[hapless]

The therapeutic index of opiates narrows continuously as addiction proceeds. Users have to skate closer and closer to dangerous levels to reach the same level of intoxication.

While dosage, purity, etc may possibly make the drug more predictable, fundamentally it doesn't matter which drug your cousin was taking. The longer he remained addicted to opiates, as a class, the greater his risk of death by overdose.

You have to be an anesthesiologist to administer fentanyl not because handling it safely is so difficult, but because managing high opiate tolerance is extremely dangerous.

[cma]

My brother died from fentanyl in 2014. It is so strong that it is harder to dose correctly and to manufacture into even batches. Things sold as something else are getting laced with it. Even when people do know what they are getting, small uneveness in the mixing of a large batch can cause multiple deaths.

It isn't just due to the normal generic tolerance increases over time, and it isn't just about all opiods being complete substitutes for one another; they aren't. Half-lifes matter, some research shows some affect repiratory pathways faster than others relative to their other effects, etc.

My brother would have likely died from heroin even if fentanyl didn't exist, but there is something more to the wave of fentanyl overdoses than you are making it sound.

I don't necessarily agree with the parent post about legalization, legal sources boomed in the 90s through doctors and brought about a lot of the current epidemic. Would complete legalization be a net positive? I don't know. It would have upsides and downsides.

[refurb]

The therapeutic index of opiates narrows continuously as addiction proceeds.

Whoa there. That's not correct. As you develop tolerance to the "high" you also develop tolerance to the side-effects, namely respiratory depression (what usually kills you during an overdose).[1]

"Tolerance to the analgesic effect of opioids can begin after a few weeks of around-the-clock dosing, as does tolerance to the respiratory depression effect of opioids (and other side effects except constipation)."

The paper I reference has a great example of just how much morphine you can give to someone in pain:

"The final dose escalation was to 1,100 mg/hour of morphine IV plus 100 mg IV every 10 minutes as needed. MK lived 3 days on this morphine dose. He was somnolent his last day, but he could be aroused to take fluids with gentle verbal stimulation."[1]

Just to provide some context, if you were to break your leg and go to the hospital, they'd probably give you 10 mg of morphine IV every 4-6 hours. This guy was on 1,100 mg every hour around the clock.

[1]http://www.promotingexcellence.org/downloads/jacs_0203.pdf

[hapless]

The therapeutic index is the ratio between the necessary dose to achieve desired effects, and the dose that incurs dangerous side effects. Both doses rise with tolerance, but the ratio between them narrows.

That opiate-tolerant fellow on 1,100mg/hr of morphine required around-the-clock monitoring by experts.

[55555]

You are missing an important point. Fentanyl is loved by traffickers because you can order it from China and its extreme potency means it's easy to sneak across borders. Moving an amount the size of a brick across borders and then selling it as oxy or cutting it into heroin could make tens of millions of dollars on the street. This extreme potency, however, means that it must be mixed/pressed perfectly or you end up with "hot spots" - a chunk of fentanyl in a pressed "OxyContin" pill that's fatal.

[mylons]

you're not characterizing overdose correctly. it's often people coming from pharmaceuticals and not knowing what they're doing, or not knowing the potency or contents of their drugs.

[ryantbrown]

The majority of overdose deaths occur after a period of abstinence (getting clean, running out, etc.) followed by using the same amount (or more in the case of withdrawal) of the drug before the cessation. It can take as little as 48 hours for your tolerance to drop by a meaningful margin.

My ex-girlfriend died in September of this year from a heroin overdose. She was in the process of getting clean and then relapsed.

http://www.businessinsider.com.au/philip-seymour-hoffman-ove...

https://www.thefix.com/content/high-risk-relapse-how-going-b...

[mahranch]

Another reason for a large amount of overdoses is drug mixing - people taking oxy and then xanax and then they're dead. But I think your comment and the guy above you both refute hapless's claim that most people who die from an OD are simply misjudging their own doses. In truth, I believe very few people misjudge their own doses. Drug addicts are notoriously good at knowing the exact amount to get them high. Why? Because too much is a waste (they try to extend their supply as long as possible) and too little won't have the desired effect.

In addition to your reason for ODing (use after a period of abstinence), the recent rash of ODs in my state are because dealers & suppliers are cutting their dope with fetanyl and other stuff that the drug user isn't/can't account for.

[pdkl95]

> taking oxy and then xanax

One of the more common "mixes" that also happens to be particularly dangerous is drinking EtOH while taking an opiate (or other depressants). Unfortunately, as beer or liquor holds a different cultural status, it isn't always listed with other drugs.

If there is any opiate involved, it will invariably be written up as a "oxy/heroin overdose" even if the main problem was the 10oz of liquor consumed the same evening.

[mylons]

this too -- i wasn't sure i wanted to mention it because i didn't have any links to back it up