Never underestimate the ingenuity or resourcefulness of an opioid aficionado. Opioid devotees turned to street heroin after physicians cracked down on opioid prescriptions, limiting the availability of oxycodone and other opioids. Heroin was and still is relatively cheap and easy to obtain, but it's now much stronger than it was 10 years ago. Street heroin now often contains powerful fentanyl and its derivatives. One shot of the extant heroin is more powerful than a handful of Percocet, and deaths from tainted heroin have skyrocketed. Recent reports of severe, systemic and cardiac toxicity from abuse of a common OTC antidiarrheal medication, loperamide (Imodium), have also surfaced.

The sagacious and clairvoyant toxicologist, Leon Gussow, MD, informed EMN readers of this news 2 years ago. Since then a variety of case reports have described the respiratory, CNS, and cardiac toxicity of loperamide. Direct cardiac toxicity is highlighted because this effect is not seen from other opioids. The Food and Drug Administration also cautioned clinicians about serious heart problems from high doses of loperamide. It is likely that the FDA will shortly mandate changes in loperamide OTC availability.

A simple ambu bag can save most patients who are still alive after an opioid overdose, but the cardiac toxicity of loperamide may be untreatable and can be fatal. Unfortunately, the emergency clinician has no way to confirm loperamide ingestion, and most will be flummoxed by the ECG findings in the patient who has overdosed on this medication. The only way to suspect loperamide toxicity is via history or finding tablets at the scene. Loperamide has been termed poor man's methadone (strange seeing that methadone treatment is free).