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Buprenorphine/naloxone/loperamide Loperamide use disorder following an abuse and precipitation of loperamide withdrawal symptoms: 3 case reports

In a case series, 3 patients (one man and two women) aged 37–39 years were described, who developed loperamide use disorder following loperamide abuse. Additionally, two of the three patients developed precipitation of loperamide withdrawal symptoms during treatment with buprenorphine/naloxone, indicated for loperamide use disorder [routes not stated; not all dosages and duration of treatments to reactions onsets stated]. Patient 1: A 38-year-old man had been using opioids for 18 years and presented with opioid use disorder. Recently, he started using loperamide at a dose of 200 mg/day (100 pills). Thus, a loperamide abuse and drug use disorder was reported after using loperamide for 1 year. Subsequently, he was started on buprenorphine/naloxone 8mg every 24 hours following his last loperamide use. Thereafter, he experienced severe loperamide withdrawal symptoms. He was prescribed with ondansetron, hydroxyzine and clonidine. He reported going into mild precipitated withdrawal even after waiting another 24 hours before taking his second dose of buprenorphine/naloxone. At 72 hours, he was successfully transitioned and stabilised onto buprenorphine/naloxone 12mg. Afterwards, he has stable on buprenorphine/naloxone 6mg. Definitive urine drug tests revealed therapeutic levels of buprenorphine, and there was no evidence of further abuse of opioids or other illicit substances during the entire duration of treatment. Patient 2: A 37-year-old woman presented with opioid use disorder and recent loperamide overdose in 2018. Her medical history was significant for chronic back pain, fibromyalgia, diabetes, bipolar disorder, depression and anxiety. After knowing that some people were using loperamide to help with withdrawal and cessation of heroin use, she had started using loperamide at a dose of 400 mg/day (200 pills). A loperamide abuse and drug use disorder was reported after using loperamide for 2 years. She had been using loperamide as she discovered that it gave her the same euphoric effects like other opioids. She was instructed to wait 36 hours before starting with buprenorphine/naloxone tablets for treatment of loperamide use disorder. Buprenorphine/naloxone was started at a dose of 2mg every 1 to 2 hours, until reaching the effective dose of 10mg. Eventually, the loperamide use disorder resolved. Definitive urine drug tests revealed therapeutic levels of buprenorphine, and there was no evidence of further abuse of opioids or other illicit substances, during the entire duration of treatment. Patient 3: A 39-year-old woman presented with opioid use disorder, polysubstance use, depression, psoriatic arthritis and anxiety. She had been using loperamide at a dose of 200–400 mg/day (100–200 pills). A loperamide abuse and drug use disorder was reported after using loperamide for 3 years. Subsequently, she was started on buprenorphine/naloxone 16mg after her last loperamide us