death from overdoseI haven’t felt like writing for the past few days.  The wind was taken out of my sails a few days ago, when a patient’s mother called to tell me that her son died from a drug overdose.  She told me to use the information in any way that I could, in order to keep someone else from dying.

I have had several patients—all young men—who eventually died from their addictions.  Each time that I have heard the news, I wanted to stay away from work, the phone, the computer—everything seems so heavy, so useless, and so sad.

The grief of their parents is so great, and I have nothing to say to make them feel better.  In each case I think through everything that occurred, trying to find something that I could have done differently.  I know that in most of the cases, the parents have done the same, over and over again.

In case any of the parents are reading this column, I want to say very clearly that you did all that you could.  There have been times in my practice when I felt that parents were too harsh or too easy on their children. But in all of the cases I am thinking about now, the parents were about as perfect as they could have been—and yet in spite of their efforts, their children died.  That the parents cared so much, and handled everything so well, makes the outcomes particularly frightening.

Of the several young men from my practice who died, two had been through residential treatment of greater than 30 days.  One had been through treatment several times.  All had been through varying amounts of counseling. Two had been on buprenorphine in the past, and none were taking it near the time they died.

Mark (not his real name) did well on buprenorphine for six months, but then returned to the pain doctor who was prescribing narcotics for his back pain, saying he had no choice because the pain was ‘unbearable.’

I could not convince him to stay on buprenorphine, and I eventually discharged him to make room for a patient on the buprenorphine waiting list.  The next time I heard from him was in a weekend phone call about six months later, sounding strung out, asking if he could get back on buprenorphine.  I told him that would be fine and to call on Monday, but he didn’t follow up.  I saw his obituary about 3 months after that, dead from a self-inflicted gunshot wound, leaving behind his fiancé and an infant daughter.

Jon was presented to my office after getting into legal trouble over alcohol.  He entered court-ordered outpatient treatment at a local program, but was kicked out for testing positive for opioids.  By his description, opioids were a minor influence in his life—something that I never believed to be true.

We considered starting buprenorphine, but his tolerance was very low, as he was taking only a couple Vicodin per day (buprenorphine has the potency of about ten Percocet tablets per day).  Instead of taking buprenorphine he planned to enter residential treatment, but then the ‘perfect job’ fell into his lap.  Surely now, he thought, he would have something to stay clean and sober for!

He moved out of state, away from the friends that had been bad influences.  But a few months later a buddy from back home paid him a visit, planning to spend the night but instead leaving to drive back home in the early morning hours.

Jon’s roommate found Jon’s body in bed, after checking on why he had not yet left for work at that perfect job.  The cause of death turned out to be an overdose of methadone, an opioid used for pain treatment and also in addiction treatment centers, but also diverted for street use.  No arrests were made.  In fact, there was not even an investigation.  After all, that type of thing happens all the time.

Brad had been through a number of treatment programs.  He was ‘a great kid’—vibrant, talkative, a nice guy.  He knew he had a problem with drugs, and would talk to me openly about his desire to stop, recognizing that the consequences of his use were becoming more and more serious.

He was ‘stable’ on buprenorphine, meaning that he took it properly, and it seemed to keep him from using opioids fairly well.  But he couldn’t avoid using everything.  And when he tested positive for THC, his PO put him in jail, forcing him off buprenorphine.

I’m sure that yanking his probation seemed like a good idea at the time, but doing so always creates a dilemma when the person is eventually released.  After a month or two in jail, Brad no longer had a tolerance for opioids.

If he was to start buprenorphine at this point, it would cause a very significant intoxication, accompanied by severe respiratory depression—particularly if combined with other substances, notably drugs like Valium or Xanax.  Most deaths related to buprenorphine occur when the drug is taken by people who are not opioid-tolerant.

At this point, Brad had only one option—to try to stay clean the old fashioned way.  I had not seen Brad since he entered jail, and if I had, there was nothing I would have done that would have changed things.  Nobody would put a person on buprenorphine at that point—after a short period of sobriety, when everyone is hoping for an extended period of sobriety.

Revia or Vivitrol are forms of the opioid blocker naltrexone, with relatively new indications for treating opioid dependence.   They may have proven helpful, but knowing Brad, I doubt he would have taken them. Naltrexone blocks all opioids, even the natural ones in our brains called ‘endorphins.’   Opioid addicts tend to shy away from naltrexone, even after hearing that people taking the medication feel essentially the same as those receiving a placebo.  But to a clean opioid addict, endorphins are all he’s got—and the idea of blocking them rarely sits well.

I don’t have anything profound to say, other than to say that I am tired, and very, very sorry.  I don’t know what else anyone could have done, but in all cases, these were young people who were moving toward death as deliberately as any cancer patient.

I could tell similar stories about a few more kids I’ve known, and it just seems that there should be more big buildings named after generous donors, with the mission of helping people like Mark, Jon, and Brad—and the thousands of other kids just like them who will die, this year alone, from the same disease.

Photo by Berkeley T. Compton, available under a Creative Commons attribution license.

To Kyle.