Severe tianeptine withdrawal symptoms managed with medications for opioid use disorder: a case report

Tianeptine is a tricyclic antidepressant (TCA) without FDA-approval that acts on dopamine and norepinephrine. It has opioid agonist activity and is increasingly being used for recreational purposes to achieve an opioid-like anxiolytic effect. This can lead to clinical addiction with subsequent withdrawal symptoms resembling symptoms of opioid withdrawal. There are limited cases detailing the management of tianeptine withdrawal.

We present the case of a 38-year-old male with chronic tianeptine use admitted to the Intensive Care Unit for treatment of encephalopathy and vital sign changes due to intake of multiple substances and suspected tianeptine withdrawal. He reported 8 to 20 g daily use of tianeptine. He was initially managed with buprenorphine/naloxone and supportive care and reported improvement in withdrawal symptoms within three days of admission. We trialed transitioning to methadone, given possible long-term benefit due to TCA-like properties, but this was discontinued due to difficulty with access on discharge. He was provided with a bridge prescription for buprenorphine/naloxone to cover until his outpatient follow-up visit and was subsequently discharged home.

This case demonstrates management of tianeptine withdrawal in a hospitalized patient presenting with significant daily use not reported previously in the literature.