Case Presentation: A 43-year-old woman with general anxiety disorder and benzodiazepine abuse was brought to the emergency department by her husband with nausea, diarrhea, agitation, and altered mental status. She also endorsed restlessness and muscle tension. Examination revealed an agitated, disoriented woman with three days of amnesia. Vitals signs were within normal limits. Drug and alcohol screening, complete blood count, comprehensive metabolic panel and electrocardiogram were unremarkable. On further history, she admitted to purchasing powdered tianeptine online and ingesting it “by the spoonful” over the course of a year, both to lose weight and because of its euphoric effects. The patient had several prior hospitalizations due to tianeptine withdrawals with her most recent admission less than a month prior. She was admitted for drug withdrawal given her history of seizures during prior withdrawal episodes. Repeat electrocardiogram demonstrated QT prolongation and QT prolonging home medications were temporarily withheld. Agitation and withdrawal symptoms were treated with lorazepam 2 mg as needed. After two days, her mentation and gastrointestinal symptoms improved. Inpatient drug rehabilitation was recommended given her multiple prior presentations; unfortunately, she declined and was discharged home.
Discussion: Though not approved in the United States, tianeptine is used as an antidepressant in Europe, Asia, and South America and can be easily purchased in large quantities online as a dietary supplement or research chemical. Though relatively obscure in the United States, reports of abuse and withdrawal have been increasing with 208 calls to national poison control centers regarding tianeptine exposure, overdose, or withdrawal from 2000-2017 (1). Such increases in abuse have prompted legislation in several states to reclassify the drug as Schedule I or II. Tianeptine’s exact pharmacological mechanism is not fully understood. Unlike other tricyclic antidepressants, tianeptine has μ-opioid and δ-opioid agonist properties, and is thought to have opioid-like anxiolytic and euphoric effects (2). In addition, it is thought to paradoxically increase serotonin uptake, increase extracellular dopamine concentrations, and increase neuronal plasticity in the hippocampus, amygdala and prefrontal cortex (2). Reports characterize common symptoms of acute intoxication as lethargy, agitation, hypertension, and tachycardia. Withdrawal can present with anxiety, gastrointestinal upset, myalgias, and diaphoresis (3). It can mimic opioid intoxication and withdrawal. At least two fatalities attributed to tianeptine toxicity and one case of neonatal abstinence syndrome have been reported (1). Case reports describe successful treatment with intravenous fluids, naloxone, and/or benzodiazepines (1,3).
Conclusions: We present a case of intoxication and withdrawal from a relatively obscure but legally accessible emerging drug of abuse with high toxicity and abuse potential. The increasing use and dangers of tianeptine warrant increased awareness within the medical community.