body, so even within the stimulant category, you need different messages. So are we lazy? Do we not care about cocaine and speed users? What’s our excuse? In my decade of harm reduction work, the most I usually hear in an overdose training is “for stimulants and coke, if they’re having a heart attack do CPR if you know how and call 911, sorry.” Is the harm reduction community (with some wonderful exceptions), shamefully heroin-centric? Is there deeply embedded racism, classism and…drugism (I made that up) effecting how much effort we put into certain aspects of harm reduction work? I think so, considering that in 2011, there are still only a handful of programs that even give out crack pipe covers, and inevitably when someone comes to the exchange tweaked on speed at least one person rolls their eyes and pretends to restock the condoms. The amount of shame and stigma still heaped onto coke and stimulant users is incredible—and I’m talking about just in the harm reduction world.
SO ANYWAY, what do we need? What do we do?
1.  First of all, we need a new word. Overdose is not the right word for what happens with cocaine or speed. Even if it was, it has too strong an association with heroin and other downers. I was talking with a group at the Speed Project in SF recently and I asked “what do you consider an overdose?” and they all said, “It’s what happens when you take too much heroin.” The word that group used to describe the uncomfortable or dangerous effects of taking speed was “overamping.” But what is it called if someone who has been smoking crack for 20 years and dies of a heart attack when they’re walking up the stairs at age 40? Is it an overdose? Not really. But there’s certainly a case to be made that a heart attack at age 40 was highly “influenced” by crack use which we know is very hard on the heart. With stimulants, the problem is not even necessarily dose-related at all. You could overamp on speed on your fourth day of a run because you are dehydrated, malnourished, haven’t slept and your body and mind are just telling you to knock it off. So long story short, like I said, overdose is the wrong word. It’s confusing and inaccurate.
2.  We need more data and research. Actually, we need better interventions and resources, but to get those, you need data and research. As Matt said in his post about “Missing Data,” we need more information on how co-morbidities or other behaviors like smoking affect risk of cocaine-related deaths. I’m curious about the speed-related deaths. What happened? I can never actually find any information on that. In the SF Medical Examiner’s report, it said that a few people died from aneurisms caused by speed. Really? I would like to know a bit more about that, thank you. I called the ME one day, and asked if all of the cocaine-related deaths were from cardiac arrest because I wondered if people also died from fatal seizures or strokes. He laughed at me and told me everyone dies from cardiac arrest. Smart ass. I guess it was a dumb question, but I didn’t know how to ask the question. This is where you researchers come in!
3.  We need to invest the same amount of effort into creating realistic messages around cocaine and speed-related harms that we did with heroin/opioid overdose. This means that drug user involvement in creating interventions for coke and speed users is an obvious necessity. We need to redefine overdose, talk to people about the amazing harm reduction strategies they already use (see part 2 of this post), and develop some real prevention strategies, not just “drink water and get some sleep.”  If we do a better job at treating co-morbidities like high blood pressure, COPD, or cardiovascular disease or offering smoking cessation, could cocaine-related heart attacks decrease?  So, is primary care the answer? Do we invest in educating physicians on how to not treat drug users like crap and to address stimulant-related harms by strengthening the rest of the body? Ah, so many questions.
So in the meantime, while you go figure all of this out, be on the lookout for part 2 of this article, which is a strategy we came up with here in SF to talk about overamping on speed. 

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