>>> Part 6 of 9...
A second possible cause of Syndrome X deaths can best be illustrated by
two examples.
One is the case of "C. G.," a heroin addict long accustomed to
mainlining his drug, who one day got drunk, took his "customary
injection of heroin and collapsed shortly thereafter." Subsequent
Another is the case of a heroin addict whose death was recently
reported by Dr. George R. Gay and his associates at the Haight-Ashbury
Medical Clinic, San Francisco. This addict first "shot some reds" (that
is, barbiturates) and then "fixed" with heroin following the
barbiturates. He died of what was diagnosed as "overdose of
heroin." [44]
Cases such as these have given rise to the question whether Syndrome X
deaths may result from injecting heroin (with or without quinine) into
a body already laden with a central-nervous-system depressant such as
alcohol or a barbiturate.
Addicts themselves would seem to deserve credit for first suspecting
that so-called "heroin overdose" deaths might in fact result from the
combined action of alcohol and heroin. Back in 1958, a team headed by
Dr. Ray E. Trussell and Mr. Harold Alksne interviewed more than 200 New
York City addicts - alumni of the Riverside Hospital addiction treatment
program (see Chapter 10). In this as in other pre-1960 studies, few
addicts drank alcohol while on heroin, and they did not drink much.
When asked why, the addicts commonly gave two reasons.
One was that the effect of alcohol is "offensive" to a man on heroin.
"The narcotic alone has an analgesic effect which tends to quiet the
individual. Alcohol, on the other hand . . . has the capacity to
agitate the individual in his relationships with other people. This
generally is offensive to the addict." [45]
The other reason given by addicts in 1958 for not drinking while on
heroin is the first extant clue to the possible relationship between
alcohol and death from "heroin overdose." Addicts, the Trussell-Alksne
team noted, "believe that the use of narcotics and alcohol in
combination is dangerous and might possibly lead to the death of an
individual." [46]  By the 1960s, this awareness of the hazard of
shooting heroin while drunk had disappeared from the addict scene.
Addicts, like others, were evidently convinced by the official
announcements that those deaths were indeed due to heroin overdose.
If the theory is sound that even an ordinary dose of an opiate injected
while drunk can produce death, then death could occur when an ordinary
drunk who is not addicted is brought into a hospital emergency room with
a painful injury and is given a routine (10 milligram) injection of
morphine to ease his pain. Drs. William B. Deichmann and Horace W.
Gerarde report in their _Toxicology of Drugs and Chemicals_ (1969
edition) that death may in fact occur under such conditions.
"The ordinary safe therapeutic dose of morphine," they warn, in italics,
in their textbook, "may be fatal to persons who have been drinking
alcoholic beverages. Morphine in therapeutic doses [similar to the doses
commonly injected by addicts] resulted in fatalities in individuals
whose blood alcohol levels ranged from 0.22 to 0.27%. Morphine is also
synergistic with barbiturates and related drugs." [47]  Thus the hazard
of death from shooting an opiate while drunk on alcohol or a barbiturate
is familiar to some toxicologists even though it has been ignored by
authorities on drug addiction - and by coroners and medical examiners -
through the years.
If this alcohol-heroin and barbiturate-heroin explanation is correct,
the fact is of the utmost practical importance - for hundreds of deaths
a year might be prevented by warning addicts not to shoot heroin while
drunk on alcohol or barbiturates.
The alcohol-barbiturate hypothesis fits the Syndrome X time schedule.
Throughout the nineteenth century and well into the twentieth, opiate
addicts were known for their *dislike* of alcohol while on opiates. As
noted earlier, they turned to alcohol only when deprived of their
opiate supply or when trying to "kick the habit." This remains generally
true today; an addict rarely drinks while *on* heroin. He often drinks,
however, when his heroin supply runs out and withdrawal symptoms set in.
During World War II, many heroin addicts were abruptly deprived of their
heroin supply for longer or shorter periods. If some of them turned to
alcohol, then connected with a fresh heroin supply and "shot up" while
still drunk, the first few identified Syndrome X deaths might have
occurred. The recent sharp increase in Syndrome X deaths might similarly
be explained by an increased tendency to alternate alcohol or
barbiturates with heroin as a result of high heroin prices. As the
amount of heroin in the New York City bag went down and down, according
to this theory, more and more addicts got drunk - and died of Syndrome
X following their next "fix."
Evidence in recent years for the use of alcohol by addicts shortly
before their death has been assembled from the New York City files by
Drs. Jane McCusker and Charles E. Cherubin. They reviewed 588 city
toxicology reports found in the files on addicts who died in 1967. In
549 of these cases, tests for alcohol had been run - and in 43 percent
of the cases tested, alcohol was in fact found. [48]  (Barbiturates were
not reported on.) Their findings led Drs. McCusker and Cherubin to
suggest that further research be promptly launched into the possible
role of alcohol and the barbiturates in so-called "heroin overdose"
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