I’ve been seeing stories all over the place about the heroin epidemic. It is terribly sad. I watched an episode of 60 minutes recently where they were talking about the epidemic and whether heroin addicts should be treated as criminals or medical patients.
That is a debate I’m going to save for another day, but there was a really, really important nugget of information regarding pharmacology/pharmacokinetics within that story that really jumped out at me. They had a former nurse who had been around patients for years and she had stated that the most common time for them to die of overdose was after they had been abstinent for a period of time.
Let’s explore this a little bit and I will tell you why this makes sense. Remember the term tolerance? Tolerance is incredibly common with opioids. Tolerance essentially means that over time, you will need higher and higher doses to get the same effect from the medication. Tolerance is the reason you can have patients on ridiculously high morphine equivalents and they can walk around like normal without toxicity.
What happens when people abstain (or stop taking opioids), is that the tolerance that was previously developed from consistent use of opioids slowly disappears over time. So what this nurse saw was that patients who abstained during treatment programs (2 weeks, 4 weeks etc.) and then relapsed, would take the same dose they had historically taken. This “usual” or tolerable dose before may now be lethal as their tolerance is no longer what it once was.
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