THE ROLE OF ETHANOL ABUSE
          IN THE ETIOLOGY OF HEROIN-RELATED DEATHS
                                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 refutes 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