Thinking Out Loud: Death from Drugs. Is it Overdoses, or Poisonings?

There comes a point in the care of an acutely critically ill patient when you can do no more for them; you’ve maxed out your options, and the outcome is out of your hands. At that moment, your attention must turn and prioritize their family, who will be left with a full blown disaster at the end of the day. The NY Times wrote about how society might make that turn, towards the survivors of the tragedy of unintentional deaths from drugs, more specifically opioids. They discussed a debate over categorizing those deaths as overdoses or poisonings.

“If I tell you my child was poisoned by fentanyl, you’re like, ‘What happened?’ It keeps the door open. But ‘overdose’ is a closed door.”

- Stefanie Turner, a co-founder of Texas Against Fentanyl

The medical profession uses several terms in describing these unintentional deaths. I suspect that it is the subtext of intention that makes poisoning less painful than overdose. The Times article quotes quite a few experts who parse the meaning of the two words and opine on their significance for policy. From a legal framing, to be poisoned requires a poisoner, and that individual may face a different legal fate than an individual who obtained one too many pills.

Regulatory framing is found in the CDC’s Injury Center, which collects data on drug-related injuries. The topic seems to have inconsistent messaging. In their 2008 report, they use drug poisoning in both the title and the introductory sentences.

“A poisoning occurs when a person's exposure to a natural or manmade substance has an undesirable effect. A drug poisoning occurs when that substance is an illegal, prescription, or over-the-counter drug. Most fatal poisonings in the United States result from drug poisoning.”

The report then reverts to the term overdose in the remaining four pages of the report. The word choice in this instance can be attributed to Dr. Leonard J. Paulozzi, a medical epidemiologist and then head of the CDC’s Division of Unintentional Injury Prevention. Dr. Paulozzi was a founding member of Physicians for Responsible Opioid Prescribing (PROP)—both PROP’s and the current CDC website only reference overdoses. The shaming and blaming serve the funding needs of PROP, but what purpose is served by the CDC's continued use of a phrase?

Our National Institute of Drug Abuse has a page with the correct terms to discuss.

“Although some language that may be considered stigmatizing is commonly used within social communities of people who struggle with substance use disorder (SUD), clinicians can show leadership in how language can destigmatize the disease of addiction.”

Ironically, based on their own recommendations, the agency should be renamed the National Institute of Drug Misuse.

For the purposes of counting, does it matter how many of our citizens die from an overdose rather than a poisoning?

Death certificates have come under more scrutiny in the age of COVID. Still, the problem of whether an individual died from COVID or with COVID is no different in some ways from whether your family member died from an opioid overdose or poisoning. Death certificates are the story we tell. Whether those deaths were overdoses or poisonings makes no societal difference; we have a problem that is only growing larger, and we need to find new or better solutions.

In the meantime, we should care for the living and help them heal as best they can and, if possible, move on with their lives. Empathy, a genuine concern for the well-being of another, is at the root of a healing relationship. Poisoning is an empathetic word choice, lifting more of the burden than academic parsing and nuance.  

The debate over whether to characterize these fatalities as overdoses or poisonings underscores the complexities inherent in framing such tragedies. While the medical profession grapples with the implications of these terms in clinical practice and data reporting, the imperative remains to prioritize support for affected families and communities, fostering healing and resilience in the face of an escalating public health crisis.