Most people who get into recovery do so when the pain of their using and the pain of their lifestyle is greater than the fear of stopping and trying a new way of life. Usually, this requires a crisis - like a health scare, legal problems, a threatened divorce or something similar.

But lately, I have been wondering how much the scare of dying from an overdose will actually cause someone to stop using heroin and get into treatment. The risk of dying from using street drugs has never been higher. Just this week we heard about four fatalities in Petersburg, Virginia and another 16 overdoses. These overdoses seem to have been caused by one batch of carfentanil. Heroin use has always been very dangerous with a high overdose fatality rate. Every heroin user knows there is a significant risk every time they use heroin. But now, with the new drugs coming in from China and Mexico, the risk has gone through the roof. Fentanyl is 50 times stronger than heroin and carfentanil is 5,000 times stronger! (See my "Ask the Doctor" column for more info about carfentanil.) The drugs are cheap to make and easy to import into the U.S. There are reports of drug dealers bringing in massive quantities of fentanyl from China and pressing it into tablets that look like Percocet, except they have enough fentanyl in them to cause instant death. Anytime someone buys what they think is heroin, or even look alike prescription drugs on the street, they are taking an incredible risk.

So, if the chance of dying every time someone used heroin was 90%, would they stop? Most likely they would, because that would be so ridiculous to use in the face of those odds. But, what if the chance of dying was 1 out of a 100? That may be what it is these days now that fentanyl and carfentanil are being added to the heroin that is for sale. If it is that high, the life expectancy of someone using street heroin could be about 3 months!

So, the question is why are people continuing to still buy and use street drugs when they know that the risk of dying is ridiculously high. Why are they not seeking or coming in for treatment with methadone, Suboxone, or naltrexone? These treatments save people's lives, and they are readily available. Sometimes they are covered by insurance or are available through Community Service Boards at no cost to the patient. Surely every person, even people with drug addiction, evaluate the risk of what they are doing compared with the pleasure they will get from doing it. The risk / benefit equation has flipped so much in the last couple of years, that it is hard to fully understand why people would take the risk.

There are a couple of possible answers to this question. One is simply ignorance or lack of knowledge. It may be that the people buying street drugs really do not understand just how dangerous this can be. Maybe they don't realize that fentanyl and these other drugs are becoming more commonplace. We are now finding traces of fentanyl in over 50% of the people using street drugs who come in for detox. Most of them thought they were using heroin, but what they were actually using was far more dangerous.

A second possibility is that people using opiates are so unhappy with their life and have a level of depression where they just don't care if they live or die. They are willing to keep using even though they know the risk is high, because they don't care anymore. They can't see there can be happiness and joy in life if they were able to get off the drugs because they are so down, so mired, and stuck in their drug world.

The most likely possibility is they believe they will be different and they will not make a mistake and overdose. The problem is these drugs poison their brain's ability to accurately assess risk. They may have used hundreds of times and then be lulled into thinking that the risk is really not that bad. Opiates strongly stimulate the reward system so people feel a lot of pleasure when they use these drugs. But, there are also opiate receptors in the frontal lobes - the thinking and decision-making part of the brain. Because the frontal lobes are also affected by the drugs, there is good evidence that the ability to weigh the risk from the drug using behavior is severely affected and diminished. This means the very drugs people are using, make it almost impossible for the addict to make decisions about what is safe and what is not safe. It is a serious problem that can only be overcome by awareness, education, clean time and being in an environment which promotes normal, rational thinking to return.

We have to attack this opiate crisis with a multi-pronged approach. We need to make sure everyone is fully aware that these drugs have changed and they are now so dangerous that people need to seek and get into treatment immediately. A fatal overdose could happen at any time to anyone. We need to make sure treatment is readily available and that everyone knows how to access treatment. If you have a loved one, or know someone who is using, it is time to do what you can to help them get into treatment so their brain can heal and they can start making good decisions again.

Peter Coleman, MD