“I just wanted to tell you that loperamide WILL WORK”: A web-based study of extra-medical use of loperamide

Abstract

Aims Many websites provide a means for individuals to share their experiences and knowledge about different drugs. Such User-Generated Content (UGC) can be a rich data source to study emerging drug use practices and trends. This study examined UGC on extra-medical use of loperamide among illicit opioid users. Methods A website that allows for the free discussion of illicit drugs and is accessible for public viewing was selected for analysis. Web-forum posts were retrieved using web crawlers and retained in a local text database. The database was queried to extract posts with a mention of loperamide and relevant brand/slang terms. Over 1,290 posts were identified. A random sample of 258 posts was coded using NVivo to identify intent, dosage, and side-effects of loperamide use. Results There has been an increase in discussions related to loperamide’s use by non-medical opioid users, especially in 2010–2011. Loperamide was primarily discussed as a remedy to alleviate a broad range of opioid withdrawal symptoms, and was sometimes referred to as “poor man’s” methadone. Typical doses ranged 70–100 mg per day, much higher than an indicated daily dose of 16 mg. Conclusions This study suggests that loperamide is being used extra-medically to self-treat opioid withdrawal symptoms. There is a growing demand among people who are opioid dependent for drugs to control withdrawal symptoms, and loperamide appears to fit that role. The study also highlights the potential of the Web as a “leading edge” data source in identifying emerging drug use practices.

Ventricular fibrillation due to overdose of loperamide, the “poor man’s methadone”

“…As an inexpensive, over-the-counter option, loperamide has been adapted for this purpose [6]. Loperamide exhibits predominantly peripheral activity, low bioavailability, and poor blood-brain barrier penetration at the FDA-approved doses.…”

“…Since dissemination of its opioid properties in online recreational drug use forums, poison control centers have noticed a doubling in referrals for loperamide overdose since 2014 [3,4]. Loperamide has peripheral mu receptor agonistic properties in the gastrointestinal tract, and accidental and deliberate overdosage has been associated with opioid-like euphoria [5,6]. In fact, loperamide was, at one time, a schedule V drug due to its opioid properties, and has been described as the ‘poor man’s methadone’ [4].…”

“…In the absence of studies indicating any tolerance developing, even at supra-therapeutic dosages, it was removed from scheduling [7]. Due to its ability to control diarrhea, the same drug forums advocated for its use to control the diarrheal symptoms of opioid withdrawal, and it has been increasingly utilized in this manner [3,6]. However, with increasing abuse, there has been a concomitant increase in the number of reports of cardiotoxicity, particular dysrhythmias during the post-marketing drug safety surveillance [2,3] These reports led to a 2016 FDA warning on potential arrhythmias from usage [7].…”

Loperamide abuse and cardiotoxicity

“…Loperamide, an over-the-counter antidiarrheal agent, has seen a steady rise in recreational abuse for its opioid-like effects [1,2]. First reported on web-based forums in 2005, the USA has seen an increase in abuse over the last decade [2], doubling from 2013 to 2015 [1].…”

“…First reported on web-based forums in 2005, the USA has seen an increase in abuse over the last decade [2], doubling from 2013 to 2015 [1]. Recreational abusers report taking doses up to 400 mg/day [1].…”