Loperamide online article

A very interesting article from the point of view of a Pharmacist (PharmD).

http://empharmd.blogspot.com/2015/07/loperamide-induced-cardiotoxicity.html

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NEW Loperamide Article! — July 2015

This extensive case study is a particularly difficult one for me to read and add to the list. A twenty-five year old woman died from repeated lope abuse. Twenty-five. Just a kid, really. How many of us know someone twenty-five years old? Someone who graduated college, maybe, and just started her life? Did she have a boyfriend (or girlfriend)? How many people did she have to hide her addiction from? What were her hopes, her dreams? What was her favorite music?

None of that matters now because she died. From an over-the-counter drug that she was taking because somebody on the internet told her it was ok. That’s a tragedy.

She was treated a few times for syncope before it was finally discovered that she was a loperamide abuser. Despite surviving the worst episode, like me, she started using again; unlike me, her next visit to the hospital was her last one. There were several interesting insights in this case that will hopefully lead to further research.

People DIE from this.  YOU don’t have to.

Need I say it again? Loperamide is just a cheap withdrawal shortcut that has real addictive and deadly cardiotoxic qualities. Don’t get caught up in it! Don’t use loperamide to get off traditional opiates or to stave off withdrawal. If you get addicted to it (and let’s face it, as a drug abuser, you probably will), it can kill you. If not the first time, then the next time you play Russian Roulette with the lope. If you have an addition to opiates, see a doctor. It will suck, but not as much as death from your next big mistake. Be smart and start making a series of decisions that will make your life better. See a professional, admit what’s going on, and get real help NOW.

I did. And because I put on my big girl panties and asked for help, I survived to tell the tale — but so many do not.

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loptab3The Long QT Teaser: Loperamide Abuse

Evbu O. Enakpene, M.D., 1; Irbaz Bin Riaz, M.D., MM, 2; Farshad M. Shirazi, MS, M.D. PhD, 3; Yuval Raz, M.D., 4; Julia H. Indik, MD, PhD, 2
1 Sarver Heart Center, University Of Arizona Medical Center, Tucson, Arizona.

2 Sarver Heart Center, University Of Arizona Medical Center, Tucson, Arizona.
3 Center for Pharmacology, Toxicology Education & Research, University of Arizona College of Medicine Phoenix, Arizona; Arizona Poison & Drug Information Center, University of Arizona College of Pharmacy, Tucson, Arizona.
4 Division of Pulmonary and Critical Care Medicine, University of Arizona Medical Center.

The American Journal of Medicine
Accepted Date: 27 May 2015
doi: 10.1016/j.amjmed.2015.05.019.

Excerpt: “The source of a 25-year-old woman’s puzzling signs and symptoms could not be determined until a search of her home yielded the answer….Her ECG irregularities resolved within 1 week, and her pacing thresholds normalized. After she recovered, she finally admitted to chronic abuse of loperamide, which she had denied during previous hospitalizations. Although she had successfully completed a drug rehabilitation program in the past, she began using loperamide after learning about it from Internet sources and friends. Her care required an interdisciplinary approach, including psychosocial counseling and social services. Upon discharge, she was in good condition. Two months after discharge, the patient was readmitted in cardiopulmonary arrest after continued loperamide abuse. Despite being placed on percutaneous femoral venoarterial extracorporeal membrane oxygenation, she had no significant improvement. She died 18 hours after admission.”

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Days of Fantastical Thinking

ashfire2

There is an uncomfortable duality to living without my Square-Jawed NP.

I am trying so hard to come to terms with his sudden disappearance. What do I do with myself when the one person I would discuss this with is the one who’s gone?

I am left with Therapist Barbie, my sunny, 25-year-old counselor who advises me to do things like recite positive affirmations and keep a “feelings” notebook. Bitch, please. She is very good at listening, but she’s not like NP who knew to push and prod and cajole me into taking positive action. I am going to try to see her this week so I can wheedle some concrete answers out of her regarding what happened to NP. I’m pretty sure I can get her to spill.

I’m heartbroken about his disappearance. I have my information and reconnaissance tendrils everywhere searching for a single scrap of information but very little has come back so far. Nobody’s talking.

As of right now, I know this: he has not lost his license, but he is not returning to the practice where I was seeing him. In fact, according to my source, the exact phrase used was, (with emphasis): “No. He is NEVER coming back.” That specific emphasis on ‘never’ tells me two things: first, the person who said it (his colleague) is angry about NP’s departure; and second, his departure was not an amicable one.

My mind, of course, immediately thinks the worst: that NP either slept with or manhandled a patient. I sincerely hope not. And frankly, I don’t believe he would. Maybe that’s wishful thinking on my part though. I would like to believe that NP would never let such a thing happen. He has strict boundaries, as I’ve seen first hand. They’re in place for a reason. Why throw away six years of hard-won education, thousands in student loans, and a talented career for a bit of quick tail from your patient pool? (As I understand it, NP can get whomever he wants in abundance on the outside, and does.) But men have their weaknesses. I just hope that wasn’t it.

Of course there are plenty of other explanations. I know NP was busy opening his own practice. Maybe his contract had a no-compete clause and he was summarily fired after announcing it officially? I don’t know. Maybe he mis-prescribed medication. Maybe he slept with a staff member. Maybe a patient overdosed. Maybe a schizophrenic patient imagined he was making love to her through his eyebrows. Who knows?

My favorite theory is that, after finally getting the business license for own practice, he walked into the old office ready to quit, flipped them all the bird, and screamed, “See ya later,… fuckers!” And maybe that embittered therapist who emphasized the word “never” was a prude who holds him in contempt due to his profane language.

Sadly, I doubt it’s the latter. These things rarely are that fantastical. That type of contempt is usually reserved for those whose infractions are more grossly immoral or unethical.

So my feelers continue to be out in an effort to divine the truth. As soon as I know, you will know, dear reader.

In the meantime, I am at sixes and sevens. I miss him desperately. I’m worried for him. I don’t know what to do with myself. I feel rudderless — and without accountability. I go over every conversation we had looking for clues — and there have been some these last few visits. Reviewing my memory, he must have known this departure was coming. But if he did, why wouldn’t he tell me? Moreover, why would it happen like this? Yes, I know it’s none of my damned business, but a part of me demands answers.

Today, I took a drive up by his house. Now before you start screaming “stalker” at me, keep in mind that his house is on a main thoroughfare in a populous neighborhood. Yes, it’s 20 minutes away, but I, like many who live around here, might, possibly be innocently passing by to shop at the fashionable grocery store down the street from him. It could happen.

As I passed, there were no signs that he was home. I turned around and drove by one more time and, still finding nothing, I kept driving on and returned to port, saddened. Disappointed. Yet, what would I have done if I saw him, anyway? Ducked down and prayed he didn’t see me? As if he’d say, “Oh, just an old rusted-out 94 Geo driving itself. Hmm. Perfectly normal!” I wasn’t exactly traveling incognito in my borrowed car. I was actually just hoping to see his car parked outside his home and somehow find comfort in knowing he was safe. No such luck.

Okay, maybe that was a little stalkery. Still, I didn’t wait outside his house like I was casing the joint, so I should at least get credit for not being totally crazy.

As I mentioned before, there is a duality to living without NP.

There’s a likelihood that I may never see him again, and if I do, it might be in real life, not in a therapy session. (If he loses his license, his personal practice is lost).

So a part of me — a wee, tiny, strengthening part of me — wants to show him what I can really do. I want to lose weight, get serious about this diet of mine, so the next time I do see him, I can look so much improved.

For some reason, in the last two days or so, I’ve become determined to carry on despite myself. I have stood straighter. I try to attend to situations like a grown-up, not like a scared little girl hiding at the bottom of a Vicodin bottle.

I want to be the legendary Phoenix rising from the ashes. I want my life to get much, much better. To get that car that The Butthead promised me (and I’m willing to hold back on working for him until he makes good on it). I am going to get a better job. Make more money. Look gorgeous. And walk into wherever he is and knock his socks off. Show him that all that therapy — all that work — wasn’t for nothing.

Because at the end of the day, the Square-Jawed NP saved my life. Regardless of what happened in his office or why he was fired, to me, the bottom line is: he saved me because he took  an interest in me when no one else did. Sure, I was paying him, but he provided over-and-above service for a medication management guy. There was something special — a repartee — that went on between the two of us. Maybe it was my imagination. Or maybe my charm won him over. All I know is, without him being MORE than just a medication management dude, I would have gone back out and used. If he hadn’t pushed me to attend AA, to quit using, holding me accountable, talking to me, badgering me, giving me the stink-eye when he thought I was just making excuses, I’d probably be hospitalized again for loperamide overdose, or I’d be dead from it. Any other med management dude would have just handed me a prescription and sent me on my way. He didn’t. And that has made all the difference in the world to me.

Because despite all that’s happened, and how crappy I feel (and I can’t overstate that), I have not used. I didn’t go out and find some Vicodin — even though I know where I can get some — and I didn’t decide to go back on loperamide. No drugs.

I have, however, smoked, and drank the occasional Margarita. I have also taken my hydroxyzine (for anxiety). And I have eaten chocolate. And okay, I had a brief, stalkery moment. But I have not gone off the deep end into drug abuse, and for that, I have him to thank.

I want to find him. I want to tell him what he meant to me — what he STILL means to me. (And God help him if he really did molest a patient. I’ll bury him myself.)

Moreover, I want answers. And I’m sorry, but I won’t rest until I get them. As I continue to strengthen myself, I pray I can handle what I discover.

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“You have seen my descent.
Now watch my rising.” — Rumi

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Random Quote of the Day

unreq

“A most mediocre person can be the object of a love which is wild, extravagant, and beautiful as the poison lilies of the swamp.”

— Carson McCullers “Ballad of the Sad Cafe and Other Stories”

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An Ordinary Kid on an Ordinary Day

candblo

This week, a young man died. In many ways, he was just like most kids his age. He was 27-years-old, the only child from a loving family in a suburb near the midwest; he loved gaming and was a sales clerk. He loved technology — the kind of kid who could probably fix your computer, teach you what to do with that iPad you just bought, and set up your new surround sound system, all while updating his Facebook page, texting a friend, and simultaneously calling another. I don’t know if he had any particular dreams or goals, but I bet he had them. Maybe his dreams never extended beyond wanting to be happy and laugh at funny jokes. He was a handsome kid with bright blue eyes and sandy blonde hair.

Then, on one quite ordinary day in May 2015, that young man died from cardiac arrest, suspected secondary to loperamide abuse/overdose. He’d been hospitalized twice before and almost died from the same thing. Neither his doctors nor his family could understand, didn’t know what was going on.

Like most addicts, this handsome, sandy-haired young man tried to hide the fact that he was sick. He lied to people and hid and denied his addiction the best he could. His family was helpless against this unknown enemy. His final post on Facebook detailed his frustration as, apparently, his parents were taking steps to try to control his usage and help him. Ultimately, it didn’t work. He died the next day.

I didn’t know this young man. I wish I had. I would have noticed his pinned pupils. I would have noticed the bottles on his shelf or empty in the trash. I could have talked to him about the loperamide. I could have tried to shake him out of his tree, addict-to-addict. I could have provided hope and encouragement. I want to reach out to him and reassure him that there’s a life beyond addiction that honestly does not suck as much as he thinks it will. That he’ll be okay! It’ll all be okay! Say something. Anything. But sometimes, despite all efforts, it still doesn’t work.

I receive quite a bit of mail like the one that prompted this article. Parents worried about their kids, sisters, brothers, aunts, uncles, friends — most from the addicts themselves, worried, scared, and needing help where there appears to be none at all.

This week I also received a letter from a new mother who was addicted to loperamide and whose baby was born also addicted to it. Again, doctors are baffled. I’m not.

Loperamide abuse, unlike pain pill addiction or heroin (and other hard drug) addictions, is an underground disorder. It’s sneaky and quiet. And perfectly legal. As a drug-of-choice, it isn’t flashy like bath salts, nor is it well known or respected within the medical community as the “public health danger”1 it is, like heroin. This is partly because it’s relatively new, but also because, loperamide addicts are afraid to speak up for fear of being laughed at — or at the very least, not being taken seriously — so they rarely report. Who wants to be known as a poop-pill addict? But as noted by character Walter White in the series Breaking Bad, “you must respect the chemistry”.

Loperamide, the active ingredient in Imodium, is an over-the-counter medication marketed and widely used as an anti-diarrheal. It also happens to be an opiate — though, theoretically, it can’t make you high. However that hasn’t stopped people from trying. Suggestions have been disseminated among internet discussion groups for how to “mega-dose” loperamide — take it in extremely high quantities — to achieve a high of sorts. And it works. Some try to use loperamide like this recreationally (sometimes combined with something like grapefruit juice or Tagamet in an attempt to ‘boost’ the euphoric effects); others use it as a “poor man’s Methadone” to ameliorate the symptoms of opiate withdrawal. Many end up hopelessly addicted to it.

Each bottle has 200 pills, equaling 2800 pills in one sold package.

Each bottle has 200 pills, equaling 2800 pills in one item offered through Amazon. If you took one pill (a normal dose for diarrhea) and decided to do that every single day, it would take you 3 1/2 years to finish this much! Does anyone using it normally really need that much at once?

And it’s perfectly legal. And cheap! And sold in quantity. Compare one pill being the normal dose for diarrhea, you will find addicts commonly taking 72 tablets or 144 tablets at once (this is the largest size commonly sold in drug stores and at Walmart). Some take much more. You can order loperamide online at Amazon right now in quantities as large as 2800 tablets at once for the low-low price of about $25 bucks (though I’ve personally seen offers of 10,000 pills and up). And yes, anyone can buy them with just a press of a button. They make it easy to get addicted to those mega-doses. All very quiet, secretive, and “normal” arriving in a plain brown box right to your doorstep. (I used to tell people they were vitamins.)

Aside from gross availability, the medical community has only been spottily aware of the problem of loperamide addiction for the last two years. My doctors at Upstate Medical University Hospital in Syracuse NY were the first to widely disseminate their research after my case was reported at the Clinical Toxicology conference in 2013. Since then, there have been other cases seen throughout the country including several more at Upstate — nearly all with life-threatening arrhythmias. Some die.

It happens often after chronic overdose use of loperamide. The usage itself, relatively uneventful, growing or maintaining over months. Then one day, you’re feeling sick, as if you’re getting the stomach flu. Sometimes in just a day. Sometimes two. You’re sleepy all the time. You get this sinking, cold feeling in your gut. Then suddenly, you wake up gasping for air. You’ve fainted. Your heart rate has slowed to 30 beats per minute or less. The heart’s electrical system short-circuited. You’re in a cardiac arrhythmia (most often ventricular tachycardia). Sometimes it degenerates further into an even worse arrhythmia called Torsade. Unaided by medical intervention, the heart stops and you go out again. Sometimes the heart restarts spontaneously, but if it keeps up without medical intervention, you will die.

A hospital visit is the only way to survive.

But, sadly, if a person addicted to loperamide were to actively seek help from an addiction specialist at a rehab or detox center to get off the drug, they’d likely be turned away. Why? Because many working in the field of addiction still don’t know about or understand loperamide. It isn’t their fault — the word just hasn’t gotten out yet. If a patient presents in an ER in cardiac arrest, loperamide won’t show on a normal tox screen, so it’s often overlooked during the differential. It’s happened. I’ve seen it. They just don’t know to ask. They don’t know what they don’t know.

I have been haunted by some of the letters I receive, especially lately. Some people send letters that I respond to but I never hear back. Some write back and update me on how they’re doing (both good and bad). And still others — ones like this — get under my skin. I’m angry and saddened; I’ve actually cried for this young man whom I have never met, and I’ve felt his pain and the pain of the parents and loved ones who had to bury him this week.

I know because I was just like that young man once. I was taking 144 tablets a day when I went into cardiac arrest at home. At the hospital, I was defibrillated 28 times wide awake and lucid for the experience. I had to be put on life support for three days. I crawled back to life through a soupy, thorned hell of my own creation. If it weren’t for the quick-thinking ER physicians at my town’s Memorial Hospital and the incredibly intelligent staff, doctors, and toxicologists at Upstate, I wouldn’t be here today. With aftercare provided by my own Square-Jawed NP who has closely monitored my recovery — I owe them all my life. Literally.

It is survivable. You can recover. Spread the word. Start the discussion.

If you are addicted to loperamide, see your GP or someone in the recovery field. Bring a printout of the most current Loperamide Medical Articles (PDF) with you to your physician, therapist, nurse, or rehab person.

Recovery from loperamide follows the same approach as normal opiate withdrawal only it lasts longer due to the drug’s prolonged half-life. Supportive medications such as Clonidine, Hydroxyzine, etc. ease the recovery. No suboxone necessary. You can tell that to your medical professional as well.

If you recover with help from the medical community both sides win — they learn, you live — and it saves other lives as well. Like some sandy-haired young man of 27 that you have never met.

He was just an ordinary kid on an ordinary day. It could have been someone you love. It could be you.

Be safe, and God Bless.

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“It’s getting critical
Takes a minute for it to set in
I’m unpredictable

And I’m dyin’ just tryin’ to feel alive again.”

                                            –“Critical”, Travie McCoy
(among that young man’s list of favorite musical artists)

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NEW Loperamide Articles in the Literature, May 2015

lopemicroAh! It’s the first of the month — and means it’s New Article Publishing time! Three new loperamide abuse articles to report on for May.

Be sure to check out the full list of articles in the ARTICLE CLEARINGHOUSE.

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loptab3Loperamide toxicokinetics: serum concentrations in the overdose setting.

Eggleston W1, Nacca N, Marraffa JM.
Clin Toxicol (Phila). 2015 Mar 30:1-2. [Epub ahead of print]

Clinical Toxicology

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loptab3Reply to: “Torsade de Pointes Associated with High‐dose Loperamide Ingestion”

Jeanna M. Marraffa, PharmD, Dabat, Michael G Holland, MD, Michael J Hodgman, MD, Upstate Medical University, Syracuse, New York, NY
Accepted 
March 16, 2015.
Journal of Innovations in Cardiac Rhythm Management, 5 (2015), 1958

“These reports underscore the need for further investigation of the cardiac effects of high‐dose loperamide. Further research into the mechanism of both QRS widening and QTc prolongation is warranted. Clinicians need to consider loperamide abuse in otherwise healthy patients with syncope or ventricular arrhythmias, especially those with a history of drug abuse or opioid dependence.”

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loptab3CASE REPORT: Loperamide dependence and abuse
Ryan MacDonald1, Jason Heiner2, Joshua Villarreal3, Jared Strote2
1Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, Washington, USA ; 2Division of Emergency Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA; 3Department of Pharmacy, University of Washington Medical Center, Seattle, Washington, USA
Published 2 May 2015

BMJ Case Reports 2015; doi:10.1136/bcr-2015-209705

“Summary: …. A 26-year-old man who was taking 800 mg of loperamide per day presented requesting detoxification referral. Loperamide has potential for euphoric effects and information on how to facilitate such effects is easily available. It is important for physicians to be aware of the potential for misuse of and dependence on loperamide, with symptoms mimicking opiate use.”

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