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Ruttenber, A. J., Kalter, H. D., and Santinga, P.

Journal of Forensic Sciences,

Vol 35, No. 4, July 1990, pp. 891-900

p. 891

"Our data suggest that ethanol enhances the acute toxicity of heroin, and that ethanol use indirectly influences fatal overdose through its association with infrequent (nonaddictive) heroin use and thus with reduced tolerance to the acute toxic effects of heroin."

[Ruttenber, A. J. and Luke, J. L., "Heroin-Related Deaths: New Epidemiologic Insights," Science, Vol 226, Oct 5, 1984, pp 14-20] "found that blood ethanol concentrations in excess of 1000 mg/L raised by a factor of 22 the odds of a heroin user experiencing a fatal overdose."

"The concomitant use of heroin and ethanol is well recognized and considered dangerous..."

"The phenomenon of combining ethanol and opiate use and the resultant toxic effects were noted as early as 1881 [Hubbard, F. H., The Opium Habit and Alcoholism, Barnes, New York, 1881, pp 3-14]."

Possibilities examined:

1. Ethanol and heroin act additively or synergistically on the central nervous and respiratory systems, producing cardiopulmonary arrest that is more often fatal than that produced by heroin alone.

2. Ethanol interferes with the metabolism of heroin, prolonging toxic effects.

3. Ethanol consumption is commonly associated with infrequent (nonaddictive) use of heroin, [Greene, M. H., Luke, J. L., and Dupont, R. L., "Opiate 'Overdose' Deaths in the District of Columbia," Medical Annals of the District of Columbia, Vol 43, #4, April 1974, pp 175- 181] which results in reduced tolerance to acute toxicity of heroin.

Decedents with toxicological evidence of drugs other than heroin/ethanol were excluded from the study.

p. 895

"We determined that HE [High Ethanol] decedents had significantly lower blood morphine concentrations than LE [Low Ethanol] decedents and identified a significant inverse correlation between concentrations of ethanol and morphine in the blood. These findings suggest that there is a dose-response relationship between consumption of ethanol and the acute toxicity of heroin. However, blood ethanol concentrations explained only 11% of the variation in blood morphine concentrations, indicating that additional factors are probably involved in the etiology of fatal overdose by users of heroin and ethanol."

"There is no evidence from our study that ethanol interferes with the metabolism of heroin." (This is in response to possibility 3.)

p. 897

"Our data suggest that decedents who consumed large quantities of ethanol before death also had used heroin infrequently in the days before death."

"Data presented here and in other studies [Ruttenber, A. J. and Luke, J. L., "Heroin-Related Deaths: New Epidemiologic Insights," Science, Vol 226, Oct 5, 1984, pp 14-20; and Kalter, H. D., Ruttenber, A. J., and Zack, M. M., "Temporal clustering of Heroin Overdoses in Washington, DC," Journal of Forensic Sciences, Vol. 34, No. 1, Jan. 1989, pp. 156- 163.] indicate that fatal heroin overdose can be influenced by the toxic effects of other drugs and by other risk factors and is not merely the consequence of injecting unusually high doses of heroin. Our results suggest that simply discouraging the practice of drinking and injecting heroin may not be effective in preventing fatal overdose. Combining chronic ethanol abuse with infrequent (nonaddictive) heroin use should also be discouraged. Since fatal overdoses are commonly associated with ethanol use, public health measures directed towards those who use both drugs may help reduce the incidence of these deaths."

"Address requests for reprints or additional information to:

A. James Ruttenber, Ph.D., M.D.

Center for Environmental Health and Injury Control

Centers for Disease Control

Mail Stop F-28

Atlanta, GA 30333"

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