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The Opioid Crisis

How sudden tolerance reduces opioid-fueled overdose

Overdose deaths are not uncommon in rehabs, especially when extreme detoxes lead to tolerance crashes and extreme cravings

Billionaire Matthew Mellon died yesterday at a rehabilitation center in Mexico where he was being treated for his long-term addiction to opioids.

It’s unclear what caused the 54-year-old’s death, but overdoses are common — though seemingly unlikely — in rehab facilities.

Intuitively, rehab would seem like the last place someone struggling with addiction could have the kind of unrestricted access to drugs that would lead to an overdose.

But tragically, reduced tolerance, inappropriate treatment, and an insufficient group of people who feel desperate can create the perfect storm and stage for a fatal overdose.

Overdose deaths are not uncommon in rehabs, especially when extreme detoxes lead to tolerance crashes and extreme cravings

Overdose deaths are not uncommon in rehabs, especially when extreme detoxes lead to tolerance crashes and extreme cravings

Mellon’s last stint in rehab was one of his several attempts to get clean.

In fact, he met his ex-wife, Jimmy Choo mogul Tamara Mellon, at a Narcotics Anonymous meeting in London in 1998, when opioids were gaining popularity as a recreational drug in the US.

About 88 percent of people addicted to heroin or alcohol relapse, and according to his ex-wife’s account in her autobiography, In My Shoes, Mellon was certainly one of them.

Opioids—prescription or otherwise—relieve pain by triggering a cascade of dopamine and endorphins.

Both the neurotransmitter, dopamine, and the hormone, dopamine, trigger feelings of reward and pleasure much more intense than our bodies can naturally create.

So the only way to feel that rush again is to do the exact same thing again, to maximize the brain’s dopamine receptors with drugs.

Every time a warm fuzzy flood of dopamine enters the brain, it lights up the reward system—which is supposed to make us feel good about doing something good for our survival.

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But the brain is not performing optimally when it is in a constant state of pleasure and reward. After each ingestion, the brain must re-balance itself, but in the habitual opiate user, the brain learns a new “normal” state of over-arousal.

Even in the best and most famous hospitals, people die in their facilities

Dr Andrew Kolodny, Executive Director, Physicians Responsible for Opioid Prescribing

To prevent this, the brain begins to shut down its dopamine receptors. So the opioid user is constantly pumping dopamine into the brain trying to get that high again, but there are fewer receptors to even experience the chemical high and the reward system doesn’t work as well.

In an attempt to compensate, opiate users try to increase their doses or use their drug of choice more often.

The flip side of the “new normal” is withdrawal where they feel depressed, so addicts go from flaring up to just using the drug to feel their “new normal”.

Tolerance can build up very quickly, depending on how often someone uses an opioid drug, and wear off just as quickly.

“Tolerance begins to decline almost immediately,” says Dr. Andrew Kolodny, executive director of Physicians Responsible for Prescribing Opioids.

“In a few days after you left, the amount [of an opioid] that you could easily carry at the height of your addiction is too high,” says Dr. Kolodny.

That’s where the problem can start for someone in rehab, especially if they’re detoxing at their facility and doing it through abstinence, he says.

In programs where their clients get off opiates by simply quitting—rather than using suboxone or methadone treatment to help them quit—horrible withdrawals are guaranteed.

Without a steady stream of drug-imported dopamine to keep the brain in the “new normal,” people struggle with severe flu-like symptoms, depression, and anxiety.

“Strong cravings can last months after detox, which is a flaw in abstinence-based programs,” he explains.

When someone stops taking drugs immediately, their tolerance drops sharply and their cravings are dazzlingly intense.

In the throes of withdrawal, those cravings give way to desperation, and “even in the best rehabs, people will find a way to bring drugs,” says Dr Kolodny.

Despite the best efforts of the rehab staff, drugs get in, through visits from friends and family, or perhaps through the crafty use of online orders from the murky dark web.

There is no clear way of knowing how, but Dr Kolodny believes that the vast majority of overdoses are fueled by drugs that have been ingested, rather than high doses of methadone or suboxone.

Regardless of where the drugs come from, Dr Kolodny says that especially in abstinence-based programs, “even in the best and most famous rehabs, people die in their facilities.”

“I think the public would be shocked at how often this happens because they’re sending their loved ones to rehab because they’re afraid they’re going to die of an overdose,” not realizing they’re still at risk right where they go for help , he says.

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“There are lawsuits all the time,” but you won’t find statistics on those deaths because “that’s a secret that rehabs don’t want anyone to know,” says Dr. Kolodny.

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