Clinicians may well have encountered a case like this one.

A man in his 50’s is admitted to a residential program for the purpose of medically supervised alcohol detox. He reports recent consumption of, on a daily basis, one quart bottle of vodka. It’s a lot, but the staff have seen worse. The surprise: he’s also currently maintained on 250 mg of methadone per diem, for treatment of his chronic heroin addiction.

“That’s a big dose, isn’t it?” I remark to the nurse. “Oh hell yes,” she states. “Wonder why so much? And on top of the vodka?”

I get on the phone to his OTP – it’s a well-run program, I know from previous contacts – and they confirm the dosage. Here’s how the current situation came about.

The client had been on 120mg for almost a year, all the while complaining of craving and withdrawal, along with chronic anxiety and insomnia. Urged on by his counselor, the medical director tried him at several different dosages, without much improvement. The counselor suspected he was drinking but couldn’t verify that until the day another client reported seeing him on the street, “falling down drunk,” to the point he barely avoided getting run over by a city bus. The staff called him in for an interview and he ‘fessed up and admitted he couldn’t stop.

The physician decided he must be undermedicated and began experimenting with increased dosages. The idea was that this would reduce the desire for alcohol.  “Seemed to be working at first,” the counselor said, “but then a few weeks ago, he showed up at 7AM absolutely s**t-faced drunk, wanting his take-homes. We gave him an ultimatum – either get help or face a taper off the program. That did the trick. He agreed to detox from drinking and we sent him over to you.”

The client was in generally good health, surprisingly, but to be safe, the physician kept him in detox for twelve days. He was discharged back to his OTP, promising to avoid alcohol in future.

“How does somebody manage to mix alcohol and methadone to that extent?” I asked, a few days afterwards. “Without OD, I mean. All that methadone plus booze – and he walks into detox on his own?” Even drove himself to the hospital (shudder).

“The theory is an abnormally accelerated metabolism,” our medical director offered. “The liver has reached the point where it gobbles up both drugs like candy. Also, he took the opioid in the early morning and the really heavy drinking started a few hours later. If his blood levels weren’t rising at the same time, it could make a difference.” He finished with a shrug. “If somebody else has a better explanation, I’d be happy to listen.”

Since then I’ve run into other explanations, focused on neurochemical and even behavioral adaptations as well as metabolic. Drug tolerance is a complex phenomenon.

Still, if anybody out there has a better explanation, we’re still listening.