Premiere Date: June 20, 2019
Expiration Date: December 20, 2020
This activity offers CE credits for:
1. Physicians (CME)
All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.
The goal of this activity is to provide a comprehensive understanding of the opioid-like effects of loperamide and kratom and raise awareness of potential dangers associated with use.
At the end of this CE activity, participants should be able to:
• Explain the evolutionary paths of loperamide and kratom
• Discuss the mechanisms for the opioid-like effects of loperamide and kratom
• Identify the pharmacodynamic/toxicodynamic effects of loperamide and kratom
This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.
CME Credit (Physicians): This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfitters, LLC, and Psychiatric Times. CME Outfitters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.
CME Outfitters designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credi™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Note to Nurse Practitioners and Physician Assistants: AANPCP and AAPA accept certificates of participation for educational activities certified for AMA PRA Category 1 Credit™.
It is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific rigor and integrity in all of their CME/CE activities. Faculty must disclose to the participants any relationships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CME/CE activity. CME Outfitters, LLC, has evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer-review process.
The following information is for participant information only. It is not assumed that these relationships will have a negative impact on the presentations.
Cornel N. Stanciu, MD, MRO, has no disclosures to report.
Samantha A. Gnanasegaram, MD, has no disclosures to report.
Thomas M. Penders, MS, MD, has no disclosures to report.
Saeed Ahmed, MD (peer/content reviewer), has no disclosures to report.
Applicable Psychiatric Times staff and CME Outfitters staff have no disclosures to report.
UNLABELED USE DISCLOSURE
Faculty of this CME/CE activity may include discussion of products or devices that are not currently labeled for use by the FDA. The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational uses (any uses not approved by the FDA) of products or devices. CME Outfitters, LLC, and the faculty do not endorse the use of any product outside of the FDA-labeled indications. Medical professionals should not utilize the procedures, products, or diagnosis techniques discussed during this activity without evaluation of their patient for contraindications or dangers of use.
For content-related questions email us at [email protected]; for questions concerning CME credit call us at 877.CME.PROS (877.263.7767)
Dr Stanciu is Assistant Professor, Dartmouth Geisel School of Medicine, Hanover, NH, and Director of Addiction Services, New Hampshire Hospital, Concord, NH; Dr Gnanasegaram is Clinical Instructor, Dartmouth Geisel School of Medicine and Attending Psychiatrist, New Hampshire Hospital; Dr Penders is Affiliate Professor, East Carolina University Brody School of Medicine and Attending Psychiatrist, Walter B. Jones Drug and Alcohol Treatment Center, Greenville, NC.
1. Bose J, Hedden SL, Lipari RN, et al. Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health. 2016. https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.htm. Accessed May 7, 2019.
2. Daniulaityte R, Carlson R, Falck R. I just wanted to tell you that loperamide will work: a web-based study of extra-medical use of loperamide. Drug Alcoh Depend. 2013;130:241-244.
3. Dierksen J, Gonsoulin M, Walterscheid P. Poor man’s methadone. Am J Foren Med Pathol. 2015;36:268-270.
4. MacDonald R, Heiner J, Villarreal J. Loperamide dependence and abuse. BMJ Case Repor. 2015. https://casereports.bmj.com/content/2015/bcr-2015-209705. Accessed May 7, 2019.
5. Erowid. Documenting the Complex Relationship Between Humans and Psychoactives. https://www.erowid.org. Accessed May 7, 2019.
6. Upton N. Cerebral uptake of drugs in humans. Clin Exp Pharmacol Physiol. 2007;34:695-701.
7. Bluelight. 2018. Bluelight. http://www.bluelight.org/vb/threads/296086-Loperamide-(Immodium)-MegathreadWe-have-now-lost-at-least-2-of-our-own-from-Lope/page21 . Accessed November 8, 2018.
8. Reddit. 2018. Reddit. https://www.reddit.com/r/Drugs/com ments/z2k45/imodium_loperamide_for_opiate_withdra wals_tips/d. Accessed November 8, 2018.
9. FAERS. 2016. FDA drug safety communication: FDA warns about serious heart problems with high doses of the antidiarrheal medicine loperamide (Imodium), including from abuse and misuse. http://www.fda.gov/Drugs/DrugSafety/ucm504617.htm. Accessed November 20, 2018.
10. Eggleston W, Marraffa JM, Stork CM, et al. Notes from the field: cardiac dysrhythmias after loperamide abuse. MMWR. 2016;65:1276-1277.
11. Marraffa JM, Holland MG, Sullivan RW, et al. Cardiac conduction disturbance after loperamide abuse. Clin Toxicol (Phila). 2014;52:952957.
12. Providers Clinical Support System. (PCSS). Kratom, A Substance of Increasing Concern. 2018. https://pcssnow.org/event/kratom-a-substance-of-increasing-concern/. Accessed May 7, 2019.
13. Grundmann O. Patterns of kratom use and health impact in the US: results from an online survey. Drug Alcoh Dep. 2017;176:63-70.
14. Post S, Spiller HA, Chounthirath T, Smith GA. Kratom exposures reported to United States poison control centers: 2011–2017. Clin Toxicol. February 2019; Epub ahead of print.
15. Stanciu C, Gnanasegaram S, Ahmed S, Penders T.Kratom withdrawal: a systematic review with case series. J Psychoact Drugs. 2018;51:12-18.
16. Suhaimi FW, Yusoff NHM, Hassan R, et al. Neurobiology of kratom and its main alkaloid mitragynine. Brain Res Bull. 2019;126:29-40.
17. Prozialeck WC, Jivan JK, Andurkar SV. Pharmacology of kratom: an emerging botanical agent with stimulant, analgesic and opioid-like effects. J Am Osteopath Assoc. 2012;112:792-799.
18. Hanapi NA, Ismail S, Mansor SM. Inhibitory effect of mitragynine on human cytochrome P450 enzyme activities. Pharmacog Res. 2013;5:241-246.
19. Hughes RL. Fatal combination of mitrgynine and quetiapine: a case report with discussion of a potential herb-drug interaction. Foren Sci Med Pathol. 2019;15:110-113.
20. Saingam D, Sawitri A, Geater AF, Lerkiatbundit S. Factor analytical investigation of krathom (Mitragyna speciosa Korth.) withdrawal syndrome in Thailand. J Psychoact Drugs. 2016;48:76-85.
21. Vicknasingam B, Narayanan S, Goh TB, Mansor SM. The informal use of ketum (Mitragyna speciosa) for opioid withdrawal in the northern states of peninsular Malaysia and implications for drug substitution therapy. Int J Drug Policy. 2010;21:283-288.
22. O’Malley Olsen E, O’Donnell J, Mattson CL, et al. Unintentional drug overdose deaths with kratom detected: 27 states, July 2016 to December 2017. MMWR Morb Mortal Wkly Rep. 2019;68:326-327.
23. Davidson L, Rawat M, Stojanovski S, Chandrasekharan P. Natural drugs, not so natural effects: Neonatal abstinence syndrome secondary to kratom. J Neonatal Perinatal Med. 201;12:109-112.
24. Mackay L, Abrahams R. Novel case of maternal and neonatal kratom dependence and withdrawal. Can Family Phys. 2018;64:121-122.