Long-term Buprenorphine Treatment for Loperamide Use Disorder: A Case Series

: Current data suggest that the opioid epidemic represents a worsening problem in the United States. However, prescribing rates of opioids have been steadily declining, suggesting that alternative opioids are becoming a major contributor to this crisis. One medication that has shown an increase in nonmedical use is loperamide. Loperamide is a peripheral mu-opioid agonist that is intended to be used for diarrhea. However, when taken at high doses and/or in combination with P-glycoprotein inhibitors, it acts centrally by penetrating the blood-brain-barrier. Loperamide crossing the blood-brain-barrier results in similar central nervous system depression as other opioids. Loperamide's over-the-counter availability and growing media presence has resulted in more cases of loperamide substance use disorder, predominantly to minimize opioid withdrawal symptoms and to produce a euphoric state. This case series presents 3 patients with loperamide-associated opioid use disorder who have been successfully treated with on-going buprenorphine treatment. To our knowledge, this is the first case-series to explore long-term buprenorphine treatment for loperamide use disorder. Our findings suggest that buprenorphine can be used for loperamide use disorder, most effectively when patients are in mild to moderate withdrawal. These cases also demonstrate how different waiting times were necessary before starting buprenorphine treatment in order to avoid precipitated withdrawal.