So there's this guy on trial for murder. Murdaugh. Don't really care about it so much, but read an article about it today where he said he had been on opioids for 2 decades (illicitly) and had been taking as much as 2000mg of oxy per day. That's 3000mmes. I mean, tolerance is a thing and I guess this is technically possible but this quantity seems bananas to me even when looking at my hardcore drug addicts that grace the ED.
Does this seem plausible? Anyone in pain or more likely palliative see anything like this?
Yes, unfortunately, its plausible. When I first started fellowship, I inherited some patients on insane morphine equivalents like this. I didn't believe it was possible. I told this to one of my attendings, about a particular patient that was on similar doses to what you describe.
"He can't possibly be taking doses this high," I said. He suggested that I do an observed dose, i.e., witness the patient take a dose of his medicine in the clinic and observe him. "After all, you're an ER doc," he said. "We've never had a better person to be here if he doesn't have a tolerance for those meds," he said.
I watched him take the insane dose of meds and sat there in the room with him for 30 minutes getting caught up on some charting. He absorbed the "impossibly high" dose with no signs of opiate overdose whatsoever.
I could tell you more stories about insane-megadoses I witnessed that year, but just take my word for it. It's very possible they're taking those doses if they gradually build up to it over years. Of course, diversion is also possible, but that's harder to determine unless you do an observed dose, document a negative drug test or call them in one day off the street, or tell them to bring their pills in immediately and count them, none of which is practical in the ED.
By the end of my fellowship year, I had almost no patients left in my fellow-clinic, because I tapered them all off high-dose opiates and they self discharged. All the other fellows were jealous.