Really Scary: How to Die from Methadone

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Here’s something really scary for Halloween.

Though methadone is a life-saving medication when used in the right way in the right patient at the right time, it can also be deadly. When methadone is used to treat opioid addiction, the first few weeks are the most dangerous. More than half of methadone drug overdose deaths occur during the first two weeks of treatment. The opioid treatment program physician is responsible for starting the methadone at the proper dose and increasing it in a proper way, but there are things the patient can do that increase the risk of overdose deaths. Here are a few of them:

1. Exaggerate your use of opioids to the doctor. Tell her you are accustomed to taking twice the amount that you actually use. You do this out of fear that you won’t get enough medication on the first day to keep you out of withdrawal, but the result may be that you get so much methadone that you don’t wake up.
2. Don’t tell your doctor about your benzodiazepine use. Even though you’ve been using two or three “ladder bars” per day, tell her you only used once last week, just to stave off opioid withdrawal. Assure her all of you drug screens will be negative for benzos, though you’re inwardly worried you won’t be able to stop taking Xanax. You tell this lie because you’re worried she would send you to a medical detox facility for benzos before accepting you into methadone treatment, and you don’t want to do that. Sadly, if you overdose and die from mixing methadone and benzo, you won’t have a chance to go to detox – or to see your children grow up.
3. Because the stupid doctor only started you on 20mg of methadone the first day, talk to drug buddies to see where you can buy extra methadone to supplement that dose. You are sure you’ll be in withdrawal, and can’t stand the thought of any discomfort. You don’t believe the doctor, who said your methadone blood level will increase each day even if you don’t go up on your dose, due to the very long action of methadone.
4. Since you know more than the doctor, drink alcohol with your methadone. You don’t believe that alcohol can kill you while you are on methadone, since alcohol is legal. After all, you don’t drink beer at the same time as your methadone dose, so you think it’s safe. Again, you don’t believe your doctor when she said alcohol later in the day is also dangerous, due to the very long action of methadone. What does she know? You are the expert on drugs.
5. You read on the internet that other people mix benzodiazepines and alcohol with methadone, and have not died. It must be true. Besides, you know your limits.

When I talk to patients about the dangers of overdose while on methadone, I hate to hear them say something like, “Don’t worry. I know my limits.” It gives me a shudder, because I remember the names of three patients who have said this to me…now all dead from drug overdoses.

Thanks to Dr. Payte for the inspiration.

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17 responses to this post.

  1. Posted by Benjamin K. Phelps on November 2, 2013 at 6:12 am

    You know, Dr Burson… I hate to admit it, but I have been guilty years ago of doing each 1 of these (except the drinking one… I’ve never liked alcohol). I’ve exaggerated my use b/c of fear of w/drawals if I wasn’t given a full 40 the 1st day (b/c you know, I knew better than the doc…) And I’ve used extra opioids the 1st few days for the same reason – fear of w/d’s. I’ve also used benzos a couple of times back in 2002 when I was in the induction phase b/c of anxiety – which would ORDINARILY be a logical reason to take 1… But it was probably THE dumbest thing I could do at that time. How I did not die, I don’t know. I literally blacked out for 3 whole days from using Xanax during induction during 2002, & I got kicked out of the halfway house (of course) that I stayed in at the time (when I came down from my other planet, totally unaware of what I’d done the last 3 days!) It was THE MOST embarrassing situation I’ve ever been involved in in my entire life, no lie. Everyone there saw me behaving all kinds of strange ways that I can’t remember (I have tiny snap-shots of memory over the 3 days here & there, but not enough to put together into anything of use). I had to go to a homeless shelter b/c I lived 2 hours almost from my parents, & the clinic was where I was, as well as my intensive probation (so I couldn’t leave the county). I lost everything I had – literally – that was in G-ville w/me at that time. I ended up back in jail w/in 3 more days, being put through abrupt w/d’s from methadone all over again. That was the LAST time I went into MMT still using!! In 2003, when I entered, I was clean & coming from an institution, so I didn’t require a + drug screen. I worked hard w/my doc & counselor to find my stable dose, & we did in 4 months or so. I have not been PERFECT all these years since then – I have had my slips here & there, but not w/opioids, & not often or many times. But I’ve been VERY successful at ending my illicit opioid use, & at getting my life back in order. What few slips I’ve had, they were 1-time use occasions that I was able to pull myself right back up from. And while I’d like to never even have 1 of those again, I can only do my best to aim for that & keep moving forward, no matter.

    Those of you reading this article that can relate b/c you’re still there, LISTEN TO DR BURSON’S WORDS – she is NOT being kill-joy! She’s telling you some real stuff – stuff that may save your life! If you enter MMT or are already in MMT (especially in the induction phase – or phase where you’re not yet on a single, stable dose but are still moving upward), & you’re still sneaking around & popping a Xanax or Valium here & there, or taking extra methadone, etc….. PLEASE, for YOUR sake & the sake of those who love you, too (even though you can’t really do it for them… it’s GOTTA be for you), either STOP the illicit use if you can, OR GET HELP. And MOST IMPORTANTLY: BE HONEST w/the clinic doc & your counselor. Take-homes are nice, but aren’t important enough to risk your life to get to quicker! If you’re using, tell somebody at your clinic & get them to go over ways with you that might help you curb that. For me, I wanted take-homes bad enough that I knew if I were tested more often, I’d stop using cocaine. I’d never used it much before MMT, but since opioids were no longer a feasible option, I switched to using it for a couple of months on occasion. So I told my counselor to start testing me EVERY WEEK until I could stop using. Since the tests cost, she took the sample every week, but never told me which one would be sent to the lab that month. That way, I didn’t have to pay 4 times a month for a test. That enabled me to get my will-power into high gear (since coke was never really my problem drug, & if I could get 2 weeks or so away from it, I usually had no cravings for it after that), & I stopped using while I was tested every week. Then, like I said, after about 2 weeks away from it, the cravings went away, & I was able to stop the frequent testing another month later. I never really bothered w/that again! And I was able to earn those take-homes I looked forward to, & I worked my way to monthly dosing at the clinic, which was GREAT! Believe me, going in daily to dose SUCKS in a HUGE way! If you’re used to it now, just imagine not having to get up every day & trek to the clinic… It’s SO nice to get to that point. And that’s not even the GOOD reason to stop using, of course! Stop using b/c you’ll fare SO MUCH BETTER in your life if you do. But as I said – if you ARE using w/your methadone, PLEASE get help 1 way or another before you kill yourself. There’s no 2nd chance once that happens, as we all know too well. Take-homes can be earned back if you have to lose them for a time – your life, family, & all you have here on earth cannot be if you kill yourself before getting help

    Thanks, Dr Burson for sharing this article.

    Reply

    • What a great idea! You related a good example of the patient working with his counselor – you gave urine samples regularly, so you had extra accountability, yet since you didn’t know which one would be sent to the lab, you weren’t charged extra. I think that’s something I can use with my patients.

      Reply

  2. Posted by kevin on November 3, 2013 at 2:00 pm

    It really does yourself good when you be honest not only to yourself but your dr and counselor. This is just one more example. I use to take 40 to 50 benadryl nightly for sleep faithfully for 3 or 4 years. I should have died. I told my counselor and dr and we had to do something similar. It was so hard coming off the the extremly high dose of benadryl cause of withdrawl from it and also cause I loved the way it made me feel before I went to sleep. I knew what it was doing to me. I was getting sick from doing it. I would pray that I would have a chance to wake up the next day. My teeth would grind. I felt like someone was sitting on my chest and it was hard to breath and for my heart to beat. Also I felt like I had to pee really bad and I would push and oush and push to force it out and sometimes only a little would come out (doc if u could tell me what that was with the urine problem that would really be helpful). But I had to decide if I wanted to live or die. I finally got over it. I still have major problems sleeping. And believe it or not I still have some doctors that try to tell me I don’t have a problem with insomnia. Do you think I would have started taking Tylenol pm and benadryl if I didnt have extreme insomnia.

    Reply

  3. Hi Dr. Burson,

    I read something this week that made me realize how deadly opiates and benzodiazepines are when taken together. Given the shortage of pentobarbital, Ohio is looking to use an easier to procure drug cocktail to carry out lethal injection. The two drugs they are planning to use are: Hydromorphone (a powerful opiate) and Midazolam (a short acting benzodiazepine). I doubt there is any clearer evidence that powerful doses of opiates + benzos = death other than the fact that the justice/penal system will be using this drug cocktail for lethal injection.

    I really enjoy reading your blog. Thank you for all of your hard work and dedication to this field.

    Source: http://www.washingtonpost.com/national/ohio-says-it-plans-never-tried-2-drug-lethal-injection-for-child-killers-upcoming-execution/2013/10/28/0ae8884c-3ff0-11e3-b028-de922d7a3f47_story.html

    Reply

    • Wow. that’s interesting information. Sure would do the trick.

      Reply

      • Posted by Benjamin Keith Phelps on April 29, 2014 at 4:29 pm

        Ohio DID indeed begin using Dilaudid (hydromorphone) for lethal injection. However, from what I read on the situation, they use like 500mg! The thing is, a dose like THAT is gonna kill you by itself. So while it’s good that Tessa uses this as an example that teaches her that opioids & benzos kill when mixed, it’s not exactly an accurate representation of that fact, due to the amounts used. This is the thing: If you mixed 500mg of Benadryl & 500mg of Dilaudid, it’s gonna kill you, as well. That doesn’t equate to saying that antihistamines and opioids are a super-deadly combination (any more so than any other combination). Shoot, for that matter, if you took an overdose that massive of Tylenol with that much opioid, you’d no doubt fall over dead. The deal is this: methadone, after induction phase, is not super-deadly if used with the APPROPRIATELY-PRESCRIBED DOSE of benzodiazepine… BUT, addicts are prone to VERY easily begin to titrate our own dose of a drug – ESPECIALLY a controlled-substance like benzos – if we don’t get the relief/feeling we’re expecting or hoping for right away. We do NOT want to wait 21 days for a blood level to accrue – so we don’t like SSRIs. We do NOT want to wait 2-3 hours for a drug to onset, so we don’t tend to go for slow-onset drugs when it comes to recreational use (though we will sometimes settle if we’re already hooked & desperate. This is why methadone is rarely sought after by addicts, except to hold off being sick for a whole day when the dope man is out or out of town. Yes, it IS sought after by opioid-naive recreational users, I know. But not those of us who have any tolerance & want a rush/buzz.) Anyway, we always go for THE fastest-possible acting drug we can get hold of. Hence, Xanax is our benzo of choice, most often. It hits fast & hard. Sure, many will settle for Klonopin, but it’s not usually the benzo of choice if given an option. So anyway, my main point is this: while benzos CAN be safe IF TAKEN PROPERLY while on methadone, with addicts, it’s most often not worth the risk that the addict will self-medicate by increasing the dose on his or her own & end up ODing from the synergistic effects of the 2 drugs together. There are actually a small number of clinics that prescribe Librium maintenance to benzo addicts on MMT. I don’t know that I disagree with this practice if the addict is intractable. Before you knee-jerk react on that, let it marinate. We DO have benzo receptors, just like we have opioid receptors. If we can botch the opioid system in our bodies, I think it’s naive to just presume that’s not possible with the GABA receptors, which contain the benzo binding sites. There are some who postulate that once a person abuses benzos, it “bends” the receptors into a particular shape, so to speak, where they don’t feel normal w/o a benzo for years. Those who believe this often agree that the antagonist for benzos, flumazinil, can bend it back into the original shape, relieving cravings & making the person feel normal again. If that works as well as some docs say it does, then yes, that would be preferable over Librium maintenance, of course! But if there are a number of addicts who cannot seem to stop their abuse of benzos but are benefiting from MMT totally (say, someone like me – I am TOTALLY opioid abstinent while on MMT – it would be a HUGE WASTE to force me off it b/c of another drug problem!! That would only bring back my opioid problem & cause me to have 2 addictions that are active & likely to either kill me or send me to jail/prison), perhaps maintaining them on Librium, if effective, is an option worth exploring more than simply banning all use of benzos at every clinic. My current clinic DOES allow benzos if a script has been presented. But the numbers of clinics that do that have dwindled b/c of knee-jerk fear. And that fear may be well-justified. I just wonder though if maintenance shouldn’t be explored &/or AT LEAST TALKED ABOUT a bit more than it has been thus far. I know 1 such clinic that was or is doing this was/is CAP Quality Care in Illinois, I believe. Dr. Marc Shinderman was the 1 who started it. And yes, I’m aware he lost his license for prescribing in a state where he wasn’t supposed to (I think that was the charge) at another of their clinics, but that doesn’t mean he wasn’t onto something. He also was a leader in exploring higher dosing for patients that didn’t respond to MMT at the usual doses. He was not afraid to give an increase to a person on 190 or 240mg, if they were still craving &/or withdrawing in the morning when presenting for dosing. What I’ve found in my years in treatment is that people who FIRST come into MMT WILL try to increase over & over to get high. That is true. HOWEVER, they will eventually hit OVER-medication, & they will feel like CRAP & ask to go back down. So what eventually happens is that they learn not to go too high for their own body’s needs, & they won’t. Like me – I needed 155mg to be stable back in 2004, after getting on MMT & getting clean for the 1st time. I stayed on that dose for 6 years. But the thing is, when I went too high (160mg/day), I didn’t feel well & was nauseous, tired, & just all-around BLAH. So I asked to go back down halfway to where I just was (150mg). I was put on 155mg/day, & I flourished – I stopped ALL illicit use, restored my credit, held down & advanced in my full-time job, began college, held down my residence (I’ve been in the same apartment now for 10.5 years as of this month!) I could NEVER HAVE DREAMED of doing ANY of this prior to finding that stable dose & being drug-free. Yes, I’d been on MMT before, but never put on the right dose b/c clinics/docs were scared to go above 100 or 120mg, & I couldn’t get to where I wasn’t craving & I kept using & would eventually get caught passing scripts every time. I was abruptly withdrawn FOUR TIMES in jail (NO methadone, NO buprenorphine, NO NOTHING except clonidine for my blood pressure, which let me tell you, STILL leaves you feeling like dog crap. That it helps w/d’s is nothing but textbook jargon. It prevents a stroke from a spike in your blood pressure while w/drawing, but that’s ALL!) all b/c I couldn’t get clean. I’m SO THANKFUL for a doc & a clinic director that weren’t afraid to do what it took to help me get clean back then! And if I did need a benzodiazepine on occasion to help w/PTSD or some other illness I couldn’t control, I’d like to hope that I’d be able to get help that really worked. Buspar did nothing but make me tremble so hard that people clear across a room could see it & caused me sexual side-effects, & the SSRIs as well as the newer ones that also effect norepi didn’t help worth 5 cents, either with my anxiety. Personally, I’ve found that gabapentin works better than anything at reducing my anxiety outside of the benzo class, so that’s what I take. I have no desire to be dependent on benzos, so I don’t take them under most circumstances (except sedation at the dentist’s office & such). But I don’t like the idea of a clinic banning an entire class of drug if a competent doc feels I need it & is willing to collaborate with my clinic doc. That’s just me though.

    • Posted by john on December 16, 2014 at 4:44 pm

      Yes but the doses they plan to use to execute someone are way, way higher than even someone with a heavy tolerance would use to get high.

      Reply

  4. Posted by cldickjr on November 19, 2013 at 8:39 am

    I have been in remission now for almost 8 years now. I am a veteran, now 59 years old, and my first day of recovery was on 18 May 2013. I am currently on two week take homes and although i do not disclose my dosage I will say that I have been on the same amount daily for the last 6 years. Today, methadone is just like my blood pressure medication, or my tamsulosin, I take that last one for my prostate and if I take it every day I function normal and my body responds “normally”, I do not “feel anything”, but I know that all is well because my body works like is is supposed to. Same with my addiction medication, and I am functional and participating member of my community. I am still attending weekly group sessions and this particular topic is one of the major reasons why. I do not have to attend as much as I still do, however, it is so important for me to remember what it was like when I could not stay stopped, or when I was substituting and compromising with my mind and body through the various combinations of substances that I used when I was not in recovery. When I had first started two week take homes, which was at the beginning of the second year, I remember that at that time we had alot of guys struggling with bennzo’s and meth and diverting weekend meds tor “a big jolt” on one day, etc. We also had a lot who went out for a month or two and then would come back. It was during that time that we lost the most members of our group. In 2009-2010 we lost 8 members of our group who’s average was 22 in attendance at that time. Every single one had been on methadone at various times for years, longer than I, and when they would come back to the VA again and begin their regiment all over, then the would slip right back into the thinking that fit their behavior pattern for the VA, including diversion on the weekend doses and such…8 of them never returned from that last jolt, and most were not even on the “killer” doses. They had just listened to their mind lie to them one too many times thinking that they knew the routine for that particular environment…Wrong!. All total we have lost 13 in the first 8 years of my recovery, but our process is beginning to work as many of those “older” patterns of behavior have gone away and most of us today help each other by continuing to educate ourselves, our brothers in arms, and our brothers in addiction and recovery. In addition, we work very hard at changing a patterns of talking and communication in our group settings to keep our selves seeking more healthy and useful ways of saying what it is that going on, which also promotes change which is what all of recovery is about. I hope that I have not rambled too much, but I am one of those for which much was taken but now much more is being replaced and/or experienced today by the grace of my God, and my continued recovery. Thanks, More is constantly being revealed…! Charles

    Reply

    • Thank you for writing!!

      Reply

    • Posted by Michelle on December 21, 2016 at 4:07 pm

      Charles, thank you for sharing. I have a question for you, Do you take methadone for chronic pain or addiction? From what I gathered it us for addiction?It can wirk wonderfully for chronic pain when taken safely and responsibly. Addiction is a disease, many say, some do not. However chronic pain patients are being hit the hardest with this war on drugs. I give anyone who has lost someone to a overdose!!!, total compassion and validation! Please remember any substance can be harnful when not taken responsibly. Thank you, have a blessed day, Oh, l am a Licensed and Board Certified Clinical Psychotherapist. Was able to achieve this and work as a Clinical psychotherapist, up until now. My dr left and CANNOT find one who truly cares about my quality of life! So its a no win, if I get off it I have ni quality of life. Plus my husband and I have a beautiful baby girl about to turn 4, able to mother with my pain under control. No hope, drs care more about not getting a visit from the DEA, then anyones quality of life. I get it I am state licensed, the answer to protect yourself and your patients, DOCUMENT !!!!! Thank you for letting me vent,take care!

      Reply

  5. Posted by Dana on October 6, 2015 at 3:24 pm

    Thank you for the article. My brother overdosed and died in 2007 from a lethal mixture of benzodiazepines/alcohol/methadone. I don’t know exactly how much of each he was taking, but I do know that he consumed a negligible amount of alcohol that night. The words that really hit home for me were “I know what I’m doing”. These are the exact words my brother used to say to me and I was young and naive and actually believed him. How I wish I could turn back time….

    Reply

  6. Posted by kirk on March 13, 2016 at 9:45 am

    all lies.. I am on methadone and benzos been for about ten years now and I never oded on this combo.. only oded when shooting dope…

    Reply

    • Posted by Michelle on December 23, 2016 at 5:20 am

      What state do youive in dear? I have been on.Methadone for 20 yrs, it has helped me reach my gial if being a Clinical Psychotherapist, state licensed and board certified. My pain is in my ears from 18 reconstructive inner ear surgeries. As well as work as a Clinical psychotherapist, be a mother to my almost 4 yr old and live a high quality of life. My pain doc of 16 yrs has moved across country and noone will take my case because ad one dr told me we never see chronic ear pain. Plus they cannot bill trigger points, facet injections etc. I would greatly appreciate you sharing with me the name and location of your dr. Drs I see are against methadone. But will not write anything else. Thank you, l am here if you need anything, bless you this hoiiday season. Michelle

      Reply

  7. Posted by Rob handlman on November 7, 2016 at 2:12 pm

    Your comments ptobably saved me

    Reply

  8. Posted by Michelle on December 21, 2016 at 7:33 am

    Yes, this can and does happen. However if Drs reported the people such as myself who take methadone or other opioid regimens, and how these regimens have given us back a,quality of life with which we are pleased. I am.a Clinical Psychotherapist, licensed and board certified. I am a wife, mother, daughter, friend, employee and chronic pain patient. My dr left and I.can say it has been horrific. I do yoga, eat oraganic take care of myself. Noone would ever want chronic pain or to be on a opioid regimen.However constant physical pain IS NOT A GOOD HAVING QUALITY OF LIFE!,

    Reply

  9. Posted by James on April 10, 2017 at 10:32 am

    Hi I take 70mls liquid methadone daily and 6x 5mg diazepam 25mg amitriptyline do you think if I were to take 1000mls of methadone and 720mg of sevradol with my daily benzos I would overdose !!!!! “Asking this as a friend has said to me he’s thinking about taking that would it kill him ” thanks

    Reply

    • there’s no way to know. There’s too much variations to know exactly how much would kill a person.
      even worse than dying would be suffering from low oxygen of the brain and ending up in a chronic vegetative state, so that’s another good reason to seek medical care if you or your friend are suicidal, please.

      Reply

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