Is Loperamide the New Black?

Posted by Jeffrey Jacobs, M.D., M.P.H.

While I was attending the American Occupational Health Conference in Denver, Colo., last week, I learned about another sad consequence of opioid over-prescribing in our country.

Some addicts have been taking large quantities of loperamide, an over-the-counter anti-diarrheal medication, to relieve opioid withdrawal symptoms. A related article in the January 2017 edition of the Annals of Emergency Medicine discusses two patients who died of cardiac arrest attributed to loperamide toxicity.

For those of you who take remedies containing loperamide for conditions such as traveler’s diarrhea, it is safe to do so as long as you take it as directed – no more than four capsules per day (8 mg) with physician consultation and if there is no symptom improvement after two days. By comparison, abusers reportedly use well over 25 times that amount in their quest to get high or avoid withdrawal.

Sometimes, as the Annals case report describes, large daily doses can cause potentially fatal cardiac rhythm disturbances. The number of reported emergency cases may only be a small sample of the problem since this national phenomenon is not detected until an individual seeks medical care.

Proposed solutions include reducing the number of tablets available in a package of diarrheal medication, restricting sales to one package at a time or placing the medication behind the pharmacy counter. This was done with pseudoephedrine when it was recognized to be a source in the production of methamphetamine a number of years ago. However, there does not appear to be a high likelihood of this happening any time soon.

Meanwhile, the problem illustrates the power of addiction and how we continue to pay for our misguided obsession with “curing” pain. Loperamide abuse is just the latest bill come due.

Ultimately, it is up to health care professionals to take steps to reduce the number of opioid prescriptions that are written. Rather than treating addiction, we need to do more to prevent it from occurring in the first place.

In the occupational health and workers’ compensation arenas, that means judiciously recommending opioids only for severe pain, in small quantities and for a short duration – not typically as a first-line choice for pain relief.

Jeffrey Jacobs, M.D., M.P.H., is an Associate Medical Director with WorkCare based in Pennsylvania.

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