Imodium is an antidiarrheal drug. The active ingredient in Imodium is loperamide (a generic drug). Loperamide, or Imodium, is typically indicated for an episode of diarrhea or to treat people who have inflammatory bowel disease.
Loperamide, after ingestion, attaches to opioid receptors in the gastrointestinal tract and does not travel to the central nervous system. The effect is that the physical activity in the gut slows down, and as a result, the user’s feces will not be watery, as it during an episode of diarrhea. Imodium only treats the diarrhea as a symptom and not the cause (e.g., a bacterial infection). Imodium is an over-the-counter drug, but earlier in its history, loperamide was only available by prescription. Loperamide was approved for over-the-counter use in 1988.
The abuse of Imodium may come as a shock. In the public mind, Imodium is a benign over-the-counter drug, one that a person may hope not to need but can safely resort to as necessary. However, at high doses, Imodium has psychoactive effects and can be abuse-forming. There is no clear rule for what a high dose of Imodium is, but it helps to know the recommended dose versus the doses people who abuse this drug may take.
According to a New York Times article on this topic, there have been reports of people taking 100 2 mg Imodium pills every day (and some abused this drug for months). There are other reports that in order to get high on Imodium, a person (depending on physiological factors, such as sex, height, and weight) would need to take 30-300 pills in a day. According to the makers of Imodium (Johnson & Johnson pharmaceuticals), the recommended dose is no more than 8 mg in a 24-hour period if self-managing the use, or a maximum of 16 mg in 24 hours if under a physician’s care.
Why is Imodium a drug of abuse? The short answer is that it can act as an alternative to prescription opioids, if consumed in high enough doses. At present, there appears to be little research available about Imodium abuse, but the research that does exist reveals the following key information:
- From 2010 to 2011, there was a tenfold increase in the number of online discussions about oral loperamide abuse. According to these forum discussions, approximately 70 percent of individuals abused loperamide/Imodium to stave off the uncomfortable or painful symptoms associated with withdrawal from prescription opioids. Approximately 25 percent abused loperamide/Imodium to get high.
- From 2011 to 2014, there was a 71 percent increase in the number of calls to poison control centers regarding loperamide abuse or misuse.
- Loperamide abuse is extremely dangerous in high doses and can cause death.
- Regarding the cost of Imodium, the Times refers to this drug as “the poor man’s methadone.” The low cost is only one of the driving factors behind Imodium abuse, but it is a significant one. According to the Times, at the time of the article’s publication (May 2016), Costco was selling 400 Imodium/loperamide pills for $7.59. Assuming these are 2 mg pills and abuse can reach 100 pills a day (though possibly more), one 400 pill pack can provide a four-day supply for only $7.59.
As the public largely knows by now, the US is experiencing a prescription opioid and heroin abuse epidemic. The pharmaceutical industry and the government have made efforts to stem the epidemic. For instance, the branded opioid pill OxyContin has been reformulated to make it harder to crush and inject. The government has called for states to implement a prescription drug monitoring system to cut down on the possibility of people “doctor shopping” for prescription opioids. While these controls are necessary in view of the epidemic, they carry unexpected consequences. One such consequence is Imodium abuse.
Presently, it is not known if Imodium abuse will spread, but there does appear to be a trend in this direction based on the statistics provided above. The public should not be surprised that individuals who are addicted to opioids have searched for, and found, a low-cost, accessible alternative.
In view of the rising levels of Imodium abuse, the Food and Drug Administration may in the near future limit the number of Imodium pills an individual can buy at any one pharmacy. This approach is akin to how the government has limited the number of certain cold medications a consumer can buy because these drugs have been used to make crystal meth. The pharmaceutical industry and the government have worked on the supply side of the prescription opioid pill epidemic, not the demand. One way to lower the demand side, and keep individuals from seeking alternatives to opioid pain pills, is to get people who need help into treatment.
Signs of Imodium Abuse
Knowing the signs of Imodium abuse is an important early step in recognizing the need for treatment. These signs can be physical, psychological, and behavioral. The following are some of the milder, more common physical side effects associated with Imodium use:
- Mild skin rash
Currently, there appears to be little research-based information about additional physical or psychological signs related to taking Imodium in high doses. However, anecdotal evidence is available from online forums in which people discuss their experience of abusing loperamide/Imodium. Some personal accounts provide the following insights on loperamide/Imodium abuse:
- A street nickname for loperamide is lobe. A concerned person may hear a loved one using the term lobe,which can be a tipoff that abuse is occurring. A person who buys Imodium for occasional diarrhea would not likely use this street term.
- Loperamide abuse can confer a warm sense of euphoria.
- Some individuals report feeling psychologically addicted to loperamide. There are numerous signs associated with a psychological addiction to Imodium, including stockpiling the drug. Another sign is that a person may spend an inordinate amount of time buying, using, or recovering from Imodium abuse.
- One person who had been taking approximately 42 (2 mg) doses of loperamide each day for over a month reported experiencing withdrawal after she stopped using the drug. Withdrawal symptoms included a panic attack, cravings for loperamide, body tremors, chattering teeth, sweating, and anxiety. She initiated a tapering process to avoid withdrawal symptoms in an attempt to stop the abuse. The taper appeared to be helping.
The behavioral signs of addiction are expansive, yet they all have one thing in common: They demonstrate a noticeable change in the affected person. Though humans are not always consistent, they do tend to have a core personality and way of doing things, but drug abuse can radically alter every facet of a person’s existence. For this reason, a radical shift in character is itself an overarching sign that drug abuse may be occurring. The following are some additional behavioral signs of substance abuse:
- Sudden or progressive decrease in school or work performance
- Having financial problems, which may provoke a person to borrow money and not pay it back, steal, lie, or cheat
- Becoming secretive about how one spends time or money, or whom one is hanging out with away from home
- Having new friends, spending time in new areas, and/or using drug lingo
- Uncharacteristically getting into fights, engaging in illegal activities, or experiencing more accidents than ever before
One of the challenges prescription and over-the-counter drugs pose to the public is their benign appearance. On the one hand, these drugs are safe; on the other hand, if abused, they are exceptionally dangerous. The type of public drug education needed today cannot be the same as in earlier times. The dual nature of prescription and over-the-counter drugs – that they can help but also harm – is a main point that needs to be made clear to the public.
The Risk of a Loperamide Overdose
According to the Times, in the 18 months leading up to May 2016, there were two loperamide overdose deaths in New York. In addition, there were at least 12 cases across the nation that involved deaths or near-fatal irregular heartbeats. At present, there is little national data available. There may be a greater incidence than known because emergency room doctors may not be aware to look for signs of Imodium abuse in patients.
The two fatal overdoses in New York were reported on April 29, 2016 in the online journal edition of the Annals of Emergency Medicine. To illuminate the dangers involved in loperamide abuse, consider the facts presented in one of the cases (referred to in the journal article as “Case 2”). This individual, a 39-year-old male, was in recovery from opioid addiction. For several years, he had been taking buprenorphine (i.e., Suboxone or Subutex) as a form of substitution treatment. In other words, he had stopped using opioids but was being maintained on a medication-assisted treatment. He, therefore, had not undergone a full detoxification, but was in recovery. One day, this individual suddenly gasped and then collapsed in his home. Emergency services were called, and he was pronounced “deceased” by the time he was brought to the hospital. The doctors learned that three years earlier, this individual stopped taking buprenorphine and began to manage his opioid addiction with antidiarrheal medication. The gasping for air and collapse that preceded the man’s death are consistent with sudden cardiac dysrhythmia. The man’s autopsy showed cardiomegaly and severe pulmonary edema. According to the doctors involved, the exact cause of the death is unknown, but loperamide abuse was a main contributing factor, if not the cause.
Not all loperamide overdoses cause death. The journal Heart Rhythm Case Reports includes an account related to a person who was abusing loperamide to stave off opioid withdrawal symptoms.
This case pertains to a 28-year-old woman who was taking 400-600 mg of loperamide daily for months. She sought medical help after experiencing a blackout. According to an electrocardiogram, she was suffering from an extremely irregular heartbeat and abnormal electric activity in her heart. After a few days without taking loperamide, her fainting spells stopped and her heartbeat returned to normal. It is not known whether abruptly stopping use of loperamide is advisable in most cases. In some instances, a tapering may be safer. A doctor or addiction specialist can provide guidance.
Treatment for Loperamide Abuse
As the foregoing discussion notes, abuse of loperamide is relatively new compared to other drugs of abuse. From a recovery standpoint, however, loperamide abuse is 100 percent treatable. As the National Institute on Drug Abuse explains, there are two main components of drug recovery treatment: medications and therapy. Regarding medications, only a few drugs of abuse are treated with medications (during the detox and/or primary care phase). While loperamide acts on opioid receptors in the gut, treatment for abuse of this drug may not align with treatment for opioid abuse. A treating physician at the rehab center will explain to incoming clients whether any medications can be safely used during the detoxification process or if a tapering process is recommended.
While the use of targeted medications is limited to specific drugs of abuse, therapy is used to treat the abuse of any drug. The goal of therapy is to address the emotions and thoughts that underlie the drug abuse. For this reason, therapy does not revolve around the type of drug abused but rather the abuse itself. There are numerous research-based therapy approaches being used in rehab centers across America, including but not limited to Cognitive Behavioral Therapy, Dialectical Behavior Therapy, Motivational Interviewing, and 12-Step facilitation therapy. Individuals in treatment generally receive both individual and group therapy to address and heal the drug abuse. These therapies, in addition to others (depending on the rehab program), can be used to help a person recover from loperamide abuse.
While medications and therapy make up the core of rehab services, there are several additional forms of treatment that a rehab program may provide. The following is a partial list of supplemental and supportive forms of drug recovery treatment:
- Drug education classes
- Family therapy
- Nutritional support and educational
- Peer support meetings (e.g., Narcotics Anonymous, SMART Recovery, etc.)
- Case management services
- Aftercare planning and support
- Meditation, including instruction on meditation techniques
Whether a person is abusing loperamide to stave off opioid withdrawal symptoms or to experience a high, rehab services can help. Presently, entering a rehab program is the most universally recommended way to treat addiction. In addition to addressing the addiction head on, a person can learn skills and develop tools to create a blueprint for a drug-free life. Though a person’s life may go down the path of addiction, there is always an exit. For many, rehab provides that exit.