Heroin overdose: Research and evidence-based intervention


Drug overdose is a major cause of premature death and morbidity among heroin users. This article examines recent research into heroin overdose to inform interventions that will reduce the rate of overdose death. The demographic characteristics of overdose cases are discussed, including factors associated with overdose: polydrug use, drug purity, drug tolerance, routes of administration, and suicide. Responses by heroin users at overdoses are also examined. Potential interventions to reduce the rate of overdose and overdose-related morbidity are examined in light of the emerging data in this field.

This is a preview of subscription content, log in to check access.


  1. 1.

    Fugelstad A, Annell A, Rajs J, Angren G. Mortality and causes and manner of death among drug addicts in Stockholm during the period 1981–1992. Acta Psychiatr Scand. 1997;96:169–175.

  2. 2.

    Goldstein A, Herrara J. Heroin addicts and methadone treatment in Albuquerque: a 22-year follow-up. Drug Alcohol Depend. 1995;40:139–150.

  3. 3.

    Oppenheimer E, Tobutt C, Taylor C, Andrew T. Death and survival in a cohort of heroin addicts from London clinics: a 22 year follow-up. Addiction. 1994;89:1299–1308.

  4. 4.

    Quaglio G, Talamini G, Lechi A, Venturini L, Lugoboni F, Mezzelani P. Study of 2708 heroin-related deaths in north-eastern Italy 1985–98 to establish main causes of death. Addiction. 2001;96:1127–1137.

  5. 5.

    Sanchez-Carbonell X, Seus L. Ten year survival analysis of a cohort of heroin addicts in Catalonia: the EMETYST project. Addiction. 2000;95:941–948.

  6. 6.

    Darke S, Zador D. Fatal heroin overdose: a review. Addiction. 1996;91:1765–1772.

  7. 7.

    Sporer K. Acute heroin overdose. Ann Int Med. 1999;130:584–590.

  8. 8.

    Warner-Smith M, Darke S, Lynskey M, Hall W. Heroin overdose: causes and consequences. Addiction. 2001;96:1113–1125.

  9. 9.

    Centers for Disease Control. Heroin overdose deaths—Multnomah County, Oregon, 1993–1999. MMWR Morb Mortal Wkly Rep. 2000;49:633–636.

  10. 10.

    Centers for Disease Control. Unintentional opiate overdose deaths—Kings County, Washington, 1990–1999. MMWR Morb Mortal Wkly Rep. 2000;49:636–640.

  11. 11.

    Ochoa KC, Hahn JA, Seal KH, Moss AR. Overdosing among young injection drug users in San Francisco. Addict Behav. 2001;26:453–460.

  12. 12.

    O’Driscoll PT, McGough J, Hagan H, Thiede H, Critchlow C, Russell AE. Predictors of accidental fatal drug overdose among a cohort of injection drug users. Am J Public Health. 2001;26:984–987.

  13. 13.

    Hall W, Degenhardt L, Lynskey M. Trends in opioid overdose and suicide mortality in young adults in Australia 1964–1997. Med J Aust. 1999;171:34–37.

  14. 14.

    Bennett G, Higgins D. Accidental overdose among injecting drug users in Dorset, UK. Addiction. 1999;94:1179–1190.

  15. 15.

    Darke S, Ross J, Hall W. Overdose among heroin users in Sydney, Australia. I. Prevalence and correlates of non-fatal overdose. Addiction. 1996;91:405–411.

  16. 16.

    Darke S, Ross J. Overdose risk perceptions and behaviours among heroin users in Sydney, Australia. Eur Addict Res. 1997;3:87–92.

  17. 17.

    Gossop M, Griffiths P, Powis B, Williamson S, Strang J. Frequency of non-fatal heroin overdose: survey of heroin users recruited in non-clinical settings. BMJ. 1996;313:402.

  18. 18.

    McGregor C, Darke S, Christie P, Ali R. Experience of non-fatal overdose among heroin users in Adelaide: circumstances and risk perception. Addiction. 1998;93:701–711.

  19. 19.

    Swift W, Maher L, Sunjic S. Transitions between routes of heroin administration: a study of Caucasian and Indochinese heroin users in south-western Sydney, Australia. Addiction. 1999;94:71–82.

  20. 20.

    Darke S, Sims J, McDonald S, Wickes W. Cognitive impairment among methadone maintenance patients. Addiction. 2000;95:687–695.

  21. 21.

    Cherubin C, McCusker J, Baden M, Kavaler F, Amsel Z. The epidemiology of death in narcotic addicts. Am J Epidemiol. 1972;96:11–22.

  22. 22.

    Darke S, Ross J, Zador D, Sunjic S. Heroin-related deaths in New South Wales, Australia, 1992–1996. Drug Alcohol Depend. 2000;60:141–150.

  23. 23.

    Frischer M, Bloor M, Goldberg D, Clark J, Green S, McKegany N. Mortality among injecting drug users: a critical reappraisal. J Epidemiol Community Health. 1993;47:59–63.

  24. 24.

    Hall W, Darke S. Trends in opiate overdose deaths in Australia, 1979–1995. Drug Alcohol Depend. 1998;52:71–77.

  25. 25.

    McGregor C, Ali R, Lokan R, Christie P, Darke S. Accidental fatalities among heroin users in South Australia, 1994–1997: toxicological findings and circumstances of death. Addict Res. 2002;26:335–346.

  26. 26.

    Zador D, Sunjic S, Darke S. Heroin-related deaths in New South Wales, 1992: toxicological findings and circumstances. Med J Aust. 1996;164:204–207.

  27. 27.

    Harlow KC. Patterns of rates of mortality from narcotics and cocaine overdose in Texas, 1976–1987. Public Health Rep. 1990;195:455–462.

  28. 28.

    Ruttenber AJ, Luke JL. Heroin-related deaths: new epidemiologic insights. Science. 1984;226:14–20.

  29. 29.

    Caplehorn JRM, Dalton SYN, Cluff MC, Petrenas AM, Retention in methadone maintenance and heroin addicts’ risk of death. Addiction. 1994;89:203–207.

  30. 30.

    Davoli M, Perucci CA, Forastiere F,et al. Risk factors for overdose mortality: a case control study within a cohort of intravenous drug users. Int J Epidemiol.1993;22:273–277.

  31. 31.

    Fugelstad A, Rajs J, DeVerdier MG. Mortality among HIV-infected intravenous drug addicts in Stockholm in relation to methadone treatment. Addiction. 1995;90:711–716.

  32. 32.

    Stewart D, Gossop M, Marsden J. Reductions in non-fatal overdose after drug misuse treatment: results from the National Treatment Outcome Research Study (NTORS). J Subst Abuse Treat. 2002;22:1–9.

  33. 33.

    Goldberger BA, Cone EJ, Grant TM, Caplan YH, Levine BS, Smialek JE. Disposition of heroin and its metabolites in heroin related deaths. J Anal Toxicol. 1994;18:22–28.

  34. 34.

    Monforte JR. Some observations concerning blood morphine concentrations in narcotic addicts. J Forensic Sci. 1977;22:718–724.

  35. 35.

    Risser D, Honigschnabl S, Stichenwirth M, et al. Drug-related emergencies and drug-related deaths in Vienna, 1995–1997. Drug Alcohol Depend. 2001;61:307–313.

  36. 36.

    Steentoft A, Worm K, Christenson H, Morphine concentrations in autopsy material from fatal cases after intake of morphine and/or heroin. J Forensic Sci Soc. 1988;28:87–94.

  37. 37.

    Gutierrez-Cebollada J, De La Torre R, Ortuno J, Garces J, Cami J. Psychotropic drug consumption and other factors associated with heroin overdose. Drug Alcohol Depend. 1994;35:169–174.

  38. 38.

    Ruttenber AJ, Kalter HO, Santinga P. The role of ethanol abuse in the etiology of heroin-related death. J Forensic Sci. 1990;35:891–900.

  39. 39.

    Caplehorn J. Risk factors for non-HIV-related deaths among methadone maintenance patients. Eur Addict Res. 1996;2:49–52.

  40. 40.

    Richards RG, Reed D, Cravey RH. Death from intravenously administered narcotics: a study of 114 cases. J Forensic Sci. 1976;21:467–482.

  41. 41.

    Darke S, Ross J. The use of antidepressants among injecting drug users in Sydney, Australia. Addiction. 2000;95:407–417.

  42. 42.

    Darke S, Hall W, Weatherburn D, Lind B. Fluctuations in heroin purity and the incidence of fatal heroin overdose. Drug Alcohol Depend. 1999;54:155–161.

  43. 43.

    Desmond DP, Maddux JF, Trevino A. Street heroin potency and deaths from overdose in San Antonio. Am J Drug Alcohol Abuse. 1978;5:39–49.

  44. 44.

    Risser D, Uhl A, Stichenwirth M, et al. Quality of heroin and heroin-related deaths from 1987 to 1995 in Vienna, Austria. Addiction. 2000;95:375–382.

  45. 45.

    Coomber R. How often does the adulteration/dilution of heroin actually occur? An analysis of 228 “street” heroin samples across the UK (1995–96) and discussion of monitoring policy. Int J Durg Policy. 1997;8:178–186.

  46. 46.

    Coomber R. The cutting of heroin in the United States in the 1990s. J Drug Issues. 1999;29:17–36.

  47. 47.

    Maher L, Swift W, Dawson M. Heroin purity and composition in Sydney, Australia. Drug Alcohol Rev. 2001;20:439–448.

  48. 48.

    Darke S, Sunjic S, Zador D, Prolov T. A comparison of blood toxicology of heroin-related deaths and current heroin users in Sydney, Australia. Drug Alcohol Depend. 1997;47:45–53.

  49. 49.

    Kintz P, Mangin P, Lugnier AA, Chaumont AJ. Toxicological data after heroin overdose. Hum Toxicol. 1989;8:487–489.

  50. 50.

    Darke S, Hall W, Kaye S, Ross J, Duflou J. Hair morphine concentrations of fatal heroin overdose cases and living heroin users. Addiction. 2002;97:977–984.

  51. 51.

    Tagliaro F, Debattisti Z, Smith FP, Marigo M. Death from heroin overdose: findings from hair analysis. Lancet. 1998;351:1923–1925.

  52. 52.

    Kronstrand R, Grundin R, Jonsson J. Incidence of opiates, amphetamines, and cocaine in hair and blood in fatal cases of heroin overdose. Forensic Sci Int. 1998;92:29–38.

  53. 53.

    Darke S, Kaye S, Finlay-Jones R. Drug use and injection risk-taking among prison methadone maintenance patients. Addiction. 1998;93:1169–1175.

  54. 54.

    Seaman SR, Brettle RP, Gore SM. Mortality from overdose among injecting drug users recently released from prison: database linkage study. BMJ. 1998;316:426–428.

  55. 55.

    Seymour A, Oliver JS, Black M. Drug-related deaths among recently released prisoners in the Strathelyde region of Scotland J Forensic Sci. 2000;45:649–654.

  56. 56.

    Strang J, Griffiths P, Powis B, Gossop M. Heroin chasers and heroin injectors: differences observed in a community sample in London, UK. Am J Addict. 1999;8:148–160.

  57. 57.

    Neaigus A, Miller M, Friedman S, et al. Potential risk factors for the transition to injecting among non-injecting heroin users: a comparison of former injectors and never injectors. Addiction. 2001;96:847–860.

  58. 58.

    Perez-Jimenez JP, Robert MS. Transitions in the route of heroin use. Eur Addict Res. 1997;3:93–98.

  59. 59.

    Darke S, Ross J. Fatal heroin overdoses resulting from non-injecting routes of administration, NSW, Australia, 1992–1996. Addiction. 2000;95:596–599.

  60. 60.

    Dinwiddie SH, Reich T, Cloninger CR. Psychiatric comorbidity and suicidality among intravenous drug users. J Clin Psychiatry. 1992;53:364–369.

  61. 61.

    Darke S, Ross J. Poly drug dependence and psychiatric comorbidity among heroin injectors. Drug Alcohol Depend. 1997;48:135–141.

  62. 62.

    Kosten TR, Rounsaville BJ. Suicidality among opioid addicts: a 2.5 year follow-up. Am J Drug Alcohol Abuse. 1998;14:357–369.

  63. 63.

    Hulse GK, English DR, Milne E, Holman CDJ. The quantification of mortality resulting from the regular use of illicit opiates. Addiction. 1999;94:221–229.

  64. 64.

    Neale J. Suicidal intent in non-fatal illicit drug overdose. Addiction. 2000;95:85–93.

  65. 65.

    Rossow I, Lauritzen G. Balancing on the edge of death: suicide attempts and life-threatening overdoses among drug addicts. Addiction. 1999;94:209–219.

  66. 66.

    Darke S, Ross J. The relationship between suicide and overdose among methadone maintenance patients in Sydney, Australia. Addiction. 2001;96:1443–1453.

  67. 67.

    Kjelsberg E, Winther M, Dahl AA. Overdose deaths in young substance abusers: accidents or hidden suicides. Acta Psychiatr Scand 1995;91:236–242.

  68. 68.

    Darke S, Ross J. Suicide among heroin users: rates, risk factors and methods. Addiction. 2002;97:1383–1394.

  69. 69.

    Darke S, Ross J, Hall W. Overdose among heroin users in Sydney, Australia. II. Responses to overdose. Addiction. 1996;91:413–417.

  70. 70.

    Strang J, Best D, Man L, Noble A, Gossop M. Peer-initiated overdose resuscitation: fellow drug users could be mobilised to implement resuscitation. Int J Drug Policy. 2000;11:437–445.

  71. 71.

    Manning FJ, Ingraham LH, Derouin EM, Vaughn MS, Kukura FC, St Michel GR. Drug “overdoses” among US soldiers in Europe, 1978–1979. II. Psychological autopsies following deaths and near-deaths. Int J Addict. 1983;18:153–156.

  72. 72.

    Garriot JC, Sturner WQ. Morphine concentrations and survival periods in acute heroin fatalities. N Engl J Med. 1973;289:1276–1278.

  73. 73.

    Nakamura GR. Toxicological assessments in acute heroin fatalities. Clin Toxicol. 1978; 13:75–87.

  74. 74.

    Bammer G, Sengoz A. Non-fatal heroin overdoses. Med J Aust. 1994;161:572–573.

  75. 75.

    McGregor C, Ali R, Christie P, Darke S. Overdose among heroin users: evaluation of an intervention in South Australia. Addict Res. 2001;9:481–501.

  76. 76.

    Darke S, Hall W. The distribution of naloxone to heroin users. Addiction. 1997;92:1195–1199.

  77. 77.

    Lenton S, Hargreaves K. Should we conduct a trial of distributing naloxone to heroin users for peer administration to prevent fatal overdose? Med J Aust. 2000;173:260–263.

  78. 78.

    Strang J, Darke S, Hall W, Farrell M, Ali R. Heroin overdose: is there a case for takehome naloxone? BMJ. 1996;312:1435.

  79. 79.

    Hunt N, Griffiths P, Southwell M, Stillwell G, Strang J. Proventing and curtailing injecting drug use: a review of opportunities for developing and delivering “route transition interventions” Drug Alcohol Rev. 1999;18:441–445.

  80. 80.

    Dolan K, Kimber J, Fry C, Fitzgerald J, McDonald D, Trautmann F. Drug consumption facilities in Europe and the establishment of supervised injecting centres in Australia. Drug Alcohol Rev. 2000;337–346.

  81. 81.

    Kemmesies UE. The Open Drug Scene and the Safe Injection Rooms Offers in Frankfurt am Main 1995. Frankfurt, Germany: Stadt Frankfurt/Dezernat Frauen und Gesundheit; 1999.

  82. 82.

    Poschadel S, Hoger R, Schnitzler J, Schreckenberg D. Evaluation der Arbeit der Drogenkonsumraume in der Bundesrepublik Deutschland. Bochum, Germany: ZEUS GmbH; 2002.

  83. 83.

    Ronco C, Spuhler G, Coda P, Schopfer R. Evaluation for alley-rooms I, II and II in Basel. Soc Prev Med. 1996;S58–S68.

  84. 84.

    Rehm J, Gschwend P, Steffen T, Gutzwiller F, Dobler-Mikola A, Uchtenhagen A. Feasibility, safety, and efficacy of injectable heroin prescription. Lancet. 2001;358:1417–1420.

  85. 85.

    Hall W. Assessing the Population-Level Impact of the Swiss Model of Heroin Prescribing. Sydney, Australia: University of New South Wales, Sydney; 1999. National Drug and Alcohol Research Centre Technical Report 76.

  86. 86.

    Warner-Smith M, Darke S, Day C. Morbidity associated with non-fatal heroin overdose. Addiction. 2002;97:963–967.

Download references

Author information

Correspondence to Dr. Shane Darke.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Darke, S., Hall, W. Heroin overdose: Research and evidence-based intervention. J Urban Health 80, 189–200 (2003) doi:10.1093/jurban/jtg022

Download citation


  • Heroin
  • Mortality
  • Overdose