26 January 2023: Articles
Unusual clinical courseGlenn R. Kauppila1ABCEF*, Kellene V. Eagen 2ABCDEF
Am J Case Rep 2023; 24:e938675
BACKGROUND: Unwashed or unprocessed poppy seeds may be an underrecognized substance that can lead to dependence, abuse, and an opioid use disorder. Poppy seeds can be purchased in an unwashed or unprocessed form, and these seeds can be contaminated with the opium alkaloids morphine, codeine, and thebaine on their surfaces. Poppy seeds that are commercially available, such as those used for baking and in other food products, are legal to purchase, as they do not contain the opium alkaloids on their seed coats. Purchase and possession of the unwashed or unprocessed seeds are not legal in the United States. These contaminated poppy seeds can then be put through a process in which they are washed, and the supernatant (tea) is collected and consumed to experience its intoxicating effect or for the treatment of pain or opioid withdrawal.
CASE REPORT: A 65-year-old man with a history of alcohol use disorder, cannabis use, and chronic pain began using this poppy seed tea for treatment of chronic pain after his provider had stopped prescribing opioid pain medications for him. He developed a dependence on the tea. He had reached out for assistance as it was his desire to stop using the poppy seed tea. The diagnosis of an opioid use disorder was made using the DSM-V criteria. He was successfully induced and maintained on a buprenorphine/naloxone product.
CONCLUSIONS: Poppy seeds in their unwashed and unprocessed form can be misused and could lead to an opioid use disorder. This disorder can be treated with buprenorphine/naloxone products.
Keywords: Opioid-Related Disorders, Substance-Related Disorders, Male, Humans, Aged, Papaver, Analgesics, Opioid, Opium, chronic pain, Morphine, Seeds, Tea, Buprenorphine, Naloxone
Poppy seeds, usually sold for baking or cooking purposes, are readily and legally available for purchase in the United States. They have been known in medical practice to be a potential cause of unexpected positive results for opioids and their metabolites in urine drug tests . The seeds themselves do not contain opiates; however, the seed coats of unwashed or un-processed seeds can contain the opium alkaloids morphine, codeine, and thebaine. These unwashed or unprocessed seeds can be purchased over the internet and are not legal in the United States . These opiates can be readily extracted into a consumable form by creating a tea from the unwashed or unprocessed seeds . In 2019, the US Drug Enforcement Administration clarified that those poppy seeds themselves are not subject to control under the Controlled Substances Act. However, the opium alkaloids that can contaminate the seeds are and are therefore illegal to purchase .
The opium alkaloids can be extracted from the surface of the seeds by soaking them in water (sometimes with lemon juice or citric acid) and shaking them vigorously to create what is called a “tea” . This supernatant is then consumed to experience the effects of the opiates. The opiate concentration on the seeds is highly variable, with the amount of morphine ranging from 10 to 105 mg/kg of seeds and codeine concentrations from 3.1 to 11.2 mg/kg [3,4]. This unpredictability of quantity consumed adds to the risks associated with use of this source of opioids.
Poppy seed tea can be consumed for the purposes of intoxication or for the treatment of pain, anxiety, or withdrawal from opioids or opiates . However, its use is not benign and presents a risk for misuse that can lead to dependence, accidental overdose, and death [3–5]. Use during pregnancy can lead to neonatal abstinence syndrome in the newborn . In a study of 24 patients at a substance use treatment facility in New Zealand, 46% of opioid-dependent patients reported a past use of poppy seed tea (PST) .
A 65-year-old man being treated at a multidisciplinary pain clinic was referred for an addiction medicine consultation due to his concerns that he had developed a dependence from the use of PST. He requested assistance with transitioning to a physician-prescribed and monitored therapy if appropriate. Due to COVID-19 restrictions, patient encounters were completed using a video telemedicine format. The patient had a history of chronic pain secondary to degenerative joint disease in his shoulders and degenerative disc disease in the lumbar spine. Opioids had been prescribed by his provider in the past. He stated that due to a urine drug test positive for cannabis, the opioids were discontinued. This prompted him to research other pain control options and he started purchasing poppy seeds online to brew and consume. He was consuming PST twice daily.
In addition to chronic pain, his past medical history was significant for diabetes mellitus type 2, hypertension, depression, and PTSD. His substance use history included alcohol use disorder, in sustained remission for 17 years. He currently attended Alcoholics Anonymous (AA) meetings weekly and regularly used cannabis. Notably, he did not meet criteria for prescription opioid use disorder when using prescribed opioids daily. The patient was married and retired.
When discussing using PST, he cited his wife’s concern regarding its use. His other motivations to stop included feeling disingenuous for going to AA while using the tea, the cost of the seeds was unsustainable, and he feared he would not be considered for future surgery if using it. Despite these motivations to stop, the patient felt unable to stop using PST on his own.
Urine drug analysis using gas chromatography was positive for morphine, codeine, hydromorphone, hydrocodone, norhydrocodone, gabapentin, and Δ-9-THC and 11-OH-THC. The first 5 were consistent with the use of PST, and the remainder were consistent with his disclosed history.
During a structured interview using the DSM-V criteria (Table 1), he was diagnosed with a moderate opioid use disorder. He also has the diagnosis of alcohol use disorder in remission. We discussed the FDA-approved treatments for opioid use disorder (methadone, buprenorphine, and naltrexone). The additional analgesic properties and accessibility in primary care of buprenorphine made it his preferred treatment agent. He consented to transition from PST use to prescribed buprenorphine/naloxone treatment for co-occurring opioid use disorder and chronic pain.
Buprenorphine-naloxone initiation was carried out at home with close telemedicine monitoring and support by addiction medicine physicians. The patient began to experience withdrawal (dysphoria and gastrointestinal upset) at about 32 h after his last dose of PST. He started by using a buprenorphine/naloxone 4-1 mg film with instructions to use one-quarter to one-half of a film every 2 h for withdrawal symptoms, up to a total of 8 mg on day 1. On day 2, he continued to have mild gastrointestinal symptoms and took a total of buprenorphine 10 mg. On day 3, he continued 10 mg and cited resolution of opioid withdrawal symptoms. He continued 10 mg from day 2 to day 13. On day 13, he reached out to the clinic reporting increased cravings for PST. He was instructed to increase his dose to 12 mg of buprenorphine. He continued 12 mg daily. Two months following initiation of buprenorphine, he reported adequate pain control and had a noticeable improvement in his overall function. He also reported abstinence from PST. He remained on prescribed gabapentin. He continued to use cannabis.
PST is a supernatant extracted from poppy seeds coated with the naturally occurring opiates morphine, codeine, and thebaine. As an available source of opiates, it can be obtained and used for self-treatment of pain or opioid withdrawal or for the purpose of achieving intoxication. As with other available substances (Kratom) with opioid effects, it may be underrecognized as a substance of abuse and dependence. Just as with other opiates and opioids, use of the tea can lead to an opioid use disorder. In this report, we discuss the case of a 65-year-old man who developed an opioid use disorder while using PST to self-medicate pain. He was successfully treated with buprenorphine/naloxone to achieve control of his use disorder and reported excellent analgesia.
The purpose of this case report is to remind clinicians that poppy seeds are an available, purchasable food item, which, in the unwashed or unprocessed form, have the potential for misuse and can be an additional cause of an opioid use disorder. PST use disorder can be treated with a buprenorphine/naloxone product.
1.. Rohrig TP, Moore C, The determination of morphine in urine and oral fluid following ingestion of poppy seeds: J Anal Toxicol, 2003; 27(7); 449-52
2.. , Unwashed Poppy Seed (DEA PRB 11-15-19-44) Published November 2019. Available from: https://www.deadiversion.usdoj.gov/drug_chem_info/unwashed_poppy_seed.pdf
3.. Garcia MR, Swortwood MJ, Aune CN, Ahmad KA, Maternal poppy seed tea ingestion and ensuing neonatal abstinence syndrome: Neonatology, 2020; 117(4); 529-31
4.. Spyres MB, Van Wijk XMR, Lapoint J, Levine M, Two cases of severe opiate toxicity after ingestion of poppy seed tea: Toxicol Commun, 2018; 2(1); 102-4
5.. Braye K, Harwood T, Inder R, Poppy seed tea and opiate abuse in New Zealand: Drug Alcohol Rev, 2007; 26(2); 215-19
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