Addiction Research and Therapy

Biography

Biography: William S Jacobs

Abstract

Opioid use disorders are a major public health concern and an ongoing epidemic in the United States. Recent efforts to restrict the diversion of prescription opioids resulted in opiate abusers attempting to find inexpensive and available alternatives for managing withdrawal or for recreational abuse. Loperamide, an OTC antidiarrheal, may give opiod-like effects at very high doses because of its mu receptor agonist activity. This case is reported to create awareness among clinicians about loperamid’s misuse as an opioid substitute. A 27-year-old male, with psychiatric history of opiates, benzodiazepines, and methamphetamine abuse and mood disorder NOS, was presented to the ED for opiate and benzodiazepine detoxification. Three years ago he became sober through intensive outpatient program with buprenorphine maintenance therapy. The patient started taking 144 mg of Loperamide daily after researching it online. The patient relapsed 1.5 years ago using benzodiazepines and methamphetamines but still taking loperamide. He attempted to quit benzodiazepines two weeks prior to admission and was feeling hopeless with passive suicidal ideation. The Patient last used of alprazolam (two 0.5 milligram tablets) and loperamide was >12 hrs prior to the hospital visit. In ROS pt. had depressed mood, anhedonia, feelings of hopelessness, increased thoughts of death, anxiety, diarrhea, nausea, restlessness, diaphoresis, tremulousness, mild tactile hallucinations and problems with initiation/maintenance of sleep. The patient was admitted to a locked inpatient psychiatric unit for stabilization and withdrawal management. Phenobarbital 120 milligram x1 then 60 milligram q. 4 hours was initiated then tapered. Clonidine 0.1 milligram was given q. 4 hours then tapered. Methocarbamol 750 milligram q. 8 hours for muscle cramping, gabapentin 400 milligram three times daily and nicotine patch 21 milligram q 24 hours were also started. GI was consulted because of patient\\\'s chronic diarrhea and loperamide use. Hepatic panel, loperamide level, X-ray of abdomen, ultrasound of abdomen and pelvis, EKG and echocardiogram were ordered. The EKG showed abnormal findings regarding left ventricular hypertrophy and pericarditis but echocardiogram was normal. Ultrasound of abdomen and pelvis and abdominal x-ray showed no significant findings. Hepatic panel did not show any positive findings; the loperamide level was 2.2 ng/ml, blood was taken after 40 hrs of last use of loperamide. The patient improved in next few days in regards to withdrawal symptoms and was discharged to residential treatment. Loperamide is used between 70-100 mg to control withdrawal or for recreational abuse. A daily dose exceeding 16 mg can be dangerous. Cases reported that loperamide use has been associated with toxic megacolon, with cardiac conduction abnormalities and life-threatening ventricular arrhythmias, and death. With the recent efforts to restrict the diversion of prescription opioids, increasing abuse of loperamide as an opioid substitute may be seen. Toxicologists should be aware of the risks of loperamide toxicity, and we urge all clinicians to report such cases to FDA Medwatch