1.2 Loperamide Intoxication in the Pursuit of Opioid Effects:
Report of Two Fatalities
J. Denton1, A. Youmans1, V. Arangelovich2
1McLean County Coroner’s Office, Bloomington, IL; 2Will County Coroners
Office, Joliet, IL
Loperamide is a common and easily available over-the- counter
medication used to treat diarrhea. Although it is classified as a synthetic
opioid, it has no central nervous system narcotic effects or abuse potential
when used correctly. When used to excess, reports of morphine euphoric
effects exist. We present two deaths from loperamide intoxication from
excess ingestion of loperamide pills, likely related to attempts at attaining
euphoria. Thorough death investigation, autopsy, and additional toxicology
testing studies were required to establish the cause of death. Loperamide
is commonly available in generic and trade form sold in both 2 mg pill and
1 mg/ml liquid form. Loperamide is classified as a phenyl piperidine opioid.
The mechanism of loperamide is slowing of intestinal contractions and
peristalsis to increase gut transit time, allowing greater absorption of
intestinal fluids. The analog diphenoxylate is a Schedule V class drug in
the U.S. and exhibits morphine-like central nervous system effects.
Loperamide stimulates opiate receptors in the intestines, but at usual
dosage is unable to cross the blood-brain barrier, preventing euphoric
effects. At high concentration the blood-brain barrier is overcome. The first
decedent was a 34 year old man with complaints of hip pain for 2 weeks
prior to death. He was found deceased at home, without evidence of foul
play or trauma. The autopsy showed severe pulmonary edema and
congestion, cerebral edema, and polycystic kidney disease. After the
death, the deceased’s roommate notified the coroner he found a baggie of
300 green loperamide pills in the deceased’s clothing. Toxicology testing
was initially positive for doxylamine, dextromethorphan, and caffeine at
normal to mildly elevated concentrations, with subsequent testing by a
second reference lab positive for loperamide at 580 ng/ml in the peripheral
blood (expected value <10 ng/ml). The second decedent was a 47 year
old woman also found deceased at home. Autopsy also showed
pulmonary edema, congestion, and cerebral edema. Toxicology testing
was significant for diazepam and metabolites, and quetiapine in the
peripheral blood at expected concentrations, and also positive for elevated
loperamide at 300 ng/ml. Both deaths were certified as accidental in
manner. Research revealed few other similar loperamide deaths. There
are reports on drug abuse web sites of abuse of loperamide with intent to
attain morphine-like euphoric effects. The excessive number of pills
needed to obtain euphoria, the cost of the high, and the side effects of
loperamide are reported barriers preventing further abuse.
