Anti-Diarrhea Drugs used by Addicts

Addicts Who Can’t Find Painkillers Turn to Anti-Diarrhea Drugs

By CATHERINE SAINT LOUISMAY 10, 2016

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The active ingredient in the anti-diarrhea drug Imodium, loperamide, can offer a cheap high if it is consumed in large amounts. Credit Daniel Acker/Bloomberg

They call it the poor man’s methadone.

The epidemic of opioid addiction sweeping the country has led to another form of drug abuse that few experts saw coming: Addicts who cannot lay hands on painkillers are instead turning to Imodium and other anti-diarrhea medications.

The active ingredient, loperamide, offers a cheap high if it is consumed in extraordinary amounts. But in addition to being uncomfortably constipating, it can be toxic, even deadly, to the heart.

A report published online in Annals of Emergency Medicine recently described two deaths in New York after loperamide abuse. And overdoses have been linked to deaths or life-threatening irregular heartbeats in at least a dozen other cases in five states in the last 18 months.

Most physicians just recently realized loperamide could be abused, and few look for it. There is little if any national data on the problem, but many toxicologists and emergency department doctors suspect that it is more widespread than scattered reports suggest.

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As efforts to limit prescription opioids intensify, a handful of experts are concerned that more addicts might turn to loperamide — much as an alcoholic might resort to mouthwash when the Jim Beam runs dry.

“We’ve seen patients who have been on loperamide for months at a time,” said William Eggleston, the lead author of the recent report and a clinical toxicologist at SUNY Upstate Medical Center.

He added, “A subset of patients take it to get high, and other patients use it as a bridge” — meaning that if they cannot obtain heroin or morphine, they take loperamide to ease withdrawal symptoms like muscle pains, vomiting, diarrhea and nausea.

Sarah Peddicord, a spokeswoman for the Food and Drug Administration, said, “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.”

After a review, she said, the agency “will take appropriate steps as soon as possible.”

The recommended dose of loperamide is safe. The standard daily dose of Imodium A-D is no more than four caplets, or eight milligrams. But lobe abusers — as they sometimes call themselves — have reported ingesting 100 two-milligram tablets daily for weeks.

In a case reported by Dr. Eggleston and his colleagues, a 24-year-old man experiencing opiate withdrawal took so much loperamide that he died. Toxicology analysis found more than 25 times the regular dose in his blood.

In another case, a 39-year-old man collapsed at home and was pronounced dead at a hospital. His family said he had once managed his opioid addiction with prescription buprenorphine, but had taken to medicating with anti-diarrhea drugs.

Anti-diarrhea medications are cheap, legal and can be bought easily in large quantities without raising suspicion. Costco sells 400 loperamide caplets for just $7.59.

Yet loperamide used to be a prescription drug and a controlled substance, in the same class as cocaine or methadone. The F.D.A. approved it in 1976, and it became an over-the-counter drug in 1988.

Typically, loperamide acts on opioid receptors in the gastrointestinal tract and does not enter the central nervous system. At recommended doses, there is no high, and low potential for abuse. But large doses can produce a high, doctors say.

Some toxicologists argue that the sales of loperamide should be limited, much as the nonprescription drug pseudoephedrine was restricted a decade ago to help prevent the manufacturing of crystal meth.