by Charlotte Gutfreund
Heroin by JohnnyCashsAshes
K.J., a young heroin user died from an overdose of heroin. He had been hospitalized numerous times for his continued drug abuse, so had had his blood morphine levels (heroin is broken down to morphine once in the bloodstream) recorded numerous times. Interestingly, his blood morphine levels were no higher than they ordinarily were, yet this particular heroin injection proved fatal (Gerevich, Bacskai, Farkas, & Danics., 2005). So what was it that made this high tragically different than his previous ones?
K.J. had not been using heroin as steadily recently, due to his frequent hospital visits, but studies have shown that, although tolerance to heroin definitely increases over continued usage, periods of abstinence do not then, re-lower tolerance (Druid, et. al., 2007), so that could not have been the cause of his different reaction this time. The only thing that was different about the last time he injected himself with heroin was that he was doing so in a different location than he normally did (Gerevich, et. al., 2005).
Surprisingly, this is actually in agreement with a phenomenon shown in other studies. In 1985, Siegel and his colleagues gave two groups of rats continued morphine injections of progressively higher dosage. Each time the injection was given in the same location. The highest location was then given again, and half of the rats were in a new location for this last dose. The rats in the new location repeatedly showed a significantly higher mortality rate, even though they were getting the same exact dose as the other group and the same dose as they had been injected with (and survived) previously. This is because, as a conditioned response to the stimuli present during previous drug use, the body learns to “expect” the drug coming when in the presence of these stimuli, and physiologically prepares itself to “tolerate” the drug (Siegel, et. al., 1985). Tolerance for a drug is caused when long-term use of the drug alters the function of neurons in the brain. For example, with long-term use of opiates, brain neurons begin to require higher and higher levels of the opiate in order to function properly. When frequently exposed to a drug, the brain will alter itself to compensate for the effects of the drug, thereby creating a “tolerance”. An increased tolerance means that the person must use a higher level of the drug to get the same effect, and so their tolerance continually increases (Somers, 2006).
The stimuli present during repeated drug use can elicit very distinct neural reactions in other ways too. Deroche-Gamonet, et. al. allowed to rats to self-administer themselves with cocaine by nose-poking in a certain hole. One group of mice was given a particular cue light every time they were injected with cocaine, the other group was shown no light, and both the groups showed generally similar cocaine-usage patterns. Then, the light stopped being shown to both groups for a prolonged period of time and both groups’ cocaine craving (based on the frequency with which they nose-poked for it) stabilized. But, when reintroduced to the cue-light, the cue-light group’s cocaine use increased drastically, even though the light originally did not seem to affect their use (Deroche-Gamonet, et. al., 2002). This indicates how a stimulus conditioned to be associated with drug use can spark a craving for the drug later on because of learned conditioning.
Originally neutral stimuli can having varied effects when they are associated with repeated drug use. But, although these stimuli can seem completely inconsequential, they can mean the difference between life and death, as with K.J., or the difference between sobriety and relapse.
References
Deroche-Gamonet, V., Piat, F., Le Moal, M., & Piazza, P. V. (2002). Influence of cue-conditioning on acquisition, maintenance and relapse of cocaine intravenous self-administration. European Journal of Neuroscience, 15(8), 1363-1370.
Druid, H., Strandberg, J. J., Alkass, K., Nyström, I., Kugelberg, F. C., & Kronstrand, R. (2007). Evaluation of the role of abstinence in heroin overdose deaths using segmental hair analysis. Forensic Science International, 168(2-3), 223-226.
Gerevich, J., Bacskai, E., Farkas, L., & Danics, Z. (2005). A case report: Pavlovian conditioning as a risk factor of heroin ‘overdose’ death. Harm Reduction Journal, 2(1), 11.
Siegel, S., Hinson, R. E., Krank, M. D., & McCully, J. (1982). Heroin “Overdose” death: Contribution of drug-associated environmental cues. Science, 216(4544), 436-437.
Somers, T. (2006). Opiate Addiction. Retrieved from The Society for Neuroscience: http://www.sfn.org/skins/main/pdf/brss/BRSS_opiateAddiction.pdf.
It is very interesting that KJ died because the location in which he injected himself changed. Even with his high tolerance of the drug, the shock of a new location of the entering Heroin was enough to kill him. Heroin can be smoked, injected or sniffed, with injecting being the most dangerous. The fact that KJ was taking his fix via the most dangerous way possible should have meant that injecting it from anywhere should have been similar, but i guess the body was conditioned to a certain stimulus, and an unconditioned stimulus lead to his death. I wonder if he would have died had he chosen to snort it or smoke it instead.
Trying to stop yourself from taking the drug would not reduce tolerance either as the body compensates and becomes more reliable on the endorphins released from the morphine rather than the bodies own natural endorphins. A study conducted in 1972 at Johns Hopkins University revealed that the endorphins released by opiates such as Morphine were stronger than the bodies because we were able to control how much of it we wanted to hit the brain. Being pleasure-seeking organisms, the motivation to administer a drug which allows us to feel pleasure is very high, which inadvertently leads to drug addiction and eventually abuse.
Comment by Rahul Kanade — April 30, 2010 @ 3:58 pm
I don’t really know much about the details of heroin injection, but I’m doubting that users are often terribly precise about the injection location. This makes me wonder how often accidental overdoses could be attributed to something as simple as a different injection location. It’s certainly nothing I would ever have thought of, though it makes perfect sense when you think about it. It’s really scary when you think about it. I’m sure there are other complications with taking other drugs as well. There’s so much room for error, and error can so easily be fatal…
Comment by Psych 105 student — April 30, 2010 @ 8:28 pm
I can’t help but wonder whether the issue of a new injection site bypassing built up tolerance is a behavioral (perceptive) or local biological issue (tissue at/near the injection site). Is it the habit of injecting yourself in a certain place that sets off the cascade of tolerating processes in the body? Or can a part of the body develop a means of buffering a drug that the rest of the body lacks? These studies seem to suggest that it is a habitual/perceptive issue. And in that case, does that mean that if an individual with a tolerance to a drug was unknowingly injected with that drug that they would not exhibit their normal level of tolerance?
Comment by Christopher Lloyd — May 2, 2010 @ 9:30 pm
It is interesting to look at the conditioned response of drug use as a possible factor into drug fatalities, but what about drug users who use in different places? What contributes to these junkies’ deaths? Not every drug user uses in the same place every time they shoot up. I think that although our bodies become conditioned to certain stimuli during certain activities, how can we say that a new environment would be the only reason for an overdose. Obviously being unfamiliar with a new location, especially when on drugs could cause you to panic and react in a different way, but it seems that at least in Greveich’s observations the death could have been attributed to other factors as well. For instance maybe after hospital visits K.J. had abstained from the drug for so long it had caused him to go on a binge and take a much more heavy dosage than he usually did. Also the brain is conditioned to respond to stimuli by chemicals released during the response. It makes sense then that any learned behavior can become a conditioned response with enough exposure but that doesn’t mean that the brain would be completely unable to cope with a drug it had abused many times before.
Comment by Samantha Garcia — May 2, 2010 @ 11:05 pm
Heroin is indeed one of the most addictive and dangerous drugs in popular culture. Increased tolerance to injections of heroin forms quickly and therefore makes the drug extremely hard to quit. Recently, in Britain, there has been an effort to legalize the administration of heroin to addicts in order to reduce crime rates (addicts often resort to stealing in order to obtain their drug money). Though at first glance it may seem ridiculous to supply addicts with even more drugs, it has been shown that administering the drug to the addicts in increasingly smaller amounts will result in decreased consumption of street drugs and decreased spending on substances in general. The real question is though…is it ethical to provide these addicts with drugs even if it does help with economy and crime rates? If Britain begins to do this with heroin addicts, will they have to do it for all drugs addicts?
Source:
Prescribe heroin to addicts on the NHS, says nursing leader. (2010, April 27). The Independent,22. Retrieved May 3, 2010, from International Newspapers. (Document ID: 2019051341).
Comment by Elaine Cheung — May 3, 2010 @ 2:23 pm
The vagueness of the location in these studies makes it hard, from a medical perspective to pinpoint the reason for overdose. Injections can be intravenous (though blood stream), inter muscular (through the muscle tissue), Subcutaneous (below skin into fatty tissue) or even intraosseous (into the bone). All of these injections could be done with the same needle. However Intravenous and Intraoseous injections are straight into the blood stream and would deliver the fastest and most potent effects, next would be intra-muscular, and then, the much slower, subcutaneous. If the person had been injecting into the fatty tissues and sunk further into the muscle the effects would be more immediate as well as far more potent which, with the use of a powerful drug such as heroine would be able to account for the difference in life or death. If by some chance the “new location” happened to be into the vein, using an amount of heroin thought to be going into the fatty tissue the effects would most likely cause a vastly more potent effect with the ability to overwhelm the body and close down respiration, which is often how addicts die. The mere exposure effect leads people not to fear things that they have become accustomed too even if they are detrimental to their health. In this situation the ignorance of location, and the effect of being familiar with the amount leads these drug users to fatally overdose.
Sources:
American Academy of Orthopedic Surgeons. “Emergency Care and Transportation of the Sick and Injured, Ninth Edition.” Jones & Barlett, 2006.
Comment by Christopher Toffoli — May 3, 2010 @ 8:22 pm
It makes sense that the location of the injection could have such a massive effect on the drug user. Throughout the semester we’ve looked at how important conditioning is to the brain. If a certain stimuli is frequently associated with a drug, it is reasonable that the body would prepare for the drug. It also seems that this was the major factor that caused the death of KJ. As the articles cited in the post state, the amount of Morphine in his blood was identical to other times he was at the hospital. The only difference was that he took the drug in a new environment. It’s fascinating that the body can force itself to prepare for even a substance it expects if it is in the correct location.
Comment by Clayton Masterman — May 7, 2010 @ 10:47 am
This is suprising news. One would think location would not have such a deep impact on the overall tolerance to opiates. Several Heroin users that I have helped to treat tend to use veins near each other. Does distance play a part into this. Is there a difference in going from arm to between the toes as opposed to a vein near the original on the arm. Many I.V. users tend to migrate their place of using due to collapsed vessels. This is astonishing and an eye opener!
Comment by jack spellman — July 14, 2011 @ 9:27 pm
This is a particularly interesting piece to me in that it provides a physiological explanation for a phenomenon I encountered during my volunteer work at a homeless shelter in Las Vegas, New Mexico. I attended a boarding school in Northern New Mexico, an area in which intergenerational heroin addiction runs rampant, for the last two of high school during which I was involved in developing a connection between my school and a local homeless shelter, Casa de Samaritan. A number of the homeless men and women with whom I interfaced at the shelter were or had been heroin addicts, and as such, their experiences with the drug and its social implications were frequent topics of conversation. In one instance, a regular of the shelter, and a heroin user, who I had gotten to know over the course of my two years working at Casa de Samaritan, was wrongly arrested, abstained from heroin use while in prison, was released from prison, used heroin once more, and ultimately overdosed. I had assumed that this might have been a result of a sharp decline in his tolerance during his time in prison, but the information in this blog post suggests that such a drop in tolerance is unlikely, and that rather, this person might have injected in an unfamiliar part of his body resulting in his overdose.
Comment by Ishan Desai-Geller — December 14, 2012 @ 9:44 pm
This is fascinating stuff, but also commonplace knowledge in circles like Narcotics Anonymous (NA) support groups. They discuss (with a very different vocabulary) how tolerance remains despite periods of abstinence, with cautionary tales of members who have been clean for any number of years and thus overestimate their threshold if they were to relapse with fatal consequences. I agree the the depth of injection influences the impact of the high like Christopher was saying, but i’d also add that not all veins are the same, in terms of their ability to deliver a high. For example, I think the larger the vein, the more of the drug that it can circulate through your system, making veins in your fore arm prime real estate for a beginner junkies, and the capillaries in fingers and feet provide vestiges of a high for an experienced user. Jack, I’m not sure how much it has to do with the relation to the original injection site, but rather with the same depth and vein compacity, if that makes sense. I wish the studies mentioned more details about how long he has been using, how deep was his fatal injection and where exactly was it. Great read overall though.
Comment by Mike P-G — March 8, 2013 @ 9:22 pm
That’s interesting! I’de be interested to see what other factors increase the likelihood of death from using heroin. I have heard that apparently one of the biggest factors that leads to death is from when it is sold cheap/ the needle has been used before, which I’m sure is true. I’m sure violence from the illegal distribution of it could be a major factor in the deaths as well. I would be very interested to see how much these different adverse affects contribute the mortality of the drug.
Comment by Jackson Miller — April 16, 2013 @ 1:36 pm