Q&A: What Pharmacists Need to Know About Tianeptine

In the United States, the atypical tricyclic antidepressant Tianeptine is sold at gas stations, convenience stores and other types of retail shops. Adverse effects from misusing unregulated tianeptine have been reported to poison control centers recently in increasing numbers. The drug, which is approved to treat major depressive disorder and anxiety in some countries, is not approved or regulated by the FDA in the US. Many states have moved to restrict or ban sales of tianeptine altogether. With more use being reported across the country, it’s important that pharmacists become aware of the drug and how it can impact patients.

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Drug Topics recently sat down with Savannah Roberts Clary, PharmD, BCPS, CPGx, a clinical pharmacist with Aegis Sciences Corporation, to discuss the potential dangers of tianeptine, how pharmacists can manage a patient who may be misusing tianeptine, how pharmacists can help warn the public about the potential hazards of tianeptine, and where pharmacists can go to learn more about tianeptine.

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Drug Topics: Can you explain what tianeptine is and what it’s used for in other countries where it’s an approved treatment?

Savannah Roberts Clary, PharmD, BCPS, CPGx: Tianeptine is marketed as an antidepressant in some other countries where it is approved for medical use. It is not approved for medical use in the United States. It is sought out for various reasons by individuals online and at various retailers, smoke shops, gas stations, that type of thing, for various uses. One can go online and scour various forums and see what individuals are talking about using it for. Some people seek it out to self-medicate for various things. It is structurally similar to a tricyclic antidepressant, but it also has activity at µ-opioid receptors. That can lend it to being sought out for various treatments and self-medication purposes, perhaps for anxiety, perhaps for withdrawals or other things, of course none of which are approved or recognized medical uses in the United States.

Drug Topics: What are the dangers of misusing tianeptine products that are sold online or through certain retail stores?

Clary: It really depends on the manner in which they approach it. There are a wide variety of doses that are discussed online that individuals may use, quite high doses in some cases. There's also discussion of individuals stacking it with other substances of abuse or other prescriptions to where we could get into a drug interaction situation, a complex scenario where multiple effects are being experienced simultaneously by the user. The risks can be very different for different individuals, depending on how they go about using it and what combinations with other substances that they decide to use.

Drug Topics: How should pharmacists manage a patient who may be abusing tianeptine?

Clary: We just need to be increasingly aware of all the many substances that individuals have access to. When counseling individuals or if there is a concern or if patients ask questions about these substances, [we need to realize] that they are not approved for any medical use in the United States [and] they can carry certain risks. While individuals may not have illicit or harmful intent by seeking out these substances—they may think it's just an accessible way to self-medicate and they feel comfortable with accessing the substances—they may be taking an uncalculated risk and can get themselves into a dependency situation or involve themselves in dangerous interactions with other medications or substances that they're taking.

Drug Topics: How can pharmacists play a role in warning the public about the potential dangers of tianeptine misuse?

Clary: It's something that I think we're all learning a lot more about. I have a bit of advantage working for Aegis and the fact that we test for tianeptine and offer that testing to providers. We have been able to learn more about it and educate providers who are considering or who are using Aegis testing with their patients. That has given me a unique opportunity to learn more, but it is something that I imagine is challenging for pharmacists and other areas of practice who might not be as engaged with illicit drug information or nontraditional novel psychoactive substance information on a regular basis. There's just more information out there for pharmacists to digest and to be aware of, that way if patients do mention these substances, particularly like in a community pharmacy, or if patients come in to the emergency department or in the hospital and dialogue about these substances comes up, pharmacists will be familiar with the effects and what to talk about with patients.

Drug Topics: Where can pharmacists go to learn more about tianeptine?

Clary: There are several outlets that individuals could go to for reputable information. Primary literature is varied on these various novel psychoactive substances. There are case reports in some situations where pharmacists can read about actual clinical scenarios where patients were evaluated and treated related to use of these [substances] or just for general knowledge. The FDA has supplied some information, some alerts for the public to be aware of regarding the potential dangers of tianeptine. The DEA as well has information regarding tianeptine. So, there are a number of well-known, validated, reputable sources where pharmacists can go for additional information and learning.

Drug Topics: Is there anything else you would like to say on the topic of tianeptine?

Clary: Tianeptine testing has added a lot in terms of the information that's available to clinicians and the path to recovery or monitoring individuals who are under care for behavioral health or pain management or other types of conditions where providers are considering monitoring for various use of non-prescribed substances. Having the ability to test for tianeptine does open another level of information to be available for providers. If they are concerned about patients using non-prescribed substances, they can have that objective data regarding what has been recently ingested and then have a different, more comprehensive conversation with individuals about that use and possibly make different care decisions based on that information. I'm excited to be a part of offering that type of information to clinicians.

Be sure to check out part 1 and part 2 from this series on tianeptine.

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