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!
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.
Dr. William Eggleston: is he cute, or what?
Not really. 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.
In 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:
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.
Regulation 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.
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.
Loperamide (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.
This 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.