Perhaps it’s not ONLY fentanyl: What very few people in addiction are told…

… and if they were, lives might be saved.

(I do not usually write of addiction issues in this blog, but the current death rate due to heroin use is too horrifying to ignore. Accordingly, I am using this opportunity to point out something that, I hope, might keep some folk alive who might otherwise die. I hope that you will spread the word, especially if you know folk in early recovery.)

Most people know, from media headlines or from the loss of dear ones, that the death rate from heroin overdose is horrifyingly high. They know that sometimes the addition of fentanyl is to blame.  However, what I am writing about is something else that leads to relapse and sometimes death that is less well known, and that very few people in addiction have thought about. Greater awareness could save lives.

Over time, when people regularly use a drug, their tolerance increases. As their bodies’ become accustomed to the drug their systems adapt to the drug’s presence. The effect of the drug weakens because the body has learned how to adapt to it. In the usual process of addiction, people start to use more and more of the drug in their effort to re-experience the earliest effects of the drug – effects that may have been strong because, initially, there was zero tolerance for the drug. With continuing use, their bodies continue to adapt to larger and larger drug doses. We call this “increased tolerance.” After some time – often a surprisingly short time – tolerance is so high that the individual is using at a level that could have been fatal at the beginning.

Conversely, though, when people stop using drug, the tolerance starts to drop. Because abstinence from the drug once again becomes the new normal, the body “forgets” the adaptation it had previously learned. The adaption is reversed and tolerance decreases.

What happens when someone decides, once and for all (we hope) to stop using a drug? They do whatever they need to do to stop using – detox, rehab, 12-step, “cold turkey”- and, as thousands of mourning families have sobbed, they are “doing so well!” Sadly, although the drug may have left the body, the disease has not left the mind.

Whatever the reason for going into recovery, relapse can happen, and here is where the issue of tolerance becomes a very ugly topic. During the time of abstinence, the tolerance has headed back toward what, prior to use, was normal. Unfortunately, the individual still remembers how much of the drug was last needed to achieve the desired effect, and is likely to take that as a guide. Very few users will add their recently reduced tolerance into the calculation. If relapse occurs, the quantity used is likely to be greater than the newly reduced tolerance can handle. The result is an overdose, which may or may not be fatal.

I have talked with many addicts in recovery about this, and asked if they had ever been told of the dangers of reduced tolerance when relapsing. Not one has ever said that they were educated on this topic.

As a former addictions counselor I know that relapse issues are covered in addiction treatment – usually very thoroughly. My concern is that many addiction counselors are reluctant to talk about this particular aspect because it involves “safe relapse.” They don’t want to sound as though relapse is okay. It is very like the parental dilemma of discussing safe sex with their offspring.

“Am I giving them permission to go ahead and do it?”

“I don’t want them to think it is okay just because I’ve talked about staying safe.”

I’ve faced those decisions both as a parent and as an addictions counselor. How does one give guidance that makes a potentially harmful act safer without making it sound as though it is okay? In the case of addiction, because withholding information has the potential for death, in my opinion there is no choice.

The issue of tolerance, and how both active addiction AND newly achieved abstinence can affect it, need to be an essential part of every form of drug education both in addiction treatment facilities AND on the street. Information about reduced tolerance can save lives.

Please, if you know anyone who may be in danger of relapse (which means anyone in recovery), make sure that they know that their recovery, which is a wonderful thing, has reduced their tolerance. If they believe they HAVE to relapse, they must do it at the level of a beginner if they are to stay alive.