“Stigma is a process by which the reaction of others spoils normal identity” ~ Erving Goffman

We recently discussed the tragic death of Dr. Laura Berman’s 16 year-old son, Samuel, from a suspected drug overdose. [1] Samuel purchased Xanax tablets on the social media app, Snapchat, and they were delivered to the house. Dr. Berman suspects that Samuel was sold counterfeit Xanax that was laced with fentanyl, a highly potent opioid.  

As we previously reported, pharmaceutical Xanax, or Alprazolam, is a dangerous and addictive substance on its own. It can cause users to become physically dependent on it, which can result in seizures during withdrawal. Much of the Xanax available nowadays is produced on the black market, which means that there is no telling how potent the tablets are. Many of them are much stronger than the pharmaceutical they are designed to emulate.

Worryingly, fentanyl has been used as a cutting agent to make black-market tablets even more powerful. This is a super-potent opioid, usually reserved for sedating people during operations and for people with severe pain. Just 3mg of fentanyl, an amount that would fit on the head of a pin, is enough to kill someone with low tolerance. Frequently, black-market Xanax contains more than this amount and is often mixed with tranquilizers,[2] which dramatically increases the overdose risk.

Research has demonstrated that the increase in opioids cut with fentanyl coincides with a dramatic increase in the total number of overdose deaths.[3] In New York, prior to 2015, fentanyl was involved in fewer than 5% of all overdose deaths annually. In 2015, this figure increased to 16%, and by the end of 2016, the figure had risen so dramatically that fentanyl was involved in approximately half of all overdoses in New York City. [4]  According to Benjamin Han et al, “[t]he increased involvement of fentanyl coincided with a 51% increase in the rate of overdose death, from 13.7 per 100,000 in 2015 to 20.7 per 100,000 in 2016, the largest single-year increase on record.”[5]

Drug Overdose

A drug overdose is defined as the use of a quantity of drug, accidentally or deliberately, in excess of its intended or prescribed dose. By definition, a drug overdose is usually confined to substances that are illegal or prescribed, rather than over the counter medicines or legally obtained toxic substances.[6]  The severity of an overdose depends on the substance taken, the amount ingested, and the medical history of the person who has taken the substance.

An overdose denotes that an excessive amount of a substance has been taken which has caused medical complications and does not necessarily mean death will occur as a result.  However, more than 70,000 Americans died from drug overdose in 2019 alone as a result of illicit drugs and prescription opioids.[7] 

Poisoning

Similarly, poisoning entails exposure to a substance that is dangerous to one’s health or that threatens a person’s life. A poison may be a drug, household product, industrial chemical, or plant or animal derivative.[8]  A poison overdose can be accidental or a deliberate act of self-poisoning. In the UK, for example, paracetamol is the medication most used in cases of deliberate poison overdose.

Any product or substance, including medications, can be harmful if it is used in the wrong way, by the wrong person, or in the wrong amount. A poisoning can occur from a substance through:

• Ingestion via eating or drinking
• Inhalation or aspiration
• Injection
• Skin contact
• Contact through the eyes[9]

In 2019, the Centers for Disease Control and Prevention recorded over 65,000 unintentional poisoning deaths.[10] Most of these cases, “are acute, are accidental (unintentional), involve a single agent, occur in the home, result in minor or no toxicity, and involve children <6 years of age.”[11] Statistics show that pharmaceuticals are involved in 47% of exposures and in 84% of serious or fatal poisonings.

Stigma of Overdose

Stigma plays an essential role when considering the implications of the terms overdose versus poisoning.  Though there is very little difference between the two, our social perceptions of the terms vary dramatically.

There are several types of stigma which can affect people’s perceptions of drug overdose.  Two key types of cultural stigmas are Social and Public Stigma:

• Social stigma arises from the collective, dominant beliefs within society that regulate acceptable behaviors within a group. This can lead to the ostracization of “unfit” members of the group or the need to coerce others into changing their behavior in order to be deemed acceptable. Within these communities, it is not uncommon for there to be rejection from the family or social group.[12] 
• Public stigma is created through stereotypes about people, for example those who take drugs or have overdosed. These perceptions may be that they are nihilistic, have moral failings, or are selfish, which then translates into negative attitudes toward people who have taken substances that have led to overdose.[13]

In America, as well as globally, there is a cultural stigma around the term overdose. 

The negative connotations attached to drug overdose often include the trope of a person with a drug history and a substance use disorder, whose tolerance level has grown to such an extent that they take more and more of the drug, resulting in a fatal overdose.  Frequently, we find that healthcare providers, even therapists, view a patient’s drug or alcohol problem as their own fault, leading to substandard care or even a rejection of treatment altogether. It is not uncommon for individuals who enter emergency rooms seeking help from acute intoxication to be expelled by staff who are fearful of their intentions (potentially seeking out prescription drugs) and their volatile behavior, and care providers often exhibit a lack of empathy for the person who is overdosing due to stigma and blame.[14]

Poisoning, on the other hand, is most often seen as accidental and, therefore, tragic. It is most commonly associated with young children, with a level of naivete, a natural curiosity, and a lack of understanding about the substance consumed.

In the case of Samuel Berman, the aforementioned 16 year-old who was isolated at home due to the Covid Pandemic and who purchased a medication that was potentially laced with fentanyl, we could argue a clear case of poisoning has occurred. 

For family and friends who have lost their loved one in a manner such as Samuel’s, the term overdose can be a harmful, painful, and inappropriate label.  I have long been an advocate for addressing and dispensing with negative and unhelpful labels. Through my work, I seek to help young people and their families find a route to clear communication, and I hope that our society learns to extend true compassion to those who have lost loved ones due to intoxication from harmful substances.

If you are concerned about any issues discussed in this blog, please contact Heather R. Hayes & Associates – call 800-335-0316 or email info@heatherhayes.com today.

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[1] “Dr. Laura Berman Speaks Out After 16-Year-Old Son Dies Of Apparent Drug Overdose At Santa Monica Home”. ABC7 Los Angeles, 2021, https://abc7.com/laura-berman-son-overdose-dead/10324568/.

[2] Arens, Ann M et al. “Adverse Effects From Counterfeit Alprazolam Tablets.” JAMA internal medicine vol. 176,10 (2016): 1554-1555. doi:10.1001/jamainternmed.2016.4306

[3] Nolan, Michelle L. et al. “Increased Presence Of Fentanyl In Cocaine-Involved Fatal Overdoses: Implications For Prevention”. Journal Of Urban Health, vol 96, no. 1, 2019, pp. 49-54. Springer Science And Business Media LLC, doi:10.1007/s11524-018-00343-z. Accessed 3 Mar 2021.

[4] Han, Benjamin H. et al. “Unintentional Drug Overdose Deaths Involving Cocaine Among Middle-Aged And Older Adults In New York City”. Drug And Alcohol Dependence, vol 198, 2019, pp. 121-125. Elsevier BV, doi:10.1016/j.drugalcdep.2019.01.042. Accessed 3 Mar 2021.

[5] Han, Benjamin H. et al. “Unintentional Drug Overdose Deaths Involving Cocaine Among Middle-Aged And Older Adults In New York City”. Drug And Alcohol Dependence, vol 198, 2019, pp. 121-125. Elsevier BV, doi:10.1016/j.drugalcdep.2019.01.042. Accessed 3 Mar 2021.

[6] “Drug Overdose: Definition, Treatment, Prevention, And More”. Healthline, 2021, https://www.healthline.com/health/drug-overdose.

[7] “Overdose Death Rates | National Institute On Drug Abuse”. National Institute On Drug Abuse, 2021, https://www.drugabuse.gov/drug-topics/trends-statistics/overdose-death-rates.

[8] “Poisoning Or Overdose | Health Topics A To Z | CKS | NICE”. Cks.Nice.Org.Uk, 2021, https://cks.nice.org.uk/topics/poisoning-or-overdose/.

[9] “Poisonings And Overdoses :: Washington State Department Of Health”. Doh.Wa.Gov, 2021, https://www.doh.wa.gov/youandyourfamily/poisoninganddrugoverdose.

[10] “Faststats”. Cdc.Gov, 2021, https://www.cdc.gov/nchs/fastats/accidental-injury.htm.

[11] Harrison, Tinsley Randolph, and Dennis L Kasper. Harrison’s Principles Of Internal Medicine. Mcgraw-Hill Medical Publ. Division, 2015.

[12] Mental Illness-Related Structural Stigma:”. Mentalhealthcommission.Ca, 2013, https://www.mentalhealthcommission.ca/sites/default/files/MHCC_OpeningMinds_MentalIllness-RelatedSructuralStigmaReport_ENG_0_0.pdf.

[13] Tsai, Alexander C. et al. “Stigma As A Fundamental Hindrance To The United States Opioid Overdose Crisis Response”. PLOS Medicine, vol 16, no. 11, 2019, p. e1002969. Public Library Of Science (Plos), doi:10.1371/journal.pmed.1002969. Accessed 3 Mar 2021.

[14] “Addressing The Stigma That Surrounds Addiction | National Institute On Drug Abuse”. National Institute On Drug Abuse, 2021, https://www.drugabuse.gov/about-nida/noras-blog/2020/04/addressing-stigma-surrounds-addiction.