People with excited delirium are said to display “superhuman strength"
May 22, 2022 2:41 PM Subscribe

Most medical authorities do not consider excited delirium to be real. A ‘city on fire’: How [1980s] Miami shaped a disputed diagnosis used to justify deaths in police custody is a May 2022 podcast episode from StatNews (pdf transcript). Earlier StatNews coverage on the topic: The term was first used in 1985 to explain a series of seven deaths among people who used cocaine, all of whom were forcibly restrained and five of whom died in police custody.

First Opinion podcast in April 2021: "Though the term excited delirium was first used in its modern sense in 1985, there’s weak — or no — evidence to support it as a valid diagnosis."

posted by spamandkimchi (54 comments total) 15 users marked this as a favorite

I haven't had a chance to listen to the piece, but if my memory is correct, excited delirium first showed up as an explanation for why people died when Tased. The idea was that the Taser couldn't kill someone (essentially by definition) therefore there had to be something wrong with the victim that lead to their death. This then gets extended to justify death or injury in other kinds of use-of-force cases. This doesn't mean that people don't get delusional and fight, but that this 'diagnosis' is political not medical.
posted by sfred at 3:02 PM on May 22, 2022 [17 favorites]

I understand it to be a medical condition that most medical authorities dispute exists, but somehow cops are able to diagnose.

A useful skill.
posted by ricochet biscuit at 3:02 PM on May 22, 2022 [33 favorites]

I don't doubt that there are people out there who exhibit extraordinary strength/speed/whatever else when they're under the effect of powerful stimulants. That's kind of what stimulants do. And adrenaline is a helluva drug--my grandma was a 5'1" lady who we never allowed to carry her own groceries because the effort was too taxing, but when a pool table fell onto her eldest child (according to family lore) and pinned him down with a broken leg, she lifted it off of him without thinking about it. It was later determined to weigh somewhere in the neighborhood of 1800 pounds, and took three big guys to move back into place.

I also don't doubt for one second that police are (a) trained in how to safely restrain physically strong people who aren't in their right minds and (b) enthusiastically leapt onto the Nancy Reagan drug hysteria bandwagon and used it as justification for their department's penchant for extrajudicially murdering minorities.
posted by Mayor West at 3:03 PM on May 22, 2022 [14 favorites]

When I was a kid in California in the early 1980s the drug scare du jour was for a time centered on PCP, under the influence of which, according to street lore, one could break out of handcuffs and lift cars into the air because on PCP you felt no pain and thus could accomplish these superhuman feats. I'm pretty this was all the most ridiculous bullshit but at the time we took it as writ.
posted by chavenet at 3:32 PM on May 22, 2022 [18 favorites]

the Taser couldn't kill someone (essentially by definition)

I don't think you're making this claim yourself, but just in case there's any doubt, the Taser can definitely kill, and that's always been known. Tasers are properly considered "less lethal" weapons, not "nonlethal" ones. The idea that an electroshock weapon is nonlethal is used by brutality apologists to justify their use in any circumstance. Tasers are supposed to be a replacement for conventional firearms in cases where police would otherwise use those, not a replacement for safer methods of physical restraint and control when those would otherwise be appropriate.

A cop tasing someone who's "uncooperative" or to force them to stop struggling (or, all too frequently, to punish them for resisting), represents an uncalled-for and unacceptable use of potentially deadly force, if physical restraint would suffice. Tasers are commonly portrayed in the popular media as painful but harmless, but this is absolutely not the case, and I think it that's important enough to push back on whenever it comes up.
posted by biogeo at 3:38 PM on May 22, 2022 [24 favorites]

Northern Calloway (David from Sesame Street) died of this.
posted by Melismata at 4:28 PM on May 22, 2022 [4 favorites]

I'm not questioning the post's central thesis of race-motivated police brutality, and the war on drugs is a failure, but I am curious if the writers investigated bath salts, flakka, or other recreational drugs that some medical researchers do seem to connect with excited delirium or other psychotic behaviors.

There’s nothing fundamentally different about how these drugs work compared to the better known stimulants (cocaine, amphetamines etc.) with which the concept was already associated. The various “bath salts” cathinones were just highly potent and available in a variety of unregulated grey-market concoctions, which lead to a number of people experiencing the worst effects of excessive stimulant use.

I think “excited delirium” can be seen similarly to “sociopathy.” It’s a category that overlaps with categories used in medicine and describes some of the same phenomena, but doesn’t represent a medical view of the world - it represents a criminal justice view of the world, classifying the way in which some people are dangerous to society and justifying what the system does to them.
posted by atoxyl at 4:38 PM on May 22, 2022 [13 favorites]

It even sounds fake: excited delirium. Like someone learned a big word and then put excited in front of it to make it sound worse. But that this BS has somehow been taken seriously by not just cops, but judges and prosecutors, is just awful.
posted by ssg at 4:43 PM on May 22, 2022 [2 favorites]

Haven't read the article (yet) but Behind The Bastards did a good pair of episodes on excited delirium and Taser's connection with it.
posted by JHarris at 5:22 PM on May 22, 2022 [3 favorites]

We've all heard about the mom who, seeing her son crushed below a car when a jack fails, rushes over and somehow manages to lift the car to free him. Would that be excited delirium or something else? Or is it just a tall tale?
posted by hypnogogue at 5:44 PM on May 22, 2022

...yes? Whenever you say "we've all heard," you should automatically suspect the next part of the sentence.
posted by praemunire at 5:57 PM on May 22, 2022 [11 favorites]

Would that be excited delirium or something else? Or is it just a tall tale?

That’s just plain old adrenaline/endorphins, which probably contributes to “excited delirium” far more frequently than the flakka du jour. But once you make the discussion about an everyday chemical/hormone that everyone experiences, the whole “tasers can’t kill” ruse falls apart.
posted by a box and a stick and a string and a bear at 6:00 PM on May 22, 2022 [2 favorites]

> flakka and bath salts

You know, if there is such a thing as flakka, and somebody who took some did something crazy violent, that is not necessarily because of the flakka. It could be just because that person is really fucked up in the head.

You can kind of tell that moral panics about drug effects are bullshit by how they come and go. I'm not going to go search on "flakka" to see how much it (the word that is) was used and when, but it's noteworthy that there were a lot of horror stories about it for a little while, and then nothing.

In conclusion, the drug that causes people to do more bad craziness than all the others combined, is alcohol.
posted by Aardvark Cheeselog at 6:15 PM on May 22, 2022 [10 favorites]

I appreciate the tenor of the conversation in here, and acknowledge that law enforcement may misuse the term, but I'm an ER doc and excited/agitated delirium is a very real clinical entity. It's what happens when you mix illegal psychostimulants (usually methamphetamines) with alcohol, other illegal drugs, and/or some degree of native mental illness, typically in a younger, and rather physically strong, person. These patients are not infrequently physically assaultative and cannot be verbally de-escalated. They're typically managed with sedating medication and, sometimes, with physical restraints, and hospital staff routinely get hurt while trying to care for them. Agitated/violent patients of this sort are among my least favorite classes of patients to treat; they're high risk and very difficult to manage safely (which is why law enforcement routinely dump them on us).
posted by killdevil at 6:28 PM on May 22, 2022 [26 favorites]

Hyperactive delirium is definitely a thing. If you know someone with advanced dementia, you'll know that they often get very agitated around sunset ("sundowning") or if they have a urinary tract infection. I have also seen it happen after seizure, and with certain psychostimulants. (ie what killdevil said)

Police leaning on inappropriate medical explanations, though, is also a thing, and probably a lot more common than hyperactive delirium.
posted by basalganglia at 6:32 PM on May 22, 2022 [16 favorites]

Echoing basalganglia, I have also seen agitated delirium in patients who are post-ictal and disoriented following a seizure. I took care of one such patient recently who managed to fracture a medic's face with his fist.
posted by killdevil at 6:35 PM on May 22, 2022 [5 favorites]

We've all heard about the mom who, seeing her son crushed below a car when a jack fails, rushes over and somehow manages to lift the car to free him. Would that be excited delirium or something else?

I believe that Doctor David Banner hypothesized that this was due to increases in background gamma radiation caused by sunspots. I'm unaware of whether he pursued this line of enquiry though - he hasn't published anything since the seventies it seems.
posted by thatwhichfalls at 6:48 PM on May 22, 2022 [28 favorites]

Dang, beaten to the Incredible Hulk reference. At least Mayor West added "(according to family lore)". There's really no science behind it.
posted by Halloween Jack at 6:57 PM on May 22, 2022 [4 favorites]

I've read a lot about sports performance, and there's a recurring theme that what we perceive to be our physical limitations are actually caused by the brain's perception of the situation and sending out pain/fatigue signals out of self-preservation, and not actually sent by the muscle or cardiovascular system.

People can perform better under situations where they believe there is food waiting for them at the finish line, or worse if there is a thermometer that says it is hot regardless of the actual temperature. It's why Crossfitters can severely damage their bodies and runners can die during marathons, because they have trained themselves to the point where their brains send those pain signals far too late to avoid disaster.

If someone brain does not have that self-preservation limiter, due to the perception that their life is in danger or because of disruptions in the brain, their bodies can perform beyond normal "safe" limits which can be perceived as unexpected or superhuman.
posted by meowzilla at 7:10 PM on May 22, 2022 [6 favorites]

I'm an ER doc and excited/agitated delirium is a very real clinical entity

Thank you.
posted by They sucked his brains out! at 8:46 PM on May 22, 2022 [2 favorites]

It's why Crossfitters can severely damage their bodies and runners can die during marathons, because they have trained themselves to the point where their brains send those pain signals far too late to avoid disaster.

It's timely you bring that up, considering what a shitshow the Brooklyn Half Marathon was yesterday.
posted by The Pluto Gangsta at 8:49 PM on May 22, 2022 [4 favorites]

Others are more skeptical. They say that the shocking stories about PCP are based more on myth than reality. Whenever a new drug sweeps the nation, they say, the reaction is always the same--to vilify it in dramatic tales of wanton violence that will justify the use of extraordinary measures in subduing its users.

New York City College pharmacologist John Morgan, who has sharply criticized the media’s portrayal of PCP, contends that every new drug experience in America is reported by the media in a way that emphasizes “individual tales of dangerous, criminal or self-destructive behavior.”

“The myth is newly erected and slightly embellished with each new drug,” Morgan said. “The best model seems to be the Frankenstein monster who advances impervious to pain, bullets and . . . fire, in order to murder (or) dismember . . . men, women, children and the household pets.”

Sure, people act weird on drugs. Big strong guys with very limited impulse control at baseline take stimulants or other drugs, or have physiological experiences such as dementia mentioned above, and they sometimes behave violently and irrationally. News at 11. That is not super-human strength. Show me the replicated high-quality research and we'll talk about special magical drug syndromes.
posted by latkes at 9:20 PM on May 22, 2022 [13 favorites]

To the docs in the thread: I have no beef with the idea that agitated strong people get dangerous especially when on stimulants or combinations of stimulants and other drugs. Is that a specific medical condition? It strikes me as more of a syndrome of sorts (a set of behaviors that appear under specific sets of conditions), if you wish to give it a medical label. But there is a huge mythology around this concept of super-human strength that justifies an 'inevitably' of death by police intervention when a person is presenting this way.

There's nothing safe or benign about working with someone who is angry, strong, has limited impulse control, or is having a psychotic episode heightened or triggered by meth for example, but that doesn't make it a disease that causes people to spontaniously die of asphyxiation: it's the cop choking them that does that.
posted by latkes at 9:27 PM on May 22, 2022 [10 favorites]

I'm an ER doc and excited/agitated delirium is a very real clinical entity.

Yeah, but they don't have super-strength. Remember how Michael Brown was supposed to have "hulked out" through a rain of bullets?
posted by praemunire at 10:03 PM on May 22, 2022 [10 favorites]

killdevil or other medical personnel, I have a question for you: as I understand the law-enforcement version of excited delirium, it is also supposed to come with a high risk of spontaneous death--through hyperthermia, or heart attack, or seizure, or something (other than what the law enforcement officer was doing). Is that also true for people with this condition in medical settings, when being treated by medical personnel, rather than law enforcement?
posted by agentofselection at 10:16 PM on May 22, 2022 [3 favorites]

I think “excited delirium” can be seen similarly to “sociopathy.”

Ugh I actually meant “psychopathy” a la Robert Hare here but similar idea.

killdevil or other medical personnel

I’m not but these

hyperthermia, or heart attack, or seizure

are all independently effects of stimulant overdose (as are agitation, psychosis and, uh, delirium) even if one is not being tased or restrained. In case it isn’t clear, the claim in my previous comment isn’t that the phenomena associated with “excited delirium” are unrelated to medical realities, but that the “package deal” of a specific syndrome in which individuals are both uniquely dangerous and uniquely fragile is better known to forensic science and “cop science” than to clinical medicine - and that it is favored in policing because it conveniently explains both the intervention and the outcome. My understanding is that the AMA and APA have both issued statements to the effect that use of the term is discouraged until a real set of diagnostic criteria are established.
posted by atoxyl at 11:33 PM on May 22, 2022 [8 favorites]

It is however apparently more accepted in the ER world (as people have backed up in the thread). Here’s a paper from the ACEP which attempts to provide some definition or at least discussion of syndromes that might fall under the umbrella, and treatment options.
posted by atoxyl at 11:54 PM on May 22, 2022 [2 favorites]

Show me the replicated high-quality research

I provided a couple links in the first comment and a medical professional confirmed the same in a later comment. It's a real thing, even if police abuse the terminology.
posted by They sucked his brains out! at 11:59 PM on May 22, 2022

It's what happens when you mix illegal psychostimulants (usually methamphetamines) with alcohol, other illegal drugs, and/or some degree of native mental illness, typically in a younger, and rather physically strong, person.

What I understand from this is that people with certain preexisting mental health conditions are more likely to exhibit agitation and violence when under the influence of stimulants. What I don't understand is where being younger and physically strong factor in. Do these actually increase the risk of a mental state of violent agitation, or do they simply worsen its consequences and influence response? To me, that is relevant in determining whether it makes sense to see excited delirium as a distinct pathological entity or as a medico-legal response to certain pathological behaviours.

I would also echo the questions about supposed superhuman strength* and increased risk of death. These are distinctive characteristics of the posited entity and, without them, I don't know how you'd distinguish it diagnostically from any other form of violent agitation with stimulants as a contributing factor.

Superhuman strength is an easy illusion to create in the right circumstances. Most people with a magic rock to sell you can demonstrate the tricks of leverage using a bit of applied kinesiology. Most things described as miraculously "lifted" off turn out to have been in a position with an unstable centre of gravity, a fact which is not noticed in the panic, turning an amazing feat of human strength into a legend of superhuman strength. We are also generally incredibly sparing of our strength without much awareness of it. Using all of our strength is very risky for a number of reasons. Not only is there risk of tears and other tissue damage, our full strength is often directly dangerous to us; e.g. we'd literally chew our own faces open if our jaw strength wasn't kept under control at an autonomic level. Deliberately bite your lip "hard" and you won't even bruise it. Now think how easily your teeth slice your flesh when you bite down full force by accident. Our fight or flight response removes many of the inhibitions of our functional strength, but the idea that we have an extra level of functional strength that we could access without doing serious harm, but just don't in nearly all naturally occuring circumstances, seems intrinsically unlikely from either a mechanical or evolutionary perspective. The evolutionary advantage of being able to access that state at will would be enormous for intelligent hierarchical creatures like us and our ancestors: you'd only have to do it once to show you could.

To me the association with the young and strong suggests the possibility that you're still describing an essentially social phenomenon: we forget how strong most young people are, and so when they become so agitated that they show us, we imagine they're doing something beyond normal human capacity. Or, if we're a US cop, we use it as an excuse to murder Black people.
posted by howfar at 12:05 AM on May 23, 2022 [7 favorites]

Hurting another human, severely, is something we tend not to do. Like the autonomic response of not crushing your own teeth, we pull punches. Even in fights. We control the force. Because we also don't want to destroy out own bodies.

Hell even when trying to kill someone there are often marks to show it took ramping up to get to severe harm. It's why we train those who do violence in the name of the state. It's why some footballers are known for aggression - they aren't stronger than the others, they just don't care as much.

Guess what interferes with empathy and care and conscious choices? Alcohol, and other drugs. Add in stimulants and you have people with lowered inhibition, high threshold for pain, and often that psychotic break with reality. Youth and strength makes them excessively dangerous in a way elderly or weak patients are not - also much more likely to engage in combining a bunch of drugs. Also less likely to injure themselves to the point of stopping - not because it hurts but because that hand just doesn't work now. Less likely to be talked down because they are not rational or reasonable at all. Think of a toddler tantrum at peak, but with adult strength and knowledge.

Cops will use all that to excuse and mandate violence in response. It's not superhuman strength or whatever, it's someone whose body chemistry has been modified enough to override the unconcious and autonomic limiters.
posted by geek anachronism at 12:30 AM on May 23, 2022 [3 favorites]

I'm certainly strongly inclined to take that view, based on everything I know. All distinctive features of the putative syndrome appear much more likely to be social constructs of interaction with medical and, in particular, policing systems. In some ways it feels like very standard ableism: using a medical model rather that a social one enables responses that require one to dehumanise the individual in question. A distinctive feature here is that in these situations the ableism will frequently be essentially secondary to another form of oppression, most notably racism.

"Hysteria", an entirely fictitious condition dreamed up by men of the Victorian and Edwardian era to explain that women who didn't respond well to lacking fundamental freedoms* were disordered and potentially corrupted, was included (albeit deracinated, despite the obvious significance of the name) as a diagnostic category in the DSM from 1968 to 1980. It wouldn't be reasonable to just rely on the word of one professional in a relevant field: entire disciplines can be wrong, so one person is anecdata at best.

* we're much more advanced than that now, of course. Now we just diagnose traumatised or otherwise socially troublesome women with emotionally unstable (typically still called "borderline" in the US, although that name makes no sense and so reveals EUPD's spurious psychopathological underpinning) personality disorder and then never ever listen to them again. Sorry, it makes me see red just thinking about the huge number people I've seen getting screwed over because of an EUPD label. Personal hobby horse.
posted by howfar at 3:20 AM on May 23, 2022 [7 favorites]

I won’t argue that it there aren’t situations in which people experiencing acute mental health crises become violent, irrational and difficult to control. That situation can arise from many different etiologies, some related to substance abuse, some to acute stressors, some to prior mental illness and so forth, and those all have specific medical descriptions even if it may be impossible to diagnose any one of them at the time the sufferer is acting out his particular crisis.

I will argue that we should not conflate that reality with a term invented by a weapons manufacturer to deflect liability for deaths caused by its (as marketed) “nonlethal” products (where the marketing led directly to indiscriminate overuse of those products), and further expanded by the police-industrial complex in an attempt to excuse all homicides at the hands of police. By accepting that term as a medical catch-all for an irrational violent outburst of presently unknown cause, we enable that intolerable defense by legitimizing it. Thus we allow bad actors to trade on the equivocation between what a doctor might mean using that term in an ER and what a police officer would mean using the term on the witness stand.
posted by gelfin at 8:11 AM on May 23, 2022 [3 favorites]

@They sucked his brains out! :

I provided a couple links in the first comment and a medical professional confirmed the same in a later comment. It's a real thing, even if police abuse the terminology.

There is always professional medical testimony about the horrible threat in the moral panic. There was professional medical testimony that marijuana use directly caused people to murder their entire families with axes. It is impossible to overstate how willingly the medical profession lends its support to these panics.

You provided two links that epitomize the "expert-testimony" support for moral panics about spurious threats. One is six years old, the other 11, and they both document "flashes in the pan:" lurid stories about the new drug threat that somehow never materialize.

Because whenever a new drug appears on the market, some of the people who take it will have poor impulse control associated with anti-social impulses, and they will take intoxication with a novel substance as permission to act out on those impulses. Hell, sometimes the new drugs seem to specifically attract users like this, who might be trying to self-medicate their issues.

But it always turns out that the spectacular behavior of those users was not due to some typical pharmacological property of the drug, it's always more about the peculiarities of a few users, whose stories get told while the stories of other users don't. Which results in mistaken attribution of the behavior of those users to their use of the drug.

In order to be credible, in other words, you have to provide not just expert medical opinion, but evidence that this time, it's different.
posted by Aardvark Cheeselog at 8:15 AM on May 23, 2022 [8 favorites]

Peer-reviewed articles and the personal testimony of doctors should be enough. I'm not sure why this is so difficult. I'll leave it at that, thanks.
posted by They sucked his brains out! at 9:19 AM on May 23, 2022 [2 favorites]

There is always professional medical testimony about the horrible threat in the moral panic. There was professional medical testimony that marijuana use directly caused people to murder their entire families with axes. It is impossible to overstate how willingly the medical profession lends its support to these panics.

The issue there, as I see it, is that the “medical experts” (who are no doubt experts in medicine) are primed by the same moral panic they then willingly frame in medical terms, but they are little more informed about the social and law-enforcement policy aspects of the phenomenon than any layman. A doctor’s opinion on those ancillary issues is orthogonal to his views on medicine, in that the field contains room for both harm-reduction-oriented physicians and law-and-order-oriented physicians, either of which has equivalent expertise in the medical aspects of substance abuse, but would offer extremely conflicting testimony in the sorts of situations expert witnesses are called for. This, to me, calls into question the relevancy of the testimony or whether a medical expert should be considered “expert” when offering testimony that states or implies an opinion on the necessity and legitimacy of a given police response.

To go off on a brief tangent, I’ve always been an ironic fan of police procedurals, and Dragnet in particular, for the way it now serves as a great exemplar after-the-fact for how modern procedurals manipulate the audience into moral panics, simply because the panics of the 1950s are so obviously overblown to a modern audience. I’m glad to live in an age when I can just directly link my favorite episode, The Big Seventeen, which starts off with a whole movie theater full of kids starting a full-blown riot with battery, maimings, assault with a deadly weapon and property damage that looks like a near total loss for the theater, all because they had access to a small amount of marijuana later described in the episode as “weak” and “diluted” because it was being sold to school kids. The money quote, after the school-level dealer fatally assaults his connection and steals his stash, is that he has “enough H to start a war.” Vietnam notwithstanding, it is unclear how one starts a war with heroin, but the phrasing is entirely calculated for its evocation of violence.

Physicians are as susceptible as anyone else to this sort of manipulation, priming them to take the word of police officers and their representatives who insist that kids on a small amount of weed have ever done worse at a movie theater than giggle too loudly and spend too much money at the concession stand. It isn’t that medical evidence supports the moral panic. It’s that the expert testimony comes from someone who has a prior acceptance of the moral panic and willingly lends his expertise to the cause as he understands it.
posted by gelfin at 9:24 AM on May 23, 2022 [11 favorites]

Someone is coming at you and about to punch you in the face, and you’re worried about moral panic?
posted by Melismata at 9:27 AM on May 23, 2022

Also, any number of health care professionals and first responders--including my own sister, a nurse of some decades' experience--will testify to the so-called lunar effect, the bulk of the professional research (and not just a couple of cherry-picked studies) showing that it doesn't exist notwithstanding.
posted by Halloween Jack at 9:28 AM on May 23, 2022 [7 favorites]

I would ask us to remember how "excited delirium" is being used. The beginning of the article/podcast with line breaks/emphasis added:

One night in 2019, Elijah McClain, a 23-year-old Black man in Colorado, was walking home when he was approached by police. Someone had deemed him “suspicious” and called the cops. The police argued with McClain, tackled him to the ground, and restrained him with a carotid hold around his neck.

Body camera footage shows an officer saying McClain, who was about 5’6” and 140 pounds, had “crazy strength.” Paramedics arrived and concluded McClain was showing signs of “excited delirium,” according to The Colorado Sun. A paramedic injected him with ketamine to sedate him, and McClain slipped into a coma. A few days after the encounter, he died.

The words “excited delirium” appeared in the medical examiner’s opinion within the autopsy report.

posted by spamandkimchi at 9:33 AM on May 23, 2022 [12 favorites]

Someone is coming at you and about to punch you in the face, and you’re worried about moral panic?

Someone is not coming at me and about to punch me in the face, and yes, I am worried about a cultural phenomenon that encourages people to automatically imagine extremely violent hypotheticals to justify extreme law enforcement response, and moreover inclines juries away from skepticism about police testimony that plays into those fantasies in an age where ubiquitous video increasingly shows such testimony to frequently be an outright lie to protect an officer who applied inexcusable brutality to a compliant suspect.
posted by gelfin at 9:40 AM on May 23, 2022 [11 favorites]

I was wondering about that aspect, spamandkimchi - the use of the diagnosis by police officers to employ assistance from medical professionals to subdue someone in police custody.
posted by Selena777 at 10:01 AM on May 23, 2022 [2 favorites]

I'll jump in to this late. Of course you can have agitation on top of delirium. No, it doesn't provide superhuman strength. Police departments are probably responsible for half of urban legends.

Many people who use drugs unwisely, mix them. Furthermore, sometimes what you get from the street is a crap roll. Finally, many people with mental illness use drugs to self-medicate, so you do have some people prone to psychotic episodes taking stimulants.

Emergency workers sometimes have to deal with those agitated and psychotic.

Here is a photo, and versions of this are wildly circulated, purporting to show why fentanyl is so deadly.

For heroin, the story says the vial has 30 mg. For fentanyl, it says the vial has 3 mg. Bullshit. If you increased the small amount of granules in the fentanyl jar by ten-fold, I doubt you'd cover the bottom. Those who have worked with measuring small milligram amounts can provide their own opinions.

Although NPR, I believe the photo originated from the Vermont State Police.

This doesn't mean that fentanyl is not more readily lethal than heroin. It is. It is just that it is exaggerated in the photo.
posted by dances_with_sneetches at 10:26 AM on May 23, 2022 [3 favorites]

Also, the story says "deadlier than heroin." A pet peeve, deadlier doesn't exist. Dead is the maxed out effect. It is more likely to be deadly, is okay.
posted by dances_with_sneetches at 10:28 AM on May 23, 2022 [2 favorites]

Yeah, either fentanyl is at least 10 times more dense than heroin (it's actually less dense, 1.1 gm/cm^3 vs 1.5 gm/cm^3), or that vial contains more like 0.3 mg at most.
posted by biogeo at 11:33 AM on May 23, 2022 [1 favorite]

I work in a busy urban safety net hospital and with a group of patients who are extremely challenging to serve within the existing emergency medical response system. A couple of my patients are large men with psychiatric disorders, brain injuries, and severe meth use disorders. This combo is extremely miserable for the person experiencing it, and basically impossible to meaningfully support in an emergency medical setting. For ER doctors and EMS workers, there may be no safe option besides medical or physical restraint, interventions which are dangerous in themselves, but also may be the least dangerous option in a medically supervised, emergency setting. It's hard to know but is a judgement better made by emergency medical personal than by police who have no fucking business injecting ketamine into people. Atoxyl's link to how ER providers may think about this is a useful perspective on how emergency medicine providers frame this issue. And I appreciate killdevil and basalganglia sharing their personal experience with dangerous patients in crisis. I also think most people would agree that the combination of stimulants (including novel and new stimulants) with a history of psychiatric disorder can lead to decreased impulse control and increased unpredictable and sometimes dangerous behaviors, along with dangerous physiological symptoms.

I agree with howfar though that this diagnosis is socially rather than biologically constructed. There are a combination of biological and social realities that together, are framed under this one heading, and this is influenced by biases and widely-held ideas. The actual set of symptoms and behaviors as described would also be more rare in a society where resources were distributed more fairly, high quality psychiatric care was widely available, no one was homeless, people of all backgrounds could access meaningful work and social support, etc.

I'll just close by saying, my demented mother on multiple psych meds used to pinch and scratch her caregivers and was certainly delirious and at times excited and violent. No one ever applied this label to the 80 year old bed bound white lady though.
posted by latkes at 12:25 PM on May 23, 2022 [15 favorites]

Yeah, either fentanyl is at least 10 times more dense than heroin (it's actually less dense, 1.1 gm/cm^3 vs 1.5 gm/cm^3), or that vial contains more like 0.3 mg at most.

Measuring <10mg amounts of drugs by sight is not recommended practice for a reason but I’d suggest that the effect is created by exaggerating the amount of powder on the “heroin” side as much as by minimizing the amount on the “fentanyl” side. If that’s 30mg I don’t think you could fit a gram in that thing and that seems way off unless I’ve got the scale totally wrong.

(Also for sure neither of those powders is actually the substance in question but you knew that)
posted by atoxyl at 1:33 PM on May 23, 2022 [1 favorite]

Although also the idea that those are equivalently lethal doses seems way off? For what the linear conversion factors are worth for drugs with pretty different kinetics, 1 mg fentanyl is usually quoted as equivalent to about 100 mg morphine (IV). And then heroin is, what, a couple times stronger than morphine by IV? 3mg of fentanyl is definitely a legitimately dangerous dose without tolerance, could have gone lower, even, but the equivalent dose of heroin should be several-fold higher than the claimed 30mg.
posted by atoxyl at 1:52 PM on May 23, 2022

killdevil:

It's what happens when you mix illegal psychostimulants

Why should the legality of the substance involved have any bearing on a medical phenomenon?
posted by The genius who rejected Anno's budget proposal. at 11:09 PM on May 23, 2022 [4 favorites]

Coming into this late, but I can offer some anecdotes?

1. My child started choking on something while I was driving. I pulled over, but forgot to turn the van off (or something) so the sliding door wouldn't open. I pulled the door off its hinges to get into the car. The service techs had never seen anything like it and it cost many thousands to repair. I hurt for weeks afterwards.

2. I had a good friend in the police, who started taking Aikido specifically because they wanted a way to deal with people who were young, strong, and enough under the influence that they were almost entirely unresponsive to pain (my friend had scars from a specific incident where someone broke their own arm to escape a hold and attack).

TL;DR: people can be much stronger than you'd expect. drugs/adrenaline make people much more dangerous than you'd expect.
posted by goddess_eris at 12:23 PM on May 24, 2022

People pushed to extremes may once in a while do things you wouldn't expect, but that doesn't begin to justify the epidemic of excited delirium excuses used by police to justify use of force, especially against black people. Those Behind the Bastards episodes I linked above are eye-opening.
posted by JHarris at 4:52 PM on May 24, 2022 [1 favorite]

Legality matters in terms of the (supposed) medical aspect of stimulants - some are unsafe because they induce psychosis and other side effects that are unwanted, with little to no other benefits for users within a medical context. It also matters for production - see the switch between regular meth (ephedrine based stimulants) and what we like to call 'bikie speed' (P2P based stimulants) - where production can include other chemicals or drugs that interact poorly. The P2P based meth, for example, has a different ration of D to L methamphetamine - meaning some of the effects of L (heart racing) have been removed, making it purer but also able to be taken in higher amounts and being much cheaper than the ephedrine based meth. The neurotoxin aspect of meth has been increased by illegal production methods and distribution.

It also matters for combination and disclosure. If you combine legal drugs (like alcohol) with stimulants that have been illegally produced and consumed, disclosure may not occur. Components of the drug have not been regulated. That all makes a difference to effects and treatment.

There's a difference between acknowledging the real effects of highly unregulated stimulants combined with lowered inhibition and pain response, and designating it a rationale for cops to murder people. But it's also not unreasonable for medical professionals to point out the difficulties in treating these patients because yes, that's what they need. They need treatment. But how do you treat a patient who is violent, who will severely harm themselves in the throes of paranoia driving them to do serious harm to others? Knowing that their body chemistry may well mean any drug you use could also kill them because they are not forthcoming about what they've taken.

Cops have always misused medical diagnostics to legitimise their violence. Same with corporations. Even the medical institutions. But there is a concrete set of issues associated with stimulant use that does result in levels of violence beyond what that person, without stimulants, would do.

See again: patients who will break their own bones, seriously wound themselves, in ways that humans usually don't because our autonomic systems and other bodily processes prevent us from it. Including taking enough meth to poison our brain because the stuff that makes your heart race alongside has been removed more thoroughly (see the brakes put on any number of medicines so that you're incapacitated before you reach lethal levels - why acetaminophen is so dangerous since liver damage is slow).
posted by geek anachronism at 6:24 PM on May 24, 2022 [2 favorites]

Yeah, take a look at a picture of Elijah McClain and try to imagine how this kid exerted "crazy strength" that required carotid holds (and involuntary injection of ketamine) from multiple cops. The myth of superhuman strength licensed his death and shielded the cops who murdered a gentle young man doing nothing wrong.
posted by praemunire at 4:36 PM on May 25, 2022 [2 favorites]

But there is a concrete set of issues associated with stimulant use that does result in levels of violence beyond what that person, without stimulants, would do.

Yes. But many such issues arise in relation to every complicating factor for emergency patients. Medicalising these issues does not help anyone see them clearly or manage them effectively.
posted by howfar at 11:17 AM on May 26, 2022 [1 favorite]

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