In a recent post, David Henderson commented on how people view the horrors of drugs:

But what so few people seem to understand is that virtually all their horror stories about drugs occurred during a time when drugs were illegal….But if all these horror stories occurred during the drug war, it is hard to see how people can so easily think that these horror stories are an argument for the drug war.

His post reminded me of something that I learned while researching the heroin chapter of my book The Seven Deadly Sins: in certain ways, heroin prohibition makes an intrinsically deadly activity even deadlier.

To help understand why this is the case, let’s consider what one paper called the main risk factors for heroin overdose:

injecting heroin, using opioids together with benzodiazepines or alcohol, not being in methadone treatment, and using opioids after a period of abstinence, generally due to having been in prison or drug-dependency treatment. (emphasis mine)

At least some people who currently inject heroin would ingest the drug through a safer method if the government made no attempt to discourage heroin use. Justifying this claim is a two-step process. Step 1: the free market, untaxed price of heroin would be a small fraction of the current street price. How cheap would unregulated heroin be? Jeffrey Miron compared the price of street heroin to the price of heroin legally produced for scientific research. This comparison suggested that interdiction increased the price of street heroin by a factor of 19. Step 2: one reason why heroin users inject is its cost effectiveness. As a heroin user’s tolerance increases, getting high without injecting becomes cost prohibitive. If heroin was much cheaper, cost would make injecting less financially imperative. As one initiate to injecting described:

I already had a habit going on because I snorted. I was already at a three bag tolerance each time to get high, and I wanted to get high, and I thought it was a waste of dope. It’s more efficient if you shoot up, it’s supposed to be like one of the most euphoric feelings you ever feel, and it costs less.

The second highlighted risk factor (having been in prison) is obviously connected to drug prohibition. The most dangerous time to be a heroin user is probably the first few weeks after getting out of prison. The primary cause of heroin overdose is respiratory depression: the user’s breathing slows down and over time body tissues suffer from a lack of oxygen. Users take more and more heroin as they develop a tolerance for its euphoric effects. These large doses of heroin would dangerously depress respiration except for the fact that the body develops a tolerance for heroin’s respiratory effects at the same time that it develops a tolerance for its euphoric effects. Abstinence lowers tolerance and makes the user more susceptible to respiratory depression, which explains why binging after a period of abstinence is so deadly. Putting heroin addicts in prison is the perfect trigger for this. As soon as they’re released, most users are eager to get back to heroin. It goes without saying that a heroin user would be less likely to face imprisonment if heroin was legal.

Prohibition might also make heroin use more dangerous by causing the purity of a user’s supply to fluctuate. Safety would recommend ingesting heroin of known purity (especially for injectors). An addict who is used to consuming low-purity heroin and then unknowingly consumes high-purity heroin might ingest more of the drug than expected. The fact that a user’s supply is continually being interrupted by law enforcement causes fluctuations in purity. (The evidence for this risk factor is weaker than for the two highlighted factors above.)

Prohibition also causes quality fluctuations due to the adulterants that black-market dealers add to heroin. Proponents of heroin legalization and many heroin users themselves often cite this as a significant cause of overdose. However, the medical literature generally views this as an insignificant risk factor. Fortunately for the prospects of safely finishing my book, reading medical research is a better way to understand the dangers of overdose than acquiring firsthand experience.

P.S. I am not suggesting that overall heroin overdoses would decrease if heroin became unregulated. Even without new heroin users, lots of financially constrained injectors would use cheap heroin to increase their heroin consumption instead of transitioning to a safer ingestion method.

P.P.S. One of the saddest facts about heroin is that seeking treatment for addiction is itself a risk factor for overdose (at least in the short term). Treatment reduces how much heroin people use, which reduces tolerance, which makes it very dangerous to fall off the wagon.