Overdose or poisoning? A new debate about what we should call a drug death.
The death certificate for Ryan Bagwell, a 19-year-old from Mission, Texas, states that he died of a fentanyl overdose.
His mother, Sandra Bagwell, says that’s wrong.
One evening in April 2022, he swallowed a pill from a bottle of Percocet, a prescription painkiller he and a friend bought earlier that day at a Mexican pharmacy just across the border. The next morning his mother found him dead in his bedroom.
A federal law enforcement laboratory found that none of the pills from the bottle tested positive for Percocet. But they all tested positive for lethal levels of fentanyl.
“Ryan has been poisoned,” said Ms. Bagwell, an elementary school reading specialist.
As millions of fentanyl-tainted pills flood the United States disguised as common drugs, families are heartbroken to call for a change in the language used to describe drug deaths. They want public health leaders, prosecutors and politicians to use “poisoning” instead of “overdose.” According to them, an ‘overdose’ indicates that their loved ones were addicted and responsible for their own deaths, while ‘poisoning’ shows that they were the victims.
“When I tell someone my child has overdosed, they assume he’s a junkie on drugs,” says Stefanie Turner, co-founder of Texas vs. Fentanyla nonprofit organization that successfully lobbied Governor Greg Abbott to approve statewide awareness campaigns about so-called fentanyl poisoning.
“When I tell you my child was poisoned by fentanyl, you’re like, ‘What happened?’” she continued. “It keeps the door open. But ‘overdose’ is a closed door.”
For decades, “overdose” has been used by federal, state, and local health and law enforcement agencies to document drug deaths. It has permeated the vocabulary of news reports and even popular culture. But in the past two years, family groups have challenged its reflexive use.
They are having some success. In September, Texas began requiring death certificates to say “poisoning” or “toxicity” instead of “overdose” if fentanyl was the primary cause. Legislation has been introduced in Ohio and Illinois for a similar change. A bill in Tennessee says that if fentanyl is involved in a death, the cause “must be reported as accidental fentanyl poisoning,” and not an overdose.
Meetings with family groups helped convince Anne Milgram, the administrator of the Drug Enforcement Administration, that more than 78 million fake pills in 2023, for routine use “fentanyl poisoning” in interviews and during congressional hearings.
During a hearing last spring Rep. Mike Garcia, Republican of California, praised Ms. Milgram’s choice of words, saying, “You did a great job calling these ‘poisonings.’ These are not overdoses. In many cases, the victims do not know that they are using fentanyl. They think they’re on Xanax, Vicodin, OxyContin.”
Last year, efforts to describe fentanyl-related deaths as poisonings began emerging in bills and resolutions in several states, including Louisiana, New Jersey, Ohio, Texas and Virginia, according to the National Conference on State Legislatures. Typically, these bills establish weeks or months of “Fentanyl Poisoning Awareness” as public education initiatives.
“Language is very important because it shapes policy and other responses,” he says Leo Beletsky, a drug policy enforcement expert at Northeastern University School of Law. In the increasingly politicized domain of public health, word choice has become imbued with ever greater message power. For example, during the pandemic the label “anti-vaxxer” fell into disrepute and was replaced by the more inclusive “vaccine-hesitant.”
Addiction is an area undergoing a dramatic change in language, and words such as ‘alcoholic’ and ‘addict’ are now often seen as limiting and stigmatizing. Research shows that terms such as ‘drug abuser’ can even influence the behavior of doctors and other healthcare professionals towards patients.
The word ‘poison’ has emotional power and carries resonances from the Bible and classic fairy tales. “’Poisoning’ adds to the victim-villain narrative that some people are looking for,” he said Sheila P. Vakhariaa senior researcher at the Drug Policy Alliance, an advocacy group.
But while “poisoning” offers many families a buffer against stigma, others whose loved ones have died from using illegal street drugs find it problematic. Using “poisoning” to distinguish certain deaths while labeling other deaths as “overdose” creates a rating hierarchy of drug-related deaths, they say.
Fay Martin said her son, Ryan, a commercial electrician, was prescribed opioid painkillers for a work injury. When he became dependent on them, a doctor stopped his prescription. Ryan turned to heroin. He eventually entered treatment and stayed sober for a while. But ashamed of his history of addiction, he kept to himself and gradually started using drugs again. Believing he was buying Xanax, he died in 2021, the day after his 29th birthday, from ingesting a fentanyl-tainted pill.
Although he, like thousands of victims, died from a counterfeit pill, his grieving mother feels like others are looking at her askance.
“When my son died, I felt the stigma from people that there was personal responsibility involved because he had used illegal drugs,” said Mrs. Martin of Corpus Christi, Texas. ‘But he didn’t get what he bargained for. He did not ask about the amount of fentanyl in his system. He tried not to die. He was trying to get high.”
To a growing number of prosecutorsIf someone was poisoned by fentanyl, then the person selling the drug was a poisoner—someone who knew or should have known that fentanyl could be fatal. More and more states are passing fentanyl homicide laws.
Critics note that the idea of a poisoner-villain does not take into account the complications of drug use. “That’s a bit too simplistic, because many people who sell or share substances with friends also suffer from a substance abuse disorder,” says Rachel Cooperwho leads an anti-stigma initiative at Shatterproof, an advocacy organization.
People who sell or share drugs are usually many steps away from those who mixed the batches. They likely wouldn’t be aware that their medications contained lethal levels of fentanyl, she said.
“In a non-politicized world, ‘poisoning’ would be accurate, but the way it is used now reframes what is likely an accidental event and reframes it as an intentional crime,” said Mr. Beletsky, who heads Northeastern’s Changing the Narrative project, which investigates addiction stigma.
In toxicology and medicine, “overdose” and “poison” have value-neutral definitions Kaitlyn Brownthe clinical director of The American Poison Centerswhich represents and collects data from 55 centers nationwide.
“But the public is going to understand the terminology differently than people who study the field, so I think there are important differences and nuances that the public may miss,” she said.
“Overdose” describes a larger dose of a substance than was considered safe, explained Dr. Brown out. The effect may be harmful (heroin) or not (ibuprofen).
‘Poisoning’ means that damage has indeed occurred. But it can be poisoning from numerous substances, including lead, alcohol and food, as well as fentanyl.
Both terms are used regardless of whether an event results in survival or death.
Until about fifteen years ago, the Centers for Disease Control and Prevention, a valued source of data on national drug deaths, often used the two terms interchangeably. A CDC report which detailed the rising drug-related deaths in 2006 was titled “Unintentional Drug Poisoning in the United States.” It also referred to “unintentional drug overdose deaths.”
To streamline growing data on drug deaths from federal and state agencies, the CDC switched exclusively to “overdoses.” (It now also collects statistics on reported non-fatal overdoses.) The CDC’s Overdose Prevention Division notes that “overdose” refers only to drugs, while “poisoning” refers to other substances, such as cleaning products.
When asked which unbiased word or phrase could best characterize drug deaths, drug policy and treatment experts struggled.
Some preferred ‘overdose’ as this is anchored in the data reporting. Others use “accidental overdose” to emphasize the lack of intention. (Most overdoses are, in fact, accidental.) News media occasionally use both, reporting that a drug overdose has occurred due to fentanyl poisoning.
Addiction medicine experts note that most of the drug supply is now on the streets falsified, ‘poisoning’ is indeed the simplest, most accurate term. Patients who buy cocaine and methamphetamine die from fentanyl in the product, they note. Those addicted to fentanyl succumb to bags containing more toxic concoctions than they expected.
Ms. Martin, whose son was killed by fentanyl, bitterly agrees. “He was poisoned,” she said. “He received the death penalty and his family received a life sentence.”