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Conditioned Heroin ‘Overdose’ Death in a Public Toilet

József Gerevich , Erika Bácskai , Tamás Kurimay , Addiction Research Institute, Budapest, Hungary: Although the phenomenon of conditioned drug overdose death was described in 1982 [1], this concept almost disappeared from the literature in the ’90s. Siegel et al . showed that situation-specific tolerance is capable of preventing the fatal consequence of a fatal-sized opiate overdose. In our case a 26-year-old man was hospitalized because of overdose, although opiate antagonist medication was not necessary. The concentration in the blood of morphine was 0.05 mg/L. Detoxification with clonidine was followed by rapid relapse. He was never abstinent for longer than a week. His wife recounted that on the day before his death, after some months of hospitalization, he had decided to begin withdrawal the following day. Next day the wife remained at home and KJ set out for work. On the way to work he changed his mind and, breaking his promise to his wife, went to the dealer and bought a usual dose of heroin. He met other drug-using friends there who had bought heroin from the same dealer that day and later told the authors that the heroin purchased then did not differ in quality from the usual. KJ did not return home with the heroin purchased as he did on other occasions but went to the public toilet where he injected the same quantity (0.5 g) he had taken the previous day in the accustomed place, at home, but this time with fatal outcome. The fluid in the syringe was heroin, while the metabolite of heroin, 6-0-acetylmorphine, and morphine 3-0-glucuronid were found in the blood and urine. The concentration in the blood of morphine, the catabolite of heroin, was 0.05 mg/L. The dose did not differ from the accustomed, daily dose. Heroin ‘overdose’ was given as the cause of death. The fatal consequence of the heroin injection may have been caused by the failure in the action of conditioned tolerance [1]. When a conditioned place preference arises, the user has to take a bigger dose each time to achieve the same effect as the user who does not have the opportunity for secondary conditioning with environmental stimuli since he or she constantly changes the place where the drug is taken [2]. When the drug is taken in a strange environment the conditioned tolerance does not operate since the organism is not ‘expecting’ the drug. The end result is that the otherwise accustomed dose leads to an overdose and thereby to death. This is why the term ‘overdose’ is misleading since the quantity taken was not greater than other doses taken without fatal complications [3]. In our case it could be determined that the heroin used by the patient did not differ in composition from what he had been using earlier. The concentration of morphine found in the blood was below the morphine values given in the literature in fatal cases (median level: 0.35 mg/L; range: 0.08–3.2 mg/L) [3,4]. This corresponds to the lower limit of morphine levels measured in current heroin users [3]. Probably the user died because he did not take the drug in the accustomed place and circumstances. The phenomenon of conditioned overdose death is of great significance for harm reduction.