Imodium/loperamide story in and on the news

walgreens vaults

Since the loperamide story broke, Walgreens has placed their Imodium in “vaults” — security containers to prevent theft.

Hi — Yeah, it’s me. I’m still here.

For those of you who may have missed the story on CNY Central, my real name is Kate and I am an addict. (Hi Kate.) Yep, I’m busted.

I’m fat and on TV. UGH! Not exactly the way I wanted this all to go, but it had to be done. And yes, OMG that eyeshadow! What was I thinking? The whole interview was set up VERY quickly, and I had to go right after work, so I looked like a hot mess. But whatever. It’s done, it’s out there. Better eyeshadow next time. The gentleman who conducted the interview, Alex Resila, was terrific and eased my anxieties for the interview. Everyone has really been great and supportive!

moi

Kate: the real Margaret

I’m the person featured in the story. I am the author behind this blog. My pen name has been Mad Margaret (Marguerite Furieux) for a few years, and I think I’ll keep using it for now. I like to amusingly think of it as the whole Stephen King/Richard Bachman thing. Just a nom-de-plume I can continue to write under.

There has now been A LOT said about the Imodium/Loperamide crisis. And the media is getting a few things wrong in the translation. Let me clarify one particular thing that’s really been bothering me.

They said that Imodium gets you as high as heroin or oxycodone if you take it in a large enough dosage. 

ht_160512_william_eggleston_120x156

Dr. William Eggleston: is he cute, or what?

Not true. I think Dr. Eggleston (who is even more adorable in person!) was trying to explain that an opiate is an opiate is an opiate — in other words, any one of them will get you high in the right quantity — and he compared it to heroin and oxy. The news media took that to mean that loperamide will get you just as high as heroin and… well, it just doesn’t work like that.

While chemically this is more-or-less accurate (it does induce a type of mild euphoria) with loperamide, any “high” you get is, in reality, pretty disappointing if you ask me. Especially if you’re expecting a heroin-like high. Speaking for myself, I often became chatty after dosing with Lope, but never got “high” per se. Most people I’ve talked to say the same thing. In reality, most abusers of loperamide (an estimated 75% 0f them) are seeking relief from the withdrawal from the “real” opiates like heroin or Oxy or Vicodin. The high isn’t what they’re in it for — it’s the lack of agony from withdrawal. And for that use, it is indeed effective. Just, you know, deadly.

People need to understand one basic fact: Loperamide is an opioid first and an anti-diarrheal second. All opiates are constipating and are therefore, anti-diarrheals. They ALL constipate you. And they will ALL get you high in some form or another as well.

The important difference with loperamide lies in its chemical structure: other opiates like heroin aren’t going to send your heart into a deadly arrhythmia; they aren’t cardiotoxic.  An overdoses on heroin or oxycodone can kill you mainly through respiratory arrest. From just one overdose, a person’s entire central nervous system can shut down until you stop breathing. You nod out and die.

A drug like Narcan (Naloxone) can be used to reverse the effects of a traditional opiate and save the patient’s life.

Loperamide doesn’t do that. With lope in mega-doses, over time, there is a cumulative effect that isn’t well understood right now. A patient’s heart will begin to beat erratically leading to cardiac arrest. Narcan won’t save them.

For this reason, loperamide in high doses is considered far more deadly than other opiates, including heroin.

BloodBrainBarrierIn normal doses (1 or 2 two-milligram pills), people feel no high at all from Imodium. Their diarrhea is relieved and that poor pooped-out patient goes about their merry day. (Ha! See? A poop joke!) It does this because the body’s system (unlike with other opioids) prevents the drug from reaching the brainthrough the Blood-Brain-Barrier (BBB). A protective enzyme called “P-glycoprotein” or PgP spits any lopermide that tries to sneak in right back out into the bloodstream — and by doing so, it protects the brain from the dangers of the drug.

But addicts are taking multiple times that normal dose. It overwhelms our brain’s bouncer PgP, so some lope manages to sneak into the brain and stays there long enough to do its damage.

Addicts report that they take high doses of Loperamide for a long time (weeks to years) until the cumulative effect finally strikes; their hearts take on an uncontrolled rhythm and they drop dead from cardiac arrest. (There’s lots more on my site and in the literature about the specifics of this and the mechanism of action.)

Bottom line is: use high-dose loperamide and you will die. It’s just a matter of time. No joke.

Okay. So that’s out of the way. On to a few other matters.

The world reacts using Kübler-Ross’s stages of grief from On Death and Dying.

It’s very interesting that regular people seem to be in a type of denial about the whole thing. Commenters on the loperamide news story on various sites, by-and-large have had some pretty mean and assholey things to say. That’s pretty hateful considering that statistics show that 1 in 5 families have an pain-pill addicted family member, and 4 in 10 Americans know someone who is addicted to prescription painkillers; that’s not counting the ones who are addicted to heroin or other types of drugs. It makes me shudder to think how such caustic comments might be targeted at one of their family members who is struggling with addiction. I mean, I can understand that the normal populace is probably sick and tired of hearing about it, and/or sick and tired of dealing with it. But come on? Where’s the compassion?

Then I realized, it’s really just a form of denial.

In the Life Span Developmental Psychology class I just completed (in which I earned an A, thankyouverymuch), we covered the death and dying process. Of course, Elizabeth Kübler-Ross’s five stages of death and dying were discussed. For those who don’t remember her stages are:

  1. Denial
  2. Anger
  3. Bargaining
  4. Depression
  5. Acceptance

And truly, this is the reaction structure for the mind’s coping mechanism and how it deals with virtually ANY bad news. If your boss calls you in and says you’re fired, your first reaction would be, “this isn’t happening!” then you’ll try to talk your boss out of it, then you get mad. Once the realization that you really have lost your job hits you, depression settles in. Finally acceptance and the job hunting process begins.

So here the general public is in denial; they have just heard an outrageous and horrible story about people taking a few hundred poop pills to “get high” and they’re all like, “What? No way! What a bunch of dumbasses. Get this off my TV!”

Am I right? Or am I right?

But it doesn’t change the fact that it’s happening. It’s really happening.

Once they’re done denying and bargaining, then they get angry. And this is kinda where we’re sitting with this story right now.

The important thing is, people know now and the conversation finally beginning.The next step is discussing what needs to be done for the hundreds or thousands of addicts who will soon be out of their maintenance medication.

Loperamide, addicts, and the FDA

For those addicts who started using Loperamide as a substitute for heroin or oxy or vicodin, or whatever, the bulk loperamide supply will soon dry up. According to the New York Times article, the FDA will be reviewing the loperamide crisis and will most likely recommend that it be held behind the pharmacy counter like pseudoephedrine.

“The F.D.A. is aware of recent reports of adverse events related to the intentional misuse and/or abuse of the anti-diarrhea product loperamide to treat symptoms of opioid withdrawal or produce euphoric effects…. [the agency] will take appropriate steps as soon as possible.” — Sarah Peddicord to the New York Times

So then what? Good question.

Aftermath: treating the loperamide addiction.

Where does this leave loperamide addicts who are using multiple pills a day just to maintain normalcy? Up shit creek? (Haha! See? I made another poop joke!!)

Here’s the thing: many people who aren’t addicts or who are not in the business of detox or recovery treatment really just don’t get this whole addiction thing. They don’t know how it works, how much people take, or what happens when they stop. It’s really hard for most “normal” people to handle what’s going on, which is why they retreat and deny or point fingers.

But even the medical community hasn’t had to deal with loperamide addiction issues before, so this is all going to be new to them. Until a month ago (before this story broke in the news) most doctors, addition specialists, and pharmacists, had no idea this was happening and no plan to deal with it. Now they know this is a real thing and will take it more seriously. We hope. And that’s good news!

Treatment can be done in an out-patient setting. Standard opioid-addiction treatment is what’s recommended. Drugs like clonidine, trazodone, etc., are often utilized to make withdrawal symptoms more bearable. Some choose to go through a rapid-detox program where the addict is placed in a deeply sedated and medicated state until they’re out of acute withdrawal.

More recently, a drug called “Suboxone” or “Subutex” has been used for chronically-addicted patients who need additional support through the withdrawal process or who need a maintenance drug. Should loperamide-addicted patients use this?

Well, that answer is complicated.

Some important crap to know (ha! See? Another poop pun!): Loperamide has a very long half-life (basically, that’s the time it takes to clear half the drug from your system). Why is that important? Think about the last time you got a prescription that said “Take one pill every four hours.” The half-life on that drug is likely 4 hours. Loperamide’s half life is estimated at about 14 hours — and recent research indicates that in chronic, high-dose use, it’s probably much longer. Loperamide’s half-life may be 18-20 hours.

So why does that matter? If a doctor plans to treat a loperamide-addicted patient with a drug like Suboxone (buprenorphine), he/she has to wait until loperamide has fully cleared the patient’s system. In a patient who has been taking most “normal” opiate addicts on heroin or oxy or vicodin the recommendation about 24 hours before their system is fully cleared of the drug before starting treatment with Suboxone. BUT — and this is important — in an loperamide patient, because the clearance time is so much longer, that wait could be several days or a week or so. If Suboxone is started too early, the patient goes into what’s called “precipitated withdrawal” — all the symptoms of withdrawal hitting suddenly and much more intensely. It’s excruciating.

Personally, I don’t recommend treatment with Suboxone therapy for loperamide-addicted patients. The reactions are too unpredictable and too poorly understood right now. Personally, I didn’t use it, and I’m very glad I didn’t. But ultimately, that choice is between patient and their medical provider to decide.

Regulating loperamide: Ramifications

Don’t worry. If the FDA chooses to put loperamide behind the counter, you can still get it. You will be able to buy what you need to treat short-term diarrhea situations. Loperamide is actually a really great drug for this and is safe and effective when used as directed. The World Health Organization considers it one of their most essential medications.

fdabldgRegulation of the drug to prevent mega-dosing won’t effect this. Nor will it stop you from getting it when you need it. And for Crohn’s disease patients, IBS-D patients, or those undergoing chemotherapy (or other legitimate needs), you too will still be able to obtain all the loperamide you require. Yes, you will have to go to the pharmacy counter and sign for it, but that’s not really that big a deal, is it? Seriously? Come on. So what? When was the last time you drove to Walgreens at 3AM searching for a 200-pack of Imodium?

Regulation will stop the exploitative massive bulk sales of the drug marketed and targeted directly at addicts. You won’t be able to go into Walmart and buy a pack of 144 or 200; and you won’t be able to get packs of 2400 or more on Amazon either.

A bit of history on Loperamide Abuse

The rise of Imodium/Loperamide abuse can be traced to the rise of the internet. Truly. It all happened concurrently — as home-based broadband reached more homes, more information became disseminated very easily. Combine that with the rise of prescription opioid abuse, and you have a perfect storm. I’ve been following this for a long time — you can trust me. I watched it happen from a front row seat.

In a recent study conducted by Wright State University, researchers were able to trace internet chatter regarding loperamide back to 2005. That said, I remember reading about it quite a few years prior to that, in the late 1990s. It started with just a few posts, amateur home-chemists and addicts, trying to figure out if loperamide, a non-high-inducing opioid-based drug that was easy to obtain and legal, could be turned into the legal drug they could get high on.

Blackboard with the chemical formula of Loperamide

Some tried (at home) altering the chemical structure thinking they could create a Frankendrug of sorts, but with no success. I remember one person recommended trying to consume loperamide with lots of strawberry ice cream; the Polysorbate-80 ingredient in strawberry ice cream was believed could “coat” the molecules and make them cross over the blood-brain-barrier and get you high. It didn’t work. Eventually, the amateur chemists concluded that the chemical structure of the loperamide molecule couldn’t be altered except in a big lab with just the right equipment.

Occasionally some addict would chime into the conversation and say he took 100 of them and felt a “dirty high” that went on for hours, but nobody believed him. Nobody could be that crazy and live, would they?

Then some desperate addicts going through withdrawal figured out that if they used 10 or 20 Imodium tablets, they could stop withdrawal in its tracks. And so many claimed that it worked, the conversation took off.

Soon 1o or 20 turned into 40. Then 60. People tried to combine loperamide with known PgP inhibitors to get it to more readily cross the blood-brain-barrier. Some claimed success. So more people tried that too.

That’s how things like this get started: desperate people doing desperate things.

Logo-JanssenLoperamide (as I understand it) started out life in the labs of Belgiums Janssen Pharmaceuticals somewhere around 1970. They were monkeying around with the chemical structure of fentanyl trying to create another super-painkiller, but the best they came up with was a drug that sucked for treating pain, but even in low doses was an effective constipator. It wasn’t what they were shooting for, but they ran with it and, in 1976, obtained approval from the FDA to sell Imodium as a controlled-substance (Sch IV) prescription drug in the USA. It was descheduled in the 1980s and was eventually sold over-the-counter. The FDA believed it to be safe thanks to Jaffe, et al’s 1980 research paper titled “Abuse potential of loperamide” which concluded that addicts were not likely to abuse loperamide in the high doses demonstrated in the study, as long as there were other opiate sources available to them.

Very important, that last bit there. As the opiate crisis has skyrocketed, and now legitimate sources of opiates dry up, the desperate addict seeks other means of maintaining “normal”.

And here we are. Talking about people taking mass quantities of poop pills.

That’s how it all started. Respect the chemistry.

Admitting the unadmittable.

Because of all the news coverage, I had to “come out” as an addict for the first time to my family, friends, and co-workers. My friends and co-workers — most of whom did not know — were all incredibly supportive. My family is struggling with how to react, mostly I think they’re just worried. (I think they need time to absorb it.) It’s disappointing, but that’s reality. And I’m OK with that.

ienewsThis past week, we did an interview with syndicated news program, Inside Edition (air date TBD), and this time you’ll be happy to know, I remembered to wear better eye makeup. Thank God! I also have been contacted by a women’s magazine interested in sharing my story (though I have yet to hear back from them). There may be more. I hope there’s more.

My whole point in coming forward is to put a human face on this addiction problem — the same human face I’ve seen in other addicts, and on the faces of the dead whose pictures have been sent to me. Men, women, young people, older people. Professionals. Students. Mothers. Daughters. Husbands. These people do not deserve the laughter and ire of the commenting community. I am willing to be the voice of those not as brave or crazy — or as alive — as I am to come forward and ask for help and understanding.

Feedback from the medical community, however, has been tremendous. They are taking it seriously. So when I call and ask to speak to them, they are finally in a position to say, “Oh yes, I’ve heard of this!” rather than laughing me off the phone. That’s an incredibly important step. This will save lives in a very immediate way.

Some pharmacies around the area are now placing their Imodium and Loperamide products in theft-resistant “vault” containers, and at least one has put the drug behind the counter for people to request. It’s a great first step.

The conversation has finally started.

I am MadMargaret and I am Kate. I have been many other things in my life too: a daughter, a co-worker, a student, a singer, an actor, an artist; I am wise, I am good, and I work hard and fight for things that matter — and (as it so happens) I am also an addict. I am alive today because of some of the fastest-thinking doctors in the world. I owe them my life. I want to make them proud that they worked so hard to give me a second chance.

And doesn’t everyone deserve that?

Stop contributing to the hate, and start helping create an atmosphere where those who have an addiction issue  — whether loperamide or not — feel safe to come out of hiding and seek treatment. To not do so sentences them to death and forces more into silence.


“You gain strength, courage, and confidence by every experience in which you really stop to look fear in the face. You are able to say to yourself, ‘I lived through this horror. I can take the next thing that comes along.'” — Eleanor Roosevelt.


 

 

 

 

Posted in addiction, loperamide, loperamide abuse, sobrietyland | 6 Comments

Addicts turning to Imodium/Loperamide – 10 Things You Need To Know

Walmart Loperamide

Imodium and Loperamide Bottles on the Shelf at Walmart

Since the news story about Loperamide Abuse broke last week, based on a study published in the Annals of Emergency Medicine, I’ve seen a bit of disinformation spreading around. Lots of misinformed comments on the news articles. There are many pieces written on Sobrietyland (like this, and this) dealing with the facts about Loperamide, its history, what it does in overdose situations, and offering my own experience, strength, and hope regarding loperamide addiction.

That said, let me clear a few things up for those commenters out there:

Some Random Factoids/Answers:

1. Yes. Imodium and Loperamide are essentially the same thing.

Imodium is simply a brand name for the drug Loperamide (just like Tylenol is a brand of the drug Acetaminophen).

Loperamide (pronounced low-PARE-a-mide) tablets have Loperamide HCl as their main ingredient. Inactive ingredients in the pills are generally fillers and binders. This is not true of liquid or combination formulations. Addicts generally use pill form loperamide. Generally speaking, users commonly call the drug Lope or Loperamide. Most consume it in pill form.

2. There are two types of Lope abuse going on.

  1. Some people use the drug recreationally as a means of getting high or as a mildly euphoric substitute for their opiate drug of choice. They’re usually disappointed as loperamide does not make a person high like a traditional opiate.
  2. The majority of users are opiate addicts trying to find a way to take away the withdrawal symptoms from their drug of choice (heroin, oxycontin, vicodin, etc.).
    • Some stop using loperamide after a week or so, being on it just long enough to through the initial withdrawal sickness.
    • A large proportion of people, however, do not stop and, over time, end up just as addicted to the loperamide as they would be to a more stereotypical opiate.

3. Addicts don’t buy brand name.

At least the ones I know don’t. So don’t bother pointing your finger at Johnson & Johnson, the makers of Imodium Brand loperamide. It simply isn’t all that popular in abuse situations. Generic loperamide is significantly cheaper and can be purchased in bulk from everyday pharmacies as well as Walmart (Equate) and Amazon (Kirkland). That, in and of itself, is a problem.

4. Selling Loperamide in bulk is an unnecessary and dangerous practice.

If you need loperamide for the occasional case of diarrhea, you should be able to purchase it. But do you really need 2800 tablets of it?

What do addicts buy? Big bottles. Selling 200+ pills at a time only serves to encourage the addicts to use more and exploits the abuse situation. And if you think 200 pills at a time is a lot, you can buy 2800 on Amazon for $50. A healthy person using Imodium as directed, would never need that much; anyone with IBS or another intestinal disorder should only use larger quantities under the direction of their physician. Reviews on Amazon like what is shown below are on most of these bulk Loperamide items. This seller definitely knows  his buyers are abusing the Loperamide they purchase from him. That’s why this dude sells so many in bulk.

An Amazon.com listing for 2800 tablets of Kirkland Brand Loperamide (Imodium).

An Amazon.com listing for 2800 tablets of Kirkland Brand Loperamide (Imodium).

5.0 out of 5 stars      best price around

By [REDACTED] on September 20, 2015

Verified Purchase

Massive amounts of “lope” . Great with an antacid like tagamet beforehand and washed down with white grapefruit juice. Works wonders. YES it does cross the bbb, or accumulates or overpowers the PGP inhibitors or whatever it works

5. Poop jokes aside, this is serious.

Yeah. Okay. Funny. We get it. Make all the poop jokes you want. We all know it’s coming. “No shit!” is the most common one. Get it all out of your system.

I’ll wait….

Then, respect the science. Loperamide is an opiate just like any other (though it was previously believed to be abuse-resistant, it’s not abuse-free). It is an opiate first, and an anti-diarrheal second.

Want to know if  these Lope abusers ever poop? Yes they do. Lope is no more constipating than any other “traditional” opioid like Vicodin or Oxycontin (even in high quantities). Speaking for myself, I ate a lot of fiber and never had much of an issue with constipation.

Remember too as you’re laughing about this, the reason this has become such a problem is SECRECY — embarrassing those who have a serious problem only discourages them from ever coming forward and asking for help. That’s how so many people are getting sick and dying. Your son or daughter could be doing this. If they wound up dead, how many people would you want snickering at their funeral? Just sayin’.

6. The news reporting Imodium abuse isn’t the same as giving permission.

Many people seem to think that by reporting loperamide abuse in the media that we are encouraging more people to try it. On the contrary: we want people to stop. Anyone with an internet connection can find out about using loperamide in mega-doses. That’s not hard at all. Anyone trying to detox off their favorite opiate has probably run across this “home remedy” in more than one internet search. And there are SO MANY sites and videos that tell people it’s perfectly safe and okay to take a hundred or so caplets of Imodium which is patently untrue. We are reporting that it will kill you. Addictions thrive in secrecy — bringing it into the open means that important conversations can start happening and fewer people wind up dead. And now that this story is hitting Big Media, more doctors and ER physicians will be made aware — they’ll better know what they’re dealing with and can save more lives. Addicts will know that Lope is not a safe substitute. It’s win-win for everyone.

7. Why is this making news when this has only happened to a couple of people?

It hasn’t only happened to a couple of people. The literature from the last couple of years reports numerous cases of this. On this site, I link to at least two dozen articles. And those are just the people who are in the case studies. Many more are not. And while Eggleston’s paper follows only two cases of people who died, many more deaths have been attributed to loperamide and anecdotally reported to me — and countless others hospitalized, many likely died because of the ignorance of the medical community and the patient’s fear of revealing their secret habit.

8. Some kind of regulation is in order.

Enough people have died or been hospitalized that this has been called “a growing public health danger,” so something needs to be done. Eggleston, et al, suggest that loperamide should become a restricted, over-the-counter medication (like Sudafed) that you have to request from your pharmacist. Loperamide started off life as a controlled substance, by prescription only. This would not re-schedule the medication, but make it so you would request a pack of Imodium from your pharmacist for occasional diarrhea instead of buying it off the shelf. It can also serve to restrict sales of high-quantity bulk packs. Perhaps those who require long-term use to control IBS can get a waiver. I’ll leave that up to the powers that be. If such a minor inconvenience could serve to save the life of you or someone you know, is that really so bad?

9. Just let ’em all die is not an option.

Come on folks, seriously? The number of letters I receive from parents, siblings, brothers, sisters, friends, spouses, and the addicts themselves speaks to the desperation and heartbreak that addiction causes. Calling for the death of all addicts is just insane. The next addict you see could be someone you love — they may be there already, but they’re afraid to tell you because they know you will treat them with contempt instead of kindness. Nice job.

10. Who am I and what do I have to do with any of this?

I’m the index case. Patient zero. The canary in the coal mine. The warning shot. The first reported case since one overdose received a paragraph at a medical conference way back in 1994 (if you dig deep enough, you might find that one). I’ve been here long enough to know the history of this thing. The researchers from Upstate Poison Control who wrote the most recent paper, “Loperamide Abuse Associated With Cardiac Dysrhythmia and Death” are the same ones who treated me back in 2012, and published my case later that same year. I thank them for my life every day and have been willing to set aside my own dignity to try to save the lives of other addicts following the same tragic path. I’ve made it my mission to gather data about loperamide abuse and help disseminate it to the general public, fellow addicts, and any medical personnel willing to listen.

Make my life matter: learn from me.

I can be reached via email at capathy@me.com.

 


“If you can quit for a day, you can quit for a lifetime.” – Benjamin Alire Sáenz


 

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Separating Church and State

mask

A heads-up for my regular readers: the Sobrietyland site is reorganizing in the coming days. Because the Loperamide health crisis is starting to break in the news, and I will be interviewed as part of it, I’m redacting a lot of my personal articles to protect my friends’ and family’s identities and — most importantly — keep my private thoughts private. The main focus of Sobrietyland will be loperamide and addiction-related issues only; my personal adventures in idiocy will have to be handled elsewhere.

It’s pretty terrifying to know that my real name and real face (and fat ass) — and even worse, my addiction issues — will become public knowledge. It was a really difficult decision to make, but one I suspected might come eventually. As they say, I’m going to put my big girl panties on and make this happen. If by going public, I can save lives (and I sincerely hope it will), I’ll give it a shot.

I’ll update again when things are sorted.

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Loperamide Abuse in the News

Bad title, good article. You’ll be hearing a lot more buzz about this very soon.

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lopequan

Each bottle has 200 pills, equaling 2800 pills in one sold package. Who will ever use that much??

Imodium® For A Legal High Is As Dumb And Dangerous As It Sounds

WASHINGTON —The over-the-counter anti-diarrhea medication Imodium®,
or its key ingredient loperamide, is increasingly being abused by people
attempting to self-treat their opioid addiction, with sometime fatal
results. Two case studies outlining the phenomenon were published online
Friday in Annals of Emergency Medicine (“Loperamide Abuse Associated
with Cardiac Dysrhythmia and Death”).

“Loperamide’s accessibility, low cost, over-the-counter legal
status and lack of social stigma all contribute to its potential for
abuse,” said lead study author William Eggleston, PharmD, of the
Upstate New York Poison Center, in Syracuse, New York. “People looking
for either self-treatment of withdrawal symptoms or euphoria are
overdosing on loperamide with sometimes deadly consequences. Loperamide
is safe in therapeutic doses but extremely dangerous in high doses.”

The paper outlines two case studies of patients with histories of
substance abuse who attempted to self-treat opioid addictions with
massive doses of loperamide. Both patients overdosed and emergency
medical services were called.  The patients were treated with
cardiopulmonary resuscitation, naloxone and standard Advanced Cardiac
Life Support. Both patients died.

Oral loperamide abuse postings to web-based forums increased 10-fold
between 2010 and 2011. A majority of user-generated content pertaining
to loperamide discussed using the medication to self-treat opioid
withdrawal (70 percent).  Users also cited abusing the medication for
its euphoric properties (25 percent). The Upstate New York Poison Center
experienced a seven-fold increase in calls related to loperamide abuse
or misuse from 2011 through 2015, which is consistent with national
poison data, that reported a 71 percent increase in calls related to
intentional loperamide exposure from 2011 through 2014.

“Our nation’s growing population of opioid-addicted patients is
seeking alternative drug sources with prescription opioid medication
abuse being limited by new legislation and regulations,” said Dr.
Eggleston.  “Health care providers must be aware of increasing
loperamide abuse and its under recognized cardiac toxicity.  This is
another reminder that all drugs, including those sold without a
prescription, can be dangerous when not used as directed.”

Annals of Emergency Medicine is the peer-reviewed scientific journal
for the American College of Emergency Physicians, the national medical
society representing emergency medicine. ACEP is committed to advancing
emergency care through continuing education, research, and public
education. Headquartered in Dallas, Texas, ACEP has 53 chapters
representing each state, as well as Puerto Rico and the District of
Columbia. A Government Services Chapter represents emergency physicians
employed by military branches and other government agencies. For more
information, visit http://www.acep.org.

# # #

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Tis the season for freshly-published Loperamide articles!

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loptab3Loperamide Abuse Associated With Cardiac Dysrhythmia and Death

William Eggleston, PharmD a; Kenneth H. Clark, MD b; Jeanna M. Marraffa, PharmD, DABAT c
a Upstate New York Poison Center, Syracuse, NY;
b Onondaga County Office of the Medical Examiner, Syracuse, NY;
c Department of Emergency Medicine, SUNY Upstate Medical University Hospital, Syracuse, NY

Abstract: Loperamide is an over-the-counter antidiarrheal with μ-opioid agonist activity. Central nervous system opioid effects are not observed after therapeutic oral dosing because of poor bioavailability and minimal central nervous system penetration. However, central nervous system opioid effects do occur after supratherapeutic oral doses. Recently, oral loperamide abuse as an opioid substitute has been increasing among patients attempting to self-treat their opioid addiction. Ventricular dysrhythmias and prolongation of the QRS duration and QTc interval have been reported after oral loperamide abuse. We describe 2 fatalities in the setting of significantly elevated loperamide concentrations.

© 2016 American College of Emergency Physicians        doi:10.1016/j.annemergmed.2016.03.047; Available online 29 April 2016

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More Lope in the Literature

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loptab3Not Your Regular High: Cardiac Dysrhythmias Caused by Loperamide

DOI: 10.3109/15563650.2016.1159310 Rachel Sarah Wightmana*, Robert S Hoffmana, Mary Ann Howlandab, Brian Ricec, Rana Biarya & Daniel Lugassya

a Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA; b St. John’s University College of Pharmacy and Health Sciences, Department of Emergency Medicine, Division of Medical Toxicology, New York, NY, USA; c Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA

Discussion: Loperamide produces both QRS and QT prolongation at supra-therapeutic dosing. A blood loperamide concentration of 210 ng/mL is among the highest concentrations reported. Supra-therapeutic dosing of loperamide is promoted on multiple drug-use websites and online forums as a treatment for opioid withdrawal, as well as for euphoric effects. With the current epidemic of prescription opioid abuse, toxicity related to loperamide, an opioid agonist that is readily available without a prescription is occurring more frequently. It is important for clinicians to be aware of the potentially life-threatening toxicity related to loperamide abuse in order to provide proper diagnosis, management and patient education.

Clinical Toxicology, Volume 54, Issue 5, 2016, pages 454-458

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loptab3High-dose loperamide abuse–associated ventricular arrhythmias

Charles W. O’Connell, MD-1, Amir A. Schricker, MD-2, MS, Aaron B. Schneir, MD-1, Imir G. Metushi, PhD-3, Ulrika Birgersdotter-Green, MD-2, Alicia B. Minns, MD-1

1 Division of Medical Toxicology, Department of Emergency Medicine, University of California – San Diego, San Diego, California; 2 Division of Cardiovascular Medicine, University of California – San Diego, San Diego, California; 3 Center of Advanced Laboratory Medicine, University of California – San Diego, San Diego, California

Conclusion: This case details the very serious and potentially life-threatening cardiac dysrhythmias that are associated with both chronic and very high doses of loperamide. Loperamide may not be as innocuous as once thought, when purposefully abused in chronic, high quantities. Isoproterenol infusion was very successful in eliminating ventricular arrhythmias in this setting. Loperamide overdose should be considered, when case appropriate, as a potential cause in similar cases of significant cardiac syncope and cardiac conduction disturbances with prolonged QRS and QTc intervals. Given the ubiquity of loperamide and the epidemic of opioid abuse, this may represent a growing problem. The number of new cases warrants further investigation and physician provider awareness.

Heart Rhythm Case Reports
Published Online: March 07, 2016, Open Access DOI: http://dx.doi.org/10.1016/j.hrcr.2016.01.002

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loptab3An Additional Clinical Scenario of Risk for Loperamide Cardiac-Induced Toxicity

Gilberto Fabián Hurtado-Torres, MD, MEda Rosa Laura Sandoval-Munro, MDb

a Internal Medicine and Clinical Nutrition Department Hospital Central Dr Ignacio Morones Prieto/UASLPS an Luis Potosí, Mexico; b Faculty of Medicine University of San Luis Potosí San Luis Potosí, Mexico

Excerpt: Because the drug is available over the counter, unregulated use is frequent to control gastrointestinal symptoms, mainly diarrhea and unfortunately as an increasing nonillicit drug of abuse in opioid users. Another potential clinical condition with risk of loperamide electrophysiologic side effects derives from the wide use and proven utility of loperamide in the management of loop ileostomy and short bowel syndrome-associated diarrhea.

The American Journal of Medicine 04/2016; 129(4):e33. DOI: 10.1016/j.amjmed.2015.10.041

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