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Over-the-counter problem no longer under the radar


Three weeks ago, I was wrapping up a discussion with a client and fellow Sedgwick colleagues on the opioid epidemic. Someone in the room received the unexpected text that Prince had died. In the next few moments, without any other information, my fellow pharmacy colleagues and I started thinking to ourselves what could have possibly led to his death. Our meeting ended shortly thereafter and when I reconvened with my colleagues outside, we had all completed the mental exercise in our head, considering the news of an emergency plane landing in the days leading up to Prince’s death. This sounded like a drug overdose.

As details about his death continue to slowly leak into the headlines, news outlets are now beginning to give more air time to the opioid issue that seems to be at play. It seems like for the first time, the media is beginning to provide the coverage this epidemic requires. If there is anything good that can come from a story of another life lost due to opioid abuse, it is awareness and action. These stories can serve to make us aware of how pervasive this issue has become, while also forcing us to act for a better way forward.

One week after the death of Prince, another headline quietly broke regarding the opioid epidemic that requires our awareness and continued action. At the end of April, The Annals of Emergency Medicine published a case report involving two separate cases. Both cases involved single men, ages 24 and 39. Both men in the report had a history of opioid abuse and both were being treated with a medication designed to help them with their opioid addiction. Unfortunately, their addiction was so intense that they both started looking at unlikely alternatives to get their next fix. Both men lost their lives due to an overdose of loperamide, an over-the-counter (OTC) medication more commonly referred to as Imodium. It’s also been called “poor man’s methadone.”

Most of us have heard of loperamide or Imodium and most likely we have some in our medicine cabinets at home. Loperamide, while not considered an opioid, actually has a place on the opioid family tree, but on a somewhat distant branch as a distant cousin. The OTC product is effective in treating diarrhea because it acts in a similar way in the gut that other opioids do, by causing constipation. While loperamide has the ability to work on the same gut receptors that morphine would, in prescribed amounts it will not affect other receptors throughout the body that morphine does. Yet, if someone was to take enough of the medication, they would realize a high similar to that of an opioid.

One of the men from this case report was found with six empty boxes of loperamide next to him and there are reports of some people taking upwards of 100 to 200 tablets per day. At these high doses, the risk for overdose and death greatly increases. If the person doesn’t succumb to respiratory depression, serious heart rhythm changes can occur, which can lead to death.

Dr. Robert Hall, Medical Director of Optum, recently said about this alarming trend, “The inappropriate use of Imodium for the purpose of generating euphoria further illustrates the challenges and severity of drug addiction in this country, in that people would knowingly choose to take a medication despite its risks of further harm. That is the definition of addiction.”

The Annals of Emergency Medicine report cited a 7-fold increase in calls related to loperamide abuse or misuse from 2011 through 2015. The national poison center also noted a 71% increase in calls related to intentional loperamide exposures from 2011 through 2014.

In the coming weeks, I expect some will push that we put loperamide behind the counter, like we do with pseudoephedrine. Such a move would make it harder to abuse loperamide, but we must realize it won’t fix our addiction problem. Those of us in the Sedgwick Pharmacy Program realize that the best way to advocate for someone is not only to advocate what we are against, but what we are for. When it comes to this issue, we will continue to demonstrate how caring countsSM by advocating for safer prescribing, clinically appropriate alternatives, and for solutions that help the whole person return back to a normal way of life.

Paul Peak, PharmD |  Director Clinical Pharmacy Complex Pharmacy Management

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