On the street, its called the “poor man’s methadone” and using it is called “loping”. Once used by the most hard-core addict, it is now coming into vogue as a result of the war on opiates. This medication is available over the counter and is dirt cheap, compared to the price of street drugs, costing just under $8.00 for a package of 400 pills at Costco.com and other online retailers.
And just last month, this medication became the focus of the Food and Drug Administration which issued a request to its makers to limit the amount available to the public and add to its packaging a “Heart Alert” telling users that using more than intended can cause heart problems and even death.
The drug being described is called loperamide, the key ingredient in anti-diarrhea medications like Imodium A-D.
Loperamide is part of the opioid family, an addictive class of drugs currently under fire due to the epidemic of overdoses nationwide. At recommended doses, the medication does an excellent job of controlling diarrhea but as the nation cracks down on doctors prescribing opioids, this medication is being abused more and more because of its ability to give an opiate type high and ease opiate withdrawal.
This, however, is not the first anti-diarrheal to run afoul of federal regulators. For those who grew up in the 1950s and 1960s, a drug called paregoric was a mainstay for people suffering from loose bowels and for new parents with fussy babies. Paregoric was used for everything from stopping a bout of diarrhea to controlling colic in a baby. Doctors even recommended that this drug, made from powdered opium, be rubbed on a child’s gum to relieve the pain of teething.
Up until 1970, paregoric could be purchased at a pharmacy without a script, allowing the purchaser to buy two ounces every 48 hours. There were some guidelines as the purchaser was required to show ID and sign a log, but like everything else, there were weak links in this process that allowed addicts to line up outside unscrupulous pharmacies to get their fix which prompted a change in the law.
In 1970, under the controlled substances act, paregoric was classified as a schedule III drug and no longer available over the counter. However, drugs like Donnagel-PG which contained a mixture of kaolin, pectin and paregoric were still available without prescription in many states until the early 1990s when the FDA banned the sale of anti-diarrheal drugs containing kaolin (a type of clay) and pectin – remember Kaopectate (which is still available today, however now contains bismuth subsalicylate as the active ingredient).
But let’s get back to Imodium.
Approved for use in 1976, Imodium was first available by prescription only, but just 12 years later it was approved for over the counter sales by the FDA for treatment of diarrhea, including traveler’s diarrhea. Sold under the brand name Imodium A-D, as well as store brands and a long list of generics, it comes with a recommended dosage of no more than 8mg a day. Like most over the counter medications, it is safe if used as directed but if abused, has some very serious side effects.
Loperamide has been implicated in heart rhythm problems such as ventricular arrhythmias, syncope and Torsades de Pointes (a specific form of polymorphic ventricular tachycardia). It has also been implicated in kidney and liver failure. Recently, the FDA has been receiving an increasing number of reports of cardiac problems and even deaths because of loperamide abuse as a direct result of the war on opioids.
Watch this CBS News report on the abuse of loperamide - Imodium AD and generic brands.
Although the problem with loperamide is just hitting the news cycle now, it has been a problem in the addict community for many years, especially in urban areas.
Don Drake, one of our community education presenters and a retired administrator of substance abuse treatment programs at hospitals and treatment centers in Boston, Philadelphia, Providence and Hartford, reports that he began seeing this crop up as early as 2009.
“When a person was admitted for treatment, the protocol was to bring in their prescriptions and over the counter medications for review by the medical team. For years, we would see patients coming in with a plethora of laxatives, especially females, as eating disorders and addiction disorders often go hand in hand. Then, around 2009, we started seeing patients bringing in boxes of Imodium. Because diarrhea is a symptom of withdraw, we assumed it was being taken for that reason. But we learned very quickly that it was being abused and was a cheap way to keep the symptoms of withdrawal at bay," Drake explains.
The interesting thing about loperamide is that, unlike heroin or methadone, it only targets the receptors in the stomach and cannot penetrate the blood/brain barrier. But addicts have found a way around that, too, by mixing loperamide with another over the counter drug, omeprazole (brand name Prilosec). Because our gastrointestinal tract has a series of pumps that work by washing away the loperamide and not allowing enough time for our bodies to absorb the drug, it required a massive amount of the drug to achieve any desired effects. However, omeprazole turns those pumps off, drastically reducing the amount of loperamide needed to feel its effects.
“We had reports of addicts using anywhere from 100 capsules to as many as 400 capsules a day of loperamide to maintain their high and ward off withdrawal symptoms,” reports Drake. “These doses can be deadly and withdrawal from loperamide, according to patients we have worked with, can be much more troublesome than traditional opiates.”
So how prevalent is the abuse of loperamide? Here are some numbers.
From 2011 to 2014, the National Poison Data System found a 71% increase in calls related to loperamide use. According to a study published by the Journal of Emergency Medicine, the number of loperamide misuse and abuse calls between 2009 and 2015 nearly doubled, with about one-third of the cases involving teens and young adults in their twenties.
A Google Trends analysis also demonstrated an increasing number of Google searches for “loperamide high” and “loperamide withdrawal” beginning in 2011. WebMD also reports a 10-fold increase in web forum postings about loperamide abuse, either for withdrawal treatment or simply to get high.
So how does this tie into seniors? Are they abusing this at record numbers?
“There is no evidence of this right now,” said Drake. “However, today’s seniors are not
our grandparents. We’re dealing with baby boomers, of which I’m one, who are much more sophisticated about drug use -- just think about what we were exposed to while growing up.”
And this is indeed true. It is estimated that 76 million baby boomers, born between 1946 and 1964, are reaching late middle age and senior status and are bringing with them the habits they had as younger individuals. In fact, a United States government survey found that the rate of illicit drug use for baby boomers has increased over the past decade while the rates for teens have declined.
“Baby boomers used drugs more than any other generation”, Drake said. “It may surprise some people, but when working with late middle-aged adults and seniors in Boston who had drug addictions, many of them belonged to senior centers and were able to buy illicit drugs from other seniors there or dealers who hung out on the corners around these locations. Therefore, we need to be aware when we hear about abuse of medications like loperamide because if it has made the news, you can be sure it is available to seniors who may have issues with opioids and are looking for an alternative.”
Again, numbers bear this out. Drug arrests for baby boomers between 1997 and 2012 outpaced arrests for teens and young adults. Statistics also show that baby boomers have also been admitted to hospitals for drug related heath issues at higher rates as well.
A Wall Street Journal story interviewed dozens of baby boomer drug addicts and found that many had used drugs their entire lives while others, who used when they were younger, returned to them as a coping tool after going through a divorce, death or job loss.
Even more distressing, current government estimates have found that more than 5.7 million people over the age of 50 will need some type of substance disorder treatment by 2020. Those who work in senior services are seeing more patients with histories of addictions entering nursing homes, senior centers or assisted living.
“Because of these numbers,” Drake continues, “Doctors, nurses, CNAs and support staff need to be aware of abuse symptoms and substances that can be abused. Today’s seniors have a much more liberal attitude towards the use of drugs and of course, don’t respond to the scare tactics, so teaching the science of addiction needs to be a reality for senior programs.”
Although senior abuse of loperamide may not be a pressing issue, it is something to be aware of given the fact that ethical medical providers are no longer prescribing opioids like they did in the past due to the increased scrutiny of the government. Seniors who are addicted to opioids may turn to loperamide to stave off withdrawal especially when one considers the cost of buying opioids on the street.
“As of the last week, the costs of just one 5mg tablet of hydrocodone on the street in Rhode Island and Boston averaged around $10, while in Connecticut it was about $8. Given the fact that someone addicted to Vicodin would probably use between 5 and 15 tabs to maintain a high and to keep from withdrawing, that would certainly be prohibitive for someone on a fixed income. But being able to purchase 400 loperamide online for just $8 would be an option for someone who is desperate,” said Drake.
For those who abuse loperamide, stopping it is apparently no easy task. Like other opiates, it has some serious early and late withdrawal symptoms. The early symptoms include agitation, anxiety, muscle aches, insomnia, tearing, a runny nose, sweating and increased yawning. As the withdrawal progresses, the person begins to experience abdominal cramping, explosive diarrhea, nausea and vomiting. Of course, it also depends on how much someone has been using.
Addicts who have turned to loperamide report that withdrawal from it has been worse than from heroin. Many report that symptoms were still present a month later causing some to return to opiate use for relief. And for seniors, withdrawal could aggravate existing health issues.
So be aware, if you see a senior with large amounts of Imodium or generic loperamide, ask why. If this is accompanied by boxes of Prilosec (omeprazole), be even more suspicious. If you suspect abuse, seek medical advice for them and don't just take away the medication. Withdrawal without medical assistance for a senior is potentially deadly.
“We’re dealing with a different generation today,” said Drake. “Rather than just cooking brownies and playing bingo, we need to be teaching our seniors about addiction, sexually transmitted diseases and even bullying. These are real issues that those providing services in elder care programs will continue to face as yesterday’s drug abusers become today’s seniors.”
Attorney Connelly practices in the area of elder law. This area of law involves Medicaid planning and asset protection advice for those individuals entering nursing homes, planning for the possibility of disability through the use of powers of attorney for the both health care and finances, guardianship, estate planning, probate and estate administration, preparation of wills, living trusts and special or supplemental needs trusts. He represents clients primarily in the states of Rhode Island, Connecticut and the Commonwealth of Massachusetts. He was certified as an Elder Law Attorney (CELA) by the National Elder Law Foundation (NELF) in 2008. Attorney Connelly is licensed to practice before the Rhode Island, Massachusetts, Connecticut, and Federal Bars.