Neonatal Abstinence Syndrome Following Tianeptine Dependence During Pregnancy

Neonatal Opioid Withdrawal Syndrome Following Prenatal Use of Supplements Containing Tianeptine

Tianeptine is an opioid receptor agonist that is prescribed as an antidepressant in many countries. In the United States, tianeptine is not approved for medical use because of its potential for abuse and addiction. Nonetheless, products containing tianeptine are easily obtainable and are marketed as dietary supplements. There are increasing reports of adverse effects and fatal toxicities resulting from tianeptine use among adolescents and adults. This emerging public health threat could escalate the opioid epidemic and drive increased newborn perinatal exposure. The impact of in utero exposure to tianeptine has not been studied, and to our knowledge, the authors of only 1 report have documented possible neonatal effects. Here, we describe a case of chronic prenatal exposure to tianeptine in the setting of maternal dependence on dietary supplements. This infant developed signs of severe withdrawal shortly after birth that were refractory to treatment with oral phenobarbital but responded to subsequent oral morphine therapy. On further questioning, the mother revealed the use of a tianeptine-containing dietary supplement. We did not perform confirmatory toxicology testing because tianeptine is not assayed by usual urine drug screening tests. For infants with clinical signs of opioid withdrawal without known etiology, we suggest that the maternal interview should inquire about the use of neurotropic over-the-counter drugs.

"Tianeptine abuse via novel, extended-release, star-shaped, drug delivery device"

We report a rare domestic case of exposure to tianeptine and use of a novel, extended-release, six-armed, star-shaped, drug delivery capsule. A 40-year-old male with a history of depression, anxiety, ethanol, opioid, cannabis, and tobacco use disorders presented to the emergency department (ED) from a substance abuse residential recovery treatment program after developing hypertension, tachycardia, and tremor for two day. He used an extended-release, six-armed, star-shaped, drug delivery device he purchased online, filling each arm with 15 mg of tianeptine (90 mg total). His intention was to mitigate the symptoms of kratom/opioid withdrawal through this extended-release method while simultaneously undergoing formal treatment for ethanol withdrawal. Tianeptine is an atypical tricyclic antidepressant that exerts complex mechanisms of action including serotonin (5-HT) neuromodulation as well as full μ-opioid and ∂-opioid receptor agonism. The capsule itself is made of caprolactone, which is a bioabsorbable material similar to absorbable sutures, initially developed as a long-term enteral antimalarial delivery method and is not FDA approved for human use. Over the course of the patients two day hospitalization course he developed symptoms consistent with uncomplicated ethanol withdrawal, which were treated with as-needed phenobarbital. No clinical manifestations of opioid or serotonin toxicity developed. Serial EKGs and telemetry monitoring remained unchanged. The patient was then medically cleared and discharged back to the residential recovery treatment program.

From Antidepressant Tianeptine to Street Drug ZaZa: A Narrative Review

Tianeptine is often incorrectly described as a selective serotonin reuptake inhibitor, but it actually is a µ-opioid receptor agonist with anxiolytic effects. It has been approved since the last 1980s in about 24 countries as a treatment for depression, but it was never cleared to market in the United States for this purpose. Nevertheless, tianeptine joined the billion-dollar US market of nootropics as ZaZa or Tianna Red and is widely available online and in small shops without a prescription, to the point that it has been nicknamed "gas station heroin." While the therapeutic dose range is about 25 to 50 mg/day, tianeptine abusers may take 100 times that amount. Tolerance occurs rapidly and users who seek to recapture the short-lived euphoric effects of the drug have to take more and more. Social media has peer-support sites for those trying to discontinue tianeptine. Tianeptine is associated with multiple side effects at high doses along with dependence, withdrawal symptoms, toxicity, respiratory depression, and even mortality. Agitation is more often a presenting symptom of withdrawal than toxicity. Tianeptine is often used by polysubstance drug abusers who may be unaware of the drug's dangers. Few clinicians are aware of tianeptine and most urine assays do not screen for it. Greater awareness is needed for this drug and steps must be taken as tianeptine or "gas station heroin" is emerging as a new public health threat.

[Modern concepts of pathogenetic therapy of anxiety disorders]

The high prevalence of anxiety disorders around the world leads to a high interest in the study of anxiety. At the moment, a lot of knowledge about the pathogenesis and therapy of anxiety disorders has been accumulated, which is well covered in modern domestic and world medical literature. It is known that many areas of the brain are involved in the modulation of anxiety, among which the amygdala is considered the key in the modulation of anxiety and fear. A large body of evidence supports the involvement of different neurotransmitter systems in the processes of anxiogenesis-anxiolysis (GABA, monoamines, glutamate, neuropeptides, neurosteroids). This article provides an analysis of methods of pharmacological impact on each of these systems, which serve to optimize the already known strategies of anxiolytic therapy.

Use of Buprenorphine-Naloxone in the Treatment of Tianeptine Use Disorder

: Tianeptine is an atypical antidepressant which exerts an opioid-like effect on the μ-opioid receptor. There is well documented intentional misuse and addiction to tianeptine in Europe, and this is increasingly being seen in the United States. We presented a case of buprenorphine/naloxone successfully being used to aid in cessation and subsequent abstinence from tianeptine after years of use. An additional consideration with tianeptine use is the potential for the development or re-emergence of depression and anxiety on cessation. Chronic daily use of tianeptine may represent tianeptine use disorder, which can have a clinical course consistent with opioid use disorder, including the development of impaired control, functional impairment, tolerance, and withdrawal. It is appropriate to consider medications for opioid use disorder for the management of tianeptine use disorder.

Endogenous Opiates and Behavior: 2016

This paper is the thirty-ninth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2016 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.

Tianeptine Abuse and Dependence in Psychiatric Patients: A Review of 18 Case Reports in the Literature

Tianeptine is an atypical antidepressant approved in 25 countries for the treatment of depressive syndromes. Tianeptine abuse among psychiatric patients in the community and at inpatient wards has been increasingly reported in recent years. The purpose of this article is to alert clinicians to tianeptine abuse potential and identify any patterns in the literature. We searched the Academic Search Complete, Google Scholar, MEDLINE, Science Citation Index, Scopus, and the Social Sciences Citation Index for articles published between 1960-2017 in any language containing the keywords: "tianeptine abuse," "tianeptine misuse," "tianeptine dependence." The search retrieved 18 cases. Higher frequency of tianeptine abuse/dependence was observed in women and 30- to 45-year-olds. Most cases (n = 13) reported a previous history of substance abuse. The therapeutic dose of tianeptine was exceeded 110-fold (i.e., up to 4125 mg/day) with a mean of about 1469 mg/day. The most prominent phenomena associated with tianeptine abuse and dependence were marked euphoria and withdrawal symptoms perpetuating further drug misuse. Tianeptine is a drug with potential for abuse and addiction. Caution should be taken when considering the prescription of tianeptine to patients with prior history of substance abuse, and close monitoring for drug misuse is needed during the treatment period.

Pharmacokinetic study of tianeptine and its active metabolite MC5 in rats following different routes of administration using a novel liquid chromatography tandem mass spectrometry analytical method

Tianeptine is an atypical antidepressant with a unique mechanism of action and recently it has been also reported that its major metabolite, compound MC5, possesses pharmacological activity similar to that of the parent drug. The current study aims to investigate the pharmacokinetics (PK) of both tianeptine and MC5 after intravenous or intraperitoneal administration of the parent drug as well as the metabolic ratio of MC5 in rats. To achieve these goals an LC-MS/MS method using the small sample volume for the quantitation of tianeptine and its active metabolite MC5 in rat plasma and liver perfusate has been developed and validated. Following an intravenous administration of tianeptine pharmacokinetic parameters were calculated by non-compartmental analysis. The average tianeptine volume of distribution at steady state was 2.03 L/kg and the systemic clearance equaled 1.84 L/h/kg. The mean elimination half-lives of tianeptine and MC5 metabolite were 1.16 and 7.53 h, respectively. The hepatic clearance of tianeptine determined in the isolated rat liver perfusion studies was similar to the perfusate flow rate despite the low metabolic ratio of MC5. Mass spectrometric analysis of rat bile indicated that tianeptine and MC5 metabolite are eliminated with bile as glucuronide and glutamine conjugates. Bioavailability of tianeptine after its intraperitoneal administration was 69%. The PK model with a metabolite compartment developed in this study for both tianeptine and MC5 metabolite after two routes of administration may facilitate tianeptine dosage selection for the prospective pharmacological experiments.