When: This event originally occurred on April 15th, 2022.

Presenter: Dr. James Caruso, Chief Medical Examiner, Denver County, CO

Loperamide (trade name Imodium) is a synthetic opioid derivative that is used to decrease the frequency of bowel movements in patients with diarrhea. It first became available to the public by prescription in the mid-1970s. At the time both loperamide and diphenoxylate (trade name Lomotil) were used to treat non-infectious causes of diarrhea, such as inflammatory bowel disease and malabsorption syndromes. Lomotil is actually a combination of diphenoxylate, which is also a synthetic opioid, and atropine. Diphenoxylate was synthesized in the 1950s. While compounds containing diphenoxylate remains only available by prescription (US Schedule V), loperamide is widely available as an over-the-counter medication at nearly every pharmacy and grocery store. Loperamide and diphenoxylate both work by slowing intestinal contractility.

The investigation of a suspected death due to loperamide overdose, as with any suspected overdose, requires at least some suspicion of the drug or drugs involved. A standard medicolegal autopsy should be performed with toxicology testing that covers quantitative detection of loperamide. Because the mechanism of death may be cardiac rather than respiratory, some of the common signs of opioid overdose seen at autopsy may not be present. The scene investigation is critical and must be thorough enough to raise the suspicion that loperamide may be involved. Generally, in these cases, a history of opioid abuse or aggressive self-medication for gastrointestinal symptoms will be obtained from friends, family members, or medical records.

As with all deaths attributed to a fatal drug overdose, multiple drugs may have contributed to the death. If high concentrations of loperamide are present alone or in combination with other drugs, the Centers for Disease Control and Prevention preferred method of filing a death certificate is to list all of the drugs thought to contribute to the death in the cause of death section.

Detailed Learning Objectives:

1. Gain a basic understanding of the pharmacology of the over-the-counter medication loperamide.

2. Appreciate how loperamide is frequently abused and how it can cause death, using case examples demonstrating the scene/history, autopsy findings, and the results of toxicology testing.

3. Learn how deaths due to loperamide ingestion have been certified by medical examiners and coroners within the context of the CDC recommendations for certifying the cause of death in cases due to drug and medication use and abuse.

*Funding for this training was made possible by a cooperative agreement between the National Network of Public Health Institutes and the Centers for Disease Control and Prevention [6 NU38OT000303-03-02]. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Centers for Disease Control and Prevention nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

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