(114) Treatment of Poppy Seed Tea Dependence with Buprenorphine in a Telehealth Practice

Background & Introduction: Poppy seeds are a legal source of opiates that are used by some individuals with opioid use disorder. Although the seeds are not permitted to be cultivated in the U.S., they can be imported and are commonly used in food preparation (1). Poppy seeds contain small amounts of alkaloids active on opiate receptors, including morphine, noscapine, papaverine and codeine (2). When appropriately prepared, the opiate content in the seeds is low, but improper washing at harvest leads to contamination from poppy straw and latex, elevating the opiate burden (3). The seeds are then washed or soaked in water by the consumer to make poppy seed tea (PST). In large quantities, PST can lead to opioid dependence, and doses can be high enough to contribute to overdose (4). PST has also been used as a substitution treatment for dependence on other opioids. However, individuals then have continued dependence to PST, which in turn can be treated with buprenorphine, methadone or a taper of extended-release morphine (5). In this report, we describe our experience with 18 patients treated with buprenorphine for PST dependence in a large telehealth practice.

Case Description: A retrospective chart review of our practice’s electronic medical record was performed. Patients were identified if their initial visit occurred between January 1, 2021 and December 31, 2022 and if their enrollment note – an intake form collected by enrollment coordinators when the patient first contacts the practice seeking treatment – contained the word “poppy”. A manual chart review was then conducted and only patients who primarily used PST at the time of enrollment were included for the case series. Primary variables of interest were the initial and maintenance doses of buprenorphine used for treatment. The secondary outcome was retention in treatment. Thirty-four patients were identified by initial screening, and 18 patients were identified as having a primary PST use disorder and are included in this case series. Of these patients, 15 (83.3%) identified as male, mean age was 40.4 (standard deviation 8.8) years, and patients resided in 10 different U.S. states. Median starting buprenorphine dose was 2 mg (interquartile range (IQR) 2-2.5 mg). Median stabilizing dose of buprenorphine was 16 mg daily (IQR 15-20.5) mg. The median most recent dose as recorded in our electronic medical record, which includes patients who were attempting to taper from buprenorphine, was 12 mg (IQR 8-16 mg). As of June 2023 five patients (27.8%) were still in active treatment, mean 475.2 (standard deviation (SD) 239.9) days. Of the thirteen patients who discontinued treatment, their treatment duration was mean 290.7 (SD 231.0) days. Two (11.1%) had completed a planned, elective taper and been discharged to non-pharmacologic care. Ten patients (55.6%) had unplanned discontinuation from treatment, including for financial reasons (i.e., no insurance and/or unable to self-pay); of these 10, two patients from Alabama tapered and discontinued treatment due to a new regulation prohibiting telehealth OUD treatment without an in-person visit, and one patient from Texas also tapered and discontinued treatment for fear of future loss of telehealth treatment availability.

Conclusion & Discussion: To our knowledge, this is the largest case series of patients in the U.S. with PST use disorder, and the first to describe its treatment in the telehealth environment. Although not common, PST is in use in the United States in the modern era. PST use disorder is treatable with buprenorphine with doses similar to treatment of other opioid use disorders. Prescribers tended to start with a lower dose (median 2 mg) and then increase. The median stabilizing dose was similar to what would be expected for treatment of other opioid use disorders (16 mg). Some patients are able to be treated in the telehealth environment, but there are barriers including financial (i.e., insurance) and state laws which hinder access. Clinicians who treat patients with opioid use disorder should be aware of PST use disorder and its treatment.

References: 1. Haber, I., Pergolizzi, J., Jr, & LeQuang, J. A. (2019). Poppy Seed Tea: A Short Review and Case Study. Pain and therapy, 8(1), 151–155.

2. Powers, D., Erickson, S., & Swortwood, M. J. (2018). Quantification of Morphine, Codeine, and Thebaine in Home-Brewed Poppy Seed Tea by LC-MS/MS. Journal of forensic sciences, 63(4), 1229–1235.

3. Kauppila, G. R., & Eagen, K. V. (2023). Opioid Use Disorder from Poppy Seed Tea Use: A Case Report. The American journal of case reports, 24, e938675.

4. Lloyd-Jones, D. M., & Bonomo, Y. (2006). Unusual presentations for pharmacotherapy-poppy seed dependence. Drug and alcohol review, 25(4), 375–376.

5. Unnithan, S., & Strang, J. (1993). Poppy tea dependence. The British journal of psychiatry: the journal of mental science, 163, 813–814.