07/12/22

Tranq Dope and Its Consequences

A church friend of mine was lamenting his recent visit to Philadelphia. He said that for a city with so many different historic sites, he thought the officials there should have done a better job keeping the sites cleaned up. One of the noticeable parts of the debris were used needles and syringes. This led to us exchanging comments on the opioid epidemic, and how fentanyl had made the situation even worse. What neither of us realized at the time was that our assessment wasn’t quite accurate. We had never heard of “tranq dope.”

Although fentanyl has been replacing the heroin in the Philadelphia drug market, increasingly a substance known as xylazine has been found combined with fentanyl. It is a non-opioid veterinary tranquilizer that is not approved for human use. A brief report by Johnson et al, published in the journal Injury Prevention, reported that xylazine was detected in merely 2% of the unintentional overdose deaths in Philadelphia between 2010 and 2015. That rose to 11% in 2016; 18% in 2018 and 31% in 2019. See the chart below taken from the brief report.

NIDA (National Institute on Drug Abuse) said most overdose deaths linked to xylazine and fentanyl also involved other substances, including cocaine, heroin, benzodiazepines, alcohol, gabapentin, methadone and prescription opioids. When xylazine is taken in combination with other central nervous system depressants, it increases the risk of overdose.

Focus groups in Philadelphia said xylazine added to fentanyl gives the ‘nod’ that heroin provided before fentanyl took over the drug market. It “makes you feel like you’re doing dope (heroin) in the old days.” STAT News reported on paper published in the journal Drug and Alcohol Dependence that said while fentanyl produces a powerful high, its euphoria is short-lived when compared to other opioids like heroin. Adding xylazine gives fentanyl “legs,” meaning it extends the high.

The newer study by Friedman et al noted xylazine use is spreading beyond the Philadelphia area. It was found increasingly present in overdose deaths in all four US Census Regions. The highest prevalence data was still in the North East, in Philadelphia (25.8% of deaths), followed by Maryland (19.3%), and Connecticut (10.2%). Disturbingly, xylazine-involved overdoses may resist naloxone since it isn’t an opioid. That’s not all. “People who used drugs with xylazine seem to be more susceptible to wounds and infections on their skin and other tissues.”

The arrival of xylazine is “when we started to see way more people coming in with necrotizing skin and soft tissue issues. The amount of medical complaints related to xylazine was pretty astounding and terrifying. Xylazine wounds are a whole other kind of … just horror.”

The term “opioid crisis” doesn’t really capture what is developing with overdoses in the U.S. over the past two years. It’s an overdose crisis of polysubstance use—opioids, stimulants, and benzodiazepines; often used in combination. Friedman was quoted by STAT News as saying xylazine was an “especially noxious contaminant that is spreading through the drug supply.” A CDC MMWR Report said during January-December of 2019, xylazine was found in the overdoses reported in 23 states. It was listed as the cause of death in 64.3% of deaths in which it was reported.

Xylazine, or “tranq dope” as it’s known on the streets in Philadelphia, is an analogue of clonidine, and is used for sedation, anesthesia, muscle relaxation and analgesia in animals. It seems to reduce sensitivity to insulin and glucose levels in humans. It can lead to diabetes mellitus and hyperglycemia. Its side effects include bradycardia (a slow, resting heart rate), respiratory depression, blurred vision, disorientation, drowsiness, fainting, slurred speech, staggering, and shallow breathing. Chronic use is associated with physical deterioration, abscesses and skin ulceration.

Since xylazine is FDA approved for veterinary use only, it is not a controlled substance by the DEA. It is available in liquid form and is structurally similar to phenothiazines (first generation antipsychotics).

Its human use in Puerto Rico was reported by Rafael Torruella in a short report for Substance Abuse Treatment, Prevention, and Policy in 2011. He said Puerto Rican injecting users had been using it since the early 2000s. There, it is called Anestesia de Caballo (Horse Anesthetic). The report contained descriptions of how xylazine was viewed from a drug user’s perspective. One individual said the following about the first time he used xylazine and his later physical dependence on both heroin and xylazine:

I shot the anestesia […] and I felt asleep face first and when I opened my eyes five hours had gone by and I was laying on the floor. […] I don’t remember anything. I don’t remember anything! I fell down and I was gone. And I said: What the hell is this?! Oh, and I woke up sick [withdrawing]!I get there and don’t cop just heroin. I cop anestesia. Because that it what is going to get me high and what is going to get me straight [and reverse withdrawal symptoms]. I am not going to waste my money in just heroin because I’m going to stay the same. Do you understand? I’m going to stay the same.

Torruella said abscesses or ulcers were a serious health concern for several reasons. First, they are very painful. This encourages further injections in the abscess site with xylazine functioning as a sedative/anesthetic. This creates a need for medical attention and treatment.

Second, these open skin ulcers ooze and emit a strong odor. In severe cases, the mobility of the extremities where they appear is limited. Sometimes, amputations have been performed on the affected limbs. Third, when xylazine users asked for help in Puerto Rico, they were denied services because of their ulcers. The drug user quoted above said he was lucky because by the time his abscesses developed, he had relocated to the states and could access medical services:

[T]he times when the abscesses […] started to appear, I would come here, to the United States. […] [When the abscesses began to appear] I already knew. […] I had seen them [before]. […] [T]here are people that take a longer time in blowing up [with abscesses] than others. […] I am one in which it took a while. But when I saw that people were rotting I would get scared because I always have said that I am a junky with style.

Without basic healthcare needs, like medical/wound care, syringe exchanges and education, these open sores look terrible to both the medically trained and the untrained-eye. When a colleague saw the ulcers and their effects on non-users, she said: “Injecting drug users are being treated as if they were lepers.”

According to NIDA, the full scope of overdose deaths involving xylazine is unknown. But research shows they have spread westward across the U.S. NIDA-supported research is underway to illuminate emerging drug use patterns and changes to the illicit drug supply across the U.S. with xylazine, opioids and the evolving pattern of polydrug use, abuse and overdose. Stay tuned for the next sea change.

01/22/19

Doubling the Risk of Overdose

In February of 2018 The New England Medical Journal published an editorial titled “Our Other Prescription Drug Problem.” The authors said that between 1996 and 2013 the number of prescriptions written for benzodiazepines increased by 67% and the quantity of pills dispensed tripled. The number of overdose deaths from benzodiazepines also increased. Three fourths of those deaths involved an opioid; and co-prescribing rates of opioids and benzos have almost doubled since 2001. “Despite this trend, the adverse effects of benzodiazepine overuse, misuse, and addiction continue to go largely unnoticed.”

Both Medscape (“Benzodiazepine Harms Overlooked, Especially in Older Adults”) and Mad in America (“Psychiatrists Warn Policymakers Benzodiazepine Overuse Could Lead to Next Epidemic”) cited the editorial and quoted the above comment. But they seem to have spun the article’s content in different directions. The Medscape article was primarily about benzodiazepine use among older adults, as the title suggests, so readers would likely get the impression ”Our Other Prescription Drug Problem” was as well. The NEMJ article cited and discussed two additional articles on the problems of “benzodiazepine use among the elderly.” But that is not what “Our Other Prescription Drug Problem” was about. In fact, seniors using benzos was not even mentioned there.

Another slight-of-hand was with how the concluding paragraph of the Medscape article sanitized the rhetoric of the authors of “Our Other Prescription Drug Problem,” which referred to opioids and benzodiazepines as “life-threatening drugs.” The final paragraph of the Medscape article is followed by the original paragraph quoted in its entirety from “Our Other Prescription Drug Problem.”

If measures designed to discourage people from using opioids divert them to benzodiazepines instead, “[i]t would be a tragedy,” Lembke and colleagues conclude in their editorial. “We believe that the growing infrastructure to address the opioid epidemic should be harnessed to respond to dangerous trends in benzodiazepine overuse, misuse, and addiction as well.” (Medscape)

It would be a tragedy if measures to target overprescribing and overuse of opioids diverted people from one class of life-threatening drugs to another. We believe that the growing infrastructure to address the opioid epidemic should be harnessed to respond to dangerous trends in benzodiazepine overuse, misuse, and addiction as well. (NEMJ; emphasis added)

The readers of Medscape did not get a clear sense of what Dr. Lembke and her coauthors were saying in “Our Other Prescription Drug Problem.” Lembke et al. said benzos had proven utility if they were used intermittently and for less than 1 month at a time. “But when they are used daily and for extended periods, the benefits of benzodiazepines diminish and the risks associated with their use increase.” They noted how prescribers often don’t realize the potential problems with benzos and that safer alternatives are available.

Many prescribers don’t realize that benzodiazepines can be addictive and when taken daily can worsen anxiety, contribute to persistent insomnia, and cause death. Other risks associated with benzodiazepines include cognitive decline, accidental injuries and falls, and increased rates of hospital admission and emergency department visits. Fortunately, there are safer treatment alternatives for anxiety and insomnia, including selective serotonin-reuptake inhibitors and behavioral interventions.

Lembke et al. did say some patients could benefit from long-term benzodiazepine use, but suggested it was best to avoid daily dosing. They also referred to the newer, highly potent forms of benzodiazepines on the illicit drug market, which are often indistinguishable from prescription benzodiazepines and said they were: “potentially as deadly as the synthetic opioid analogue fentanyl.” They called for efforts to shut down illegal online pharmacies and drug-trafficking networks where individuals purchase illicit benzodiazepines, particularly the “superpotent analogues.”

The Mad in America article by Zenobia Morrill had several quotes from the original editorial and additional discussion of its contents, which addressed how benzodiazepine overuse, misuse and addiction has not received the attention that opioid overuse, misuse and addiction has received. And Morrill did not spin the original editorial. Her article also reproduced the following graph of overdose deaths in the U.S. involving benzodiazepines found in “Our Other Prescription Drug Problem.”

Morrill said Lembke et al. hypothesized the acceleration of benzodiazepine-related overdose deaths may be overlooked because the concurrent use of opioids in 75% of those deaths. Given the dangers of benzodiazepine use alone and in conjunction with opioids, providers should strive to taper benzodiazepines in patients who have been stabilized using opioid-agonist therapy, “taking into account patient’s preferences, the risks and benefits of benzodiazepines, and possible alternatives.”

Hernandez et al. looked at how the risk of overdose changed over time with concurrent opioid and benzodiazepine use in “Concurrent Opioid and Benzodiazepine Use and Risk of Opioid-Related Overdose.” The researchers looked at a random sample of data among Medicare Part D beneficiaries between 2013 and 2014. Their main outcome of interest was opioid-related overdoses—including fatal and nonfatal overdoses. They found that during the first 90 days of concurrent benzodiazepine use, there was a fivefold increase in the risk of opioid-related overdose.

Our study yielded 3 main findings. First, we found that 29% of Medicare Part D beneficiaries who did not have cancer and who used prescription opioids concurrently filled prescriptions for benzodiazepines. Second, we found that the risk of opioid-related overdose is particularly high during the first days with concurrent opioid and benzodiazepine use and then decreases over time. Specifically, during the first 90 days of concurrent benzodiazepine use, the risk of opioid-related overdose is 5 times higher compared with opioid use alone. Third, the numbers of opioid and benzodiazepine prescribers were associated with an increased likelihood of concurrent opioid and benzodiazepine use and an increased risk of overdose and were strong confounders in examining the association between concurrent use and overdose.

Among patients who used both medications longer than 90 days and did not overdose, they still had almost double the risk of overdose between 91 and 180 days of concurrent use. Concurrent use without overdose for more than 180 days did not predict an increased risk of overdose. But those results did not mean patients exposed to concurrent opioid and benzodiazepine use for longer time periods had a lower risk of overdose. “In fact, the longer the duration of concurrent use, the higher the risk of overdose, because the increased risk of overdose predicted during each time window (1-90, 91-180, 181-270, and 271 days of concurrent use) would be cumulative.”

Hernandez et al. said that despite the known increased risk of overdose associated with concurrent opioid and benzodiazepine use, “it is very common in the Medicare population.” They said policy interventions should advocate against concurrent use. Performance measures should be redefined to prevent or restrict their concurrent use. The risk of overdose is also exacerbated by fragmented medical care.

Overall, these results demonstrate the important role that fragmentation of care plays in the inappropriate use of opioids and in the subsequent risk of overdose, and warrant the extended use of prescription monitoring programs and the implementation of new policy interventions that further control the receipt of opioid prescriptions by multiple prescribers.

The bottom line is the concurrent use of opioids and benzodiazepines at least doubles the risk of an overdose.

05/17/16

Overdosing

Melanie (not her real name) was one of the first persons I counseled at White Deer Run in the late 1980s. She was 18 at the time, and a heroin addict before it was being called a national epidemic. She completed treatment; relapsed and returned about a year later as an adult patient. I think she even completed treatment that time as well. I can’t tell you much more about her, except that she was from Philly; and she is the first person I worked with who became an overdose statistic. There have been many more since then.

Most of the places I’ve worked as a drug and alcohol counselor have been within Pennsylvania. So when I heard of the study done by Balmert et al. on the accidental poisoning deaths in Pennsylvania from 1979 to 2014, I was interested in reading it. There aren’t too many ways that statistics, especially death statistics, can be interesting reading. But buried within those tables and figures are people I knew.

Within a data set attached to the study, I found the reported deaths by accidental drug poisoning for the years 1987 through 1989. In 1987, there were 41 individuals between the ages of 15 and 24 who died from accidental poisoning, 6 of whom were female; in 1988 there were 39, 12 of whom were female; in 1989 there were 54, 9 of whom were female. Somewhere in those statistics is Melanie’s overdose.

When I compared those deaths with the last three in the data set, 2012, 2013 and 2014, the stats grew exponentially. In 2012, there were 224 individuals between the ages of 15 and 24 who died from accidental poisoning, 63 of whom were female; in 2013 there were 203, 47 of whom were female; in 2014 there were 277; 70 of whom were female. That’s a lot of Melanie’s.

The CDC published a data brief indicating drug poisoning became the leading cause of injury-related death in 2008, surpassing deaths from motor vehicle accidents. 90% of those deaths were from drug poisoning. From 1999 to 2008 the number of drug poisoning deaths from opioid analgesics more than tripled. “Of the 36,500 drug poisoning deaths in 2008, more than 40% (14,800) involved opioid analgesics.”

Most of those 14,800 deaths involved natural and semi-synthetic opioid analgesics such as morphine, hydrocodone and oxycodone. The number of drug poisoning deaths from methadone, a synthetic opioid, increased sevenfold from 1999 to 2007. Then it decreased between 2007 and 2008. The age group with the highest death rate from opioid poisonings was between 45 and 54 years of age.

In 2007-2008 48% of Americans reported the use of at least one prescription drug in the past month. Not surprisingly, this was related to increases in drug use, misuse and nonfatal health outcomes. Over 5 million reported using prescription pain relievers nonmedically in the previous month.

In 2012 the CDC looked specifically at drug-poisoning deaths from opioid analgesics and heroin. Their report in Health E-Stats noted that from 1999 to 2012 the drug poisoning deaths from opioid analgesics increased from 1.4 per 100,000 in 1999 to 5.1 in 2012. The death rates from heroin overdoses nearly tripled from .7 per 100,000 in 1999 to 1.9 in 2012. The states with death rates significantly higher than the overall U.S. rate of 13.1 per 100,000 included Pennsylvania, Ohio and West Virginia, which had the highest overall rate at 32.0 per 100,000. See the linked CDC reports for more detailed information.

Returning to the Balmert et al. study on accidental poisoning deaths in Pennsylvania, we can see how the Pennsylvania rates compare to those just reviewed. Table 1 in Balmert et al. indicated the overall death rate for Pennsylvania in 2014 was 29.16 per 100,000. The death rate was highest for the 25-34 age group (39.87), and lowest among the 15-24 age group (16.25). See Table 1 in the Balmert et al. article.

Examining the mortality patterns by county showed that the highest rates for males from 2010 to 2014 were in the counties of southwestern PA (the Pittsburgh metro area), the counties surrounding Philadelphia and those near Scranton in the Northeast part of the state. The highest rates for females were in the same areas.

The county level findings provide possible avenues for targeting interventions to areas with the highest mortality from accidental poisoning. Counties with the highest 2010–2014 rates in females are primarily in suburban southwest PA. In males, the highest prevalence rates are more widespread and include both southwest and southeast PA, plus the northeast area including Carbon and Susquehanna. These patterns emphasize that, currently, accidental poisoning deaths especially among white females are occurring in suburban and rural areas. Other area-specific analyses should focus on non-urban mortality patterns.

In September of 2014 legislation went into effect allowing first responders to carry naloxone for reversing the effects of an overdose. As of September 1, 2015, 302 overdoses had been reversed with naloxone. The following graphic represents the drug-related overdose deaths by county in Pennsylvania for 2014. See the original here.

In September of 2015, Tom Wolf, the governor of Pennsylvania, announced that the CDC had granted the Pennsylvania Department of Health $900,000 to prevent overdose deaths related to prescription opioids. Governor Wolf said: “Too many citizens of our commonwealth are dying from drug overdose, and Pennsylvania families in hardworking communities are impacted by prescription drug addiction every day.” The “Prevention for States” grant will support 16 states with annual awards between $750,000 and $1 million over the next four years. The goal is to hopefully turn the tide on the prescription drug overdose epidemic by implementing prevention strategies and improving safe prescribing practices.

On March 18, 2016, the CDC published revised guidelines for primary care physicians when prescribing pain medication. Nearly half of all opioid prescriptions are dispensed by primary care clinicians. An estimated 20% of patients with noncancer pain symptoms or pain-related diagnoses receive an opioid prescription. While evidence supports the short-term efficacy of opioids for reducing pain, few studies have assessed the long-term benefits of opioids for chronic pain. An estimated 9.6 to 11.5 million adults (3% to 4% of the adult U.S. population) were prescribed long-term opioid therapy in 2005.

This guideline is intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death.

The guidelines are not mandatory, but if they are followed, maybe the opioid-related overdose deaths will start to decrease and people like Melanie will live instead of die.

01/29/16

High on Overdoses

A recent CDC Morbidity and Mortality Weekly Report indicated that in 2014 more people in the U.S. died from drug overdoses than any other year on record. There were approximately one and a half times more deaths from drug overdoses than from motor vehicle accidents. Sixty-one percent (28,647) of all drug overdose deaths were from opioids; the rate has tripled since 2000. Drug overdose deaths from heroin have more than tripled in 4 years. The overdose death rate involving synthetic opioids almost doubled between 2013 and 2014.

Drug overdose deaths are up for both men and women; in adults of nearly all age groups. The following table presents data for all overdose deaths in 2013 and 2014; by sex; and by age group. The death rates per 100,000 are given, as is the percentage increase from 2013 to 2014.

	2013	2014	% change 2013-2014
	#	Rate	#	Rate
All	43,982	13.8	47,055	14.7	6.5%
Male	26,799	17.0	28,812	18.3	7.6%
Female	17,183	10.6	18,243	11.1	4.7%
Age Group (yrs)
0-14	105	0.2	109	0.2	0.0%
15-24	3,664	8.3	3,798	8.6	3.6%
25-34	8,947	20.9	10,055	23.1	10.5%
35-44	9,320	23.0	10,134	25.0	8.7%
45-54	12,045	27.5	12,263	28.2	2.5%
55-64	7,551	19.2	8,122	20.3	5.7%
≥65	2,344	5.2	2,568	5.6	7.7%

The authors of the Report said these figures indicate the opioid overdose epidemic is worsening. That almost seems to be an understatement. In a CDC Press Release Tom Frieden, the Director of the CDC, said the increased number of overdose deaths was alarming. “The opioid epidemic is devastating American families and communities. To curb these trends and save lives, we must help prevent addiction and provide support and treatment to those who suffer from opioid use disorders.” He added how important it was for law enforcement to intensify its efforts to reduce the availability of heroin, illegal fentanyl and other illegal opioids.

The 2014 data on overdose deaths showed there were two interrelated trends driving the increase: “a 15-year increase in overdose deaths involving prescription opioid pain relievers and a recent surge in illicit opioid overdose deaths, driven largely by heroin.” Natural and semisynthetic opioids, which include oxycodone and hydrocodone, continued to be the most common type of opioid involved in overdose deaths.

Drug overdose deaths involving heroin continued to climb sharply, with heroin overdoses more than tripling in 4 years. This increase mirrors large increases in heroin use across the country and has been shown to be closely tied to opioid pain reliever misuse and dependence. Past misuse of prescription opioids is the strongest risk factor for heroin initiation and use, specifically among persons who report past-year dependence or abuse. The increased availability of heroin, combined with its relatively low price (compared with diverted prescription opioids) and high purity appear to be major drivers of the upward trend in heroin use and overdose.

The 2014 rates were highest in these five states: West Virginia, New Mexico, New Hampshire, Kentucky and Ohio. There were statistically significant increases in overdose deaths for fourteen states: Alabama, Georgia, Illinois, Indiana, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Mexico, North Dakota, Ohio, Pennsylvania and Virginia. Here is an interactive CDC map with this data.

Supporting these findings by the CDC, the National Institute on Drug Abuse (NIDA) reported in “Overdose Death Rates” that there was a 3.4-fold increase in the total number of overdose deaths from opioid pain relievers and a six-fold increase in the total number of overdose deaths from heroin from 2001 to 2014. The following charts are from the NIDA report.

The CDC pointed to four ways to prevent overdose deaths:

Limit initiation into opioid misuse and addiction. Opioid pain reliever prescribing has quadrupled since 1999. Providing health care professionals with additional tools and information—including safer guidelines for prescribing these drugs—can help them make more informed prescribing decisions.
Expand access to evidence-based substance use disorder treatment—including Medication-Assisted Treatment—for people who suffer from opioid use disorder.
Protect people with opioid use disorder by expanding access and use of naloxone—a critical drug that can reverse the symptoms of an opioid overdose and save lives.
State and local public health agencies, medical examiners and coroners, and law enforcement agencies must work together to improve detection of and response to illicit opioid overdose outbreaks to address this emerging threat to public health and safety.

Overdoses are not just a U.S. problem. The World Health Organization (WHO) estimated that globally 69,000 people die from opioid overdose each year. The World Drug Report 2014 estimated thee were 183,000 drug-related deaths worldwide in 2012. The main type of drug implicated in those deaths is opioids.

International Overdose Awareness Day reported that like the U.S. both the UK and Australia have had more deaths due to overdose than road fatalities. Nearly four Australians die each day from overdoses. Ontario, Canada had a 242% increase in fatal opioid overdoses between 1991 and 2010. European Union nations reported 6,100 overdose deaths in 2012. “It is estimated that more than 70,000 lives were lost to drug overdoses in European union countries in the first decade of the 21st Century.”

The CDC recommendations, for the most part, are ones I’d endorse. But like riders attached to big spending bills that have to be passed by Congress, the little phrase in the second recommendation “including Medication-Assisted Treatment” isn’t necessary. Medications like naloxone and naltrexone have a place in the expansion of substance use disorder treatment. But the phrase “medication-assisted treatment” refers to these medications as well as two opioids—methadone and buprenorphine—used in opioid substitution therapy. There is proposed legislation to expand the availability of buprenorphine, the Recovery for Addiction Treatment Act, in committee.

My objection is simple. You don’t “treat” an opioid use disorder with another opioid. You simply substitute dependence on one opioid for another.

I’ve regularly voiced concern over the treatment of opioid dependency with methadone and buprenorphine. Stop and think for a minute. Isn’t it reasonable to find that an individual who was physically addicted to heroin or prescription opioids would improve when they substitute ingesting enough methadone (a Schedule II controlled substance) or buprenorphine (a Schedule III controlled substance) to neutralize their physical withdrawal symptoms? The positive evidence base for opioid substitution treatment is based upon medically assisting an addict to begin using another opioid.

The “evidence-based” effectiveness of opioid “maintenance” treatment involves using these acknowledged addictive substances (methadone and burprenorphine) for weeks and even years to manage or stabilize an addiction to other opioids. There is more information on this issue in other articles I’ve written: “The Seduction of Opioid Substitution,” “Another Head for the Hydra,” and “A Double-Edged Drug.”

Another one of the drug types showing an increase in overdose deaths since 2001 in NIDA’s “Overdose Death Rates” was benzodiazepines. There has been a five-fold increase in the total number of deaths related to benzodiazepines. “Benzos” combined with opioids like methadone and buprenorphine have a synergistic effect and will give the person a heroin-like euphoria with the right drug cocktail. They also contribute to the higher rates of accidental overdose deaths. Expect the opioid overdose death rates to continue to rise even if the expansion of opioid substitution curtails overdose deaths from heroin.

Faith Seeking Understanding

Charles Sigler, D.Phil.

Tag Archives: overdose

Tranq Dope and Its Consequences

Doubling the Risk of Overdose

Overdosing

High on Overdoses