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 two days after arrival there. The patient noted he had been using tianeptine the past four months in an effort to self-treat kratom abuse. At the time of presentation he had used an extended-release, six-armed, star-shaped, drug delivery device he purchased online (Image 1), 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. He denied intentional self-harm or other co-ingestion. The last dose of the tianeptine containing drug delivery capsule was two days prior to presenting to the treatment facility, or approximately four days prior to ED presentation.

Initial vital signs were blood pressure 166/117 mmHg, heart rate 111 beats per minute, respiratory rate 18 breaths per minute, peripheral oxygen saturation 97%, and temperature 98.1°F. The patient was anxious appearing, notably with tachypnea and asterixis but had an otherwise unremarkable exam; no nystagmus, tongue fasciculations, hyperreflexia, clonus, diaphoresis, or mental status changes were noted. .

Laboratory testing was significant for platelets of 128,000 cells/µL(150,00 – 450,000 cells/µL), AST 105 IU/L (5–35 IU/L), ALT 99 IU/L (5–35 IU/L). All other elements of the complete blood count and comprehensive metabolic panel were within normal limits. Serum ethanol concentration was undetectable. Urine drug screen was positive for barbiturates, benzodiazepines, and THC metabolites and negative for amphetamines, cocaine, methadone, opiates, and oxycodone. EKG showed normal sinus rhythm with normal cardiac intervals. Supine and upright radiographs of the abdomen did not show evidence of radiopaque foreign body.

Due to the structural similarity between tianeptine and tricyclic antidepressants, the toxicology service recommended close electrocardiographic and clinical monitoring for development of cardiotoxicity and manifestations of serotonin toxicity [5], [6], [7], [8]. As tianeptine is also known to have opioid effects, clinical monitoring for opioid toxicity was recommended as well [9], [10], [11], [12], [13], [14].

In regard to the delayed-release device, literature review of the capsule reported the device was composed of the biodegradable polyester polycaprolactone. It was designed to open within the stomach and abut the pylorus while slowly releasing medication for up to ten days [15]. As the patient had presented to the emergency department nearly 72 h post-ingestion, admission for continued observation for a period of at least 24 h was recommended due to his uncertain clinical trajectory.

During the patient’s subsequent two-day hospitalization, 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. Serological studies were within normal studies. The patient was then medically cleared and discharged back to the residential recovery treatment program.