WHAT IS A LETHAL DOSE OF HEROIN?
The figure 1.52 mg actually refers to the level of drugs found in Cobain’s blood, not the amount he originally injected. This can be seen in other reports, both biographical and mass media, where the
1.52 mg level is sometimes further described as "per liter of blood" or "triple the lethal dose," usually
with subsequent notes that an addict has higher tolerance.
Cobain would have needed to inject much more than 1.52 mg of heroin to help even the mildest headache. (In fact Cobain would have had to inject as much as 225 to 240 mgs of heroin to
reach a blood morphine level of 1.52 mg.)
No doubt exists that a blood level of 1.52 mg of morphine per liter is over three times the lethal dose, (for a hard-core heroin addict), but the implications of this fact are not well understood. There is no such thing as a "blood heroin level" because heroin is transformed into morphine when it enters the blood.
The lethal dose range of intravenous heroin is generally regarded as 10 mg to 12 mg. Sometimes even a tiny dose can kill, so the lethal dose of intravenous heroin can go as low as 3 mg, possibly even lower. Some people get confused and think that high variability in the minimum lethal dose means that a similar variability exists for the maximum lethal dose. The most serious heroin addicts will die with virtual certainty with much less than a dose of 75 mg to 80 mg of heroin.
After studying many hundreds of such cases, it is clearly established that 75 mg to 80 mg is the maximum lethal dose for even the most severe heroin addicts. Note that in a low tolerance person; in an average hospital setting, a small effective therapeutic dose of intravenous heroin is only 3 mg to 4 mg. (Compare that amount to the 225 mgs or more injected into Kurt Cobain before his death, ed.).
The important thing to note here is that the problems associated with establishing a "lethal dose" for intravenous heroin primarily relates to the problem of establishing a "minimal lethal dose," i.e. the smallest amount of heroin which will kill.
The "maximum lethal dose," i.e. the highest dose of intravenous heroin a severe heroin addict can withstand without immediately collapsing into a coma and/or immediately dying, is very well
The blood morphine level of 1.52 mg per liter found in Cobain’s body represents a heroin dose which is substantially higher than this well established maximum lethal dose.
HOW MUCH CAN A SEVERE ADDICT SURVIVE?
One study involved a small group of severe addicts who used high doses ranging from 150 mg to 200 mg of morphine four times daily (75).
This is equivalent to an intake of approximately 45 mg to 60 mg of heroin, four times daily. These addicts showed some signs of serious effects, but continued for several years without fatality and showing average blood levels of 0.3 mg per liter.
Another study points to the potential lethality of even low doses, with 5 fatalities showing an average of a mere 0.021 mg per liter of blood, representing an approximate intake of 3 mg, i.e. the average functioning dose. The average person without pain or addiction will overdose with 60 mg of morphine (18 mg heroin), yet a patient in serious pain will likely require the same dose, 60 mg of morphine (18 mg heroin) to relieve such serious pain symptoms.
Platt also mentions a particular study where severe heroin addicts were monitored, and the maximum dose seen was a daily total of 260 mg heroin, taken in four divided doses, i.e. 65 mg heroin
each dose (75).
Again, the maximum lethal dose of heroin is shown to be 75 mg - 80 mg for a 150 lb. severe addict. Such a lethal dose, of about 75 mg - 80 mg heroin, will give the soon-to-be-dead individual a blood morphine level of approximately 0.5 mg of morphine per liter of blood. Astonishingly, this is less than one-third of the level that was found in Cobain’s tiny body at least three days after his death.
More than 100mg of morphine (30 mg heroin) almost always presents major complications. Doses over 250mg morphine (75 mg - 80 mg heroin) are usually associated with certain death, i.e. 75 mg - 80 mg of heroin, leads to a blood level of approximately 0.5mg per liter, the high end of toxic doses. Thus it is clear that Cobain ingested at least triple the lethal dose for even the most severe addict. If he were not a severe addict, then 1.52 mg per liter potentially represents up to 75 times the lethal dose.
Details regarding common heroin doses are explained by Tong & Pond who state that, "the basic unit of sale is the ‘tenth,’ which is 1/10 of a gram or 100 mg of pure drug. This unit... provides approximately 4 ‘hits’ or doses. A quarter of a tenth (25 mg powder) contains 20 mg to 24 mg of heroin, which is more than the usual street addict is used to per dose." (94). Severe addicts may require 3 such hits in 1 dose, 4 times daily, while Cobain’s blood morphine level represents a dose of approximately 8 to 10 such "hits."
INCAPACITATED OR DEAD BEFORE GUNSHOT?
The following quotes from Krivanek describe the rapid action of this deadly narcotic, especially when taken intravenously, "Heroin has a far more positive slope than either morphine or methadone- that is, its effects begin, and reach a peak more rapidly...3 mg of heroin...given by subcutaneous injection will provide adequate analgesia in about 70 per cent of patients with moderate to severe pain.
At that dose sedative effects and respiratory depression should both be minimal. As doses increase, they become more pronounced, and the respiratory depression will become life-threatening with about 30 mg morphine.(9 - 10 mg heroin, ed.) ...Intravenous doses, on the other hand, can be considerably smaller, - about one-fifth of the subcutaneous dose."(53).
Additionally, Platt remarks on the amazing rapid action of intravenous heroin by explaining that "...the high uptake of heroin...indicates that an abrupt entrance of heroin into brain tissue probably occurs 10 to 20 seconds after the usual intravenous injection by addicts...15 seconds, 68% uptake into brain with heroin compared to 42% for methadone, 24% for codeine, and morphine too small to measure."(75).
SOME DATA ON SPEED OF DEATH
The Lange manual for Poisoning & Drug Overdose states that for opiates, "with higher doses, coma is accompanied by respiratory depression and apnea often results in sudden death." (68).
Basically, a high lethal dose of heroin will either cause immediate death, or, in an unlikely scenario, immediate incapacitation by rendering the recipient comatose. This is described by Staub, et. al. as follows: "...we have shown that in 85% of the cases, the death should be attributed to a so
called ‘golden shot’. In the remaining cases, the death is not so rapid and a survival period in a comatose state has to be taken into consideration." (90).
Similarly, Garriot & Sturner, describe how "...morphine in the blood was found to correlate with the time of survival and ranged from 10 to 93 mcg per 100ml (.1 to .93 mg per liter, ed.) in the short-term
interval group...6 mcg per 100 ml (.6 mg per liter, ed.)." (28).
Notably, as of 1973, Garriott & Sturner did not find any blood morphine level over 0.93 mg per liter,
i.e. Cobain’s blood level was over 50% higher than the highest level they had ever encountered.
Regarding the common sequelae of heroin overdoses, Nakamura explains " there are vivid accounts of victims lapsing into a deep coma immediately following a ‘fix’ with a syringe still affixed in the arm or on the floor underneath the body, and/or with an improvised tourniquet still in place around the arm." (63). Gossell & Bricker report that "for a large overdose, the victim rapidly lapses into coma and is not arousable by verbal or painful stimuli." (32).
OTHER FACTORS ENSURED OVERDOSE LETHALITY:
-Compensating For Body Weight
A blood morphine level of 1.52 mg/L indicates a heroin intake of approximately 225 mg - 240 mg. Thus, despite suggestions that Cobain may have simply been incapacitated by a normal, large dose fit for an addict, it must be noted that his body weight was at highest 130 lbs., and he was listed as being 115 lbs. in late 1993. This would generally increase his susceptibility to overdose by as much as 20%, since toxicity data is based on a 150 lb. adult.
-Compensating For Adulteration
Heroin purity has been shown to vary widely, with samples containing as little as 1% heroin. Mexican black tar is usually no higher than 40% pure, but is not uncommonly up to 80% pure, while highest recorded purity level for Mexican black tar heroin is 93% pure (89). If the heroin used in this case was indeed Mexican black tar heroin, and it was in the range of the highest potency recorded, i.e. 93% purity, then the dose required to reach a blood morphine level of 1.52 mg per liter would be approximately 245 mg to 260 mg.
Whatever the physical source of heroin was, it does not really matter; the only thing that makes one type of heroin stronger than another is concentration of dose, so it was approximately 225 mg to
240 mg of some type of heroin. If the purity was 40%, a more common figure, then the lethal dose,
including adulterants, would have been around 600 mg.
Thus there is a definite chance of up to 350 mg of procaine or acetyl procaine as an adulterant. Note that procaine is commonly found in samples of Mexican black tar heroin. Regarding the potential toxicity of procaine, it should be noted that procaine levels would likely be undetectable in Cobain’s blood due to the fact that the body was found at least three days after death.
Still, the importance of procaine’s potential toxicity is emphasized by Nakamura, who says "Nearly all the contraband heroin in the western areas is obtained from Mexico and contains an appreciable amount of procaine, or acetyl-procaine, as a filler material. ...The potential danger of a large concentration of this dilutor in street heroin needs to be better understood. (63).
CASE UNPARALLELED IN SUICIDE & OVERDOSE REPORTS:
-Very High Blood Morphine Levels Are Rare
Overdose reports normally show results similar to those from Logan & Luthi, who described 16 deaths caused by intravenous heroin or morphine in which blood levels were measured, and the highest serum morphine level seen was 0.920 mg/L. (57).
A Compendium of Intravenous Heroin Related Deaths Where Blood Morphine Levels Were Measured, shows the rarity of occurrence of a blood morphine level equal to or greater than Cobain’s. Thousands of opiate related deaths were reviewed, and for the purposes of this report, over 3000 of these deaths were determined to be specifically related to overdoses among addicts involving the intravenous use of morphine or heroin.
Next, this group was further narrowed to eliminate those cases in which blood morphine levels were not available. Cases where the drug was known to be morphine were eliminated, as were cases
where the cause of death was determined to be other than overdose.
The 1526 cases remaining showed 26 instances where the blood morphine levels were equal to or above Cobain’s, an occurrence rate of 1.7%.
None of the above cases reportedly involve a gun or violent suicide. Additionally, no case reported overdose sequlelae of a nature which would even imply the possibility of anything other than
immediate incapacitation and/or death. Where data was available, it was remarkably clear in presenting images of addicts with tourniquets in place, syringes in hand, and other evidence of abrupt
-Review Of Rare Overdose Cases In Cobain’s Range
Remarkably, 8 studies out of 19 reported on at least one of the 26 rare blood morphine levels in Cobain’s range. Staubb, et. al., listed 12 cases in particular out of the 52 cases studied which showed total blood morphine levels equal or above Cobain’s level. (90). However, it is vital to note that all these cases involved abrupt death immediately following injection, and none of any of the 52 cases studies was reported to have committed suicide with a gun of any kind.
Basically, their study showed a remarkable consistency in abrupt reactions, indicating an 85% probability of instant death, and 15% chance of instantaneous collapse into a comatose state. Still, it is worth pointing out that this is the single largest group of cases at or above Cobain’s range. Coumbis & Balkrishena (16) show four high level cases, while Gottschalk & Cravey (33) and Hine, et. al. (42) each show 3 such cases. Studies which found only one such level are Richards, et. al. (77), Paterson (70), and Monforte (62).
Finally, Nakamura (63), mentioned previously, also found only one very high level case, with 1.8 mg/L, and the manner of death was known to be instantaneous.
-Washington State Heroin Overdoses
Regarding Washington State heroin overdose deaths, including Seattle, a 1996 report by Logan & Smirnow in a study of 32 cases of "...deaths involving morphine." The focus of their research basically concerned testing the reliability of postmortem blood samples over time, and the variability’s between morphine levels when collected from different tissues, including different "sites" of blood collection, eg. femoral, iliac, and ventricular sites. Also of specific relevance to the Cobain case is the authors noted "...the pattern of opiate use in this population is almost exclusively one of Mexican black tar heroin." Generally, they conclude that "Although both site dependent differences and time dependent changes have been shown to affect the concentration of some drugs in postmortem samples, neither appears to be the case with morphine." (58).
The main point is that the Cobain blood data is generally regarded as reliable, despite the fact that the body was discovered at least three days after death. More importantly, note that only one case of 32 was suicide, with the remainder listed as accidents or probable accidents. The highest total blood morphine level, collected initially from the iliac site, is 0.4 mg/L, shows black tar heroin use among a population of addicts does not appear to necessarily lead to significantly higher blood morphine levels than those found in addict populations where black tar heroin is uncommon.
-Preponderance of Evidence
Further confirmation of these findings is seen ubiquitously throughout the scientific literature, creating a preponderance of evidence. Gottschalk & Cravey’s study of 128 heroin-related deaths showed only 3 cases in Cobain’s range. (33). Only one of the 128 deaths involved secondary self-inflicted trauma of any kind, in which one person committed suicide by hanging. Notably, despite evidence of intravenous heroin and/or morphine use, and despite the fact that morphine levels in other tissues confirmed death by overdose, there was no morphine detectable in the blood at all, which helps explain how the individual had time to hang himself.
The individual in question tested positive for several drugs, as is common in cases of self- poisoning, and this accounts for the lethality of the otherwise low dose of opiates. Specifically, oral methadone was also consumed, thus there would be a moderately delayed reaction before the combined effects of the drugs took effect and killed the victim before he died from the hanging itself.
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