Tianeptine Misuse, Dependence, and Clinical Management: Three Case Reports and Literature Review

Tianeptine, an antidepressant approved only in Europe, Asia, and Latin America, is available without regulation in the United States through online vendors and various retail locations. The rise in its misuse has raised public concerns, marked by dramatic dose escalation, rapid tolerance, toxicity, and withdrawal symptoms. Substance use disorder due to another substance (tianeptine) commonly presents with symptoms similar to opioid use disorder. Symptoms of intoxication include euphoria, respiratory depression, and CNS sedation. Withdrawal symptoms may include anxiety, agitation, and gastrointestinal distress. Acute intoxication management may include the use of naloxone and supportive measures. Withdrawal management should consider the use of buprenorphine as a first-line treatment. Clonidine and other medications used for opioid withdrawal may also be beneficial. Cases with chronic use may require intensive interventions, including residential care, long-term follow-up, and close monitoring, as relapse rates are high. This report presents three cases of tianeptine misuse, detailing their presentation, withdrawal symptoms, and treatment, including pharmacological interventions and treatment setting. We further highlight the problems associated with misuse, the unique presentation of the disorder, treatment options for substance use disorder due to another substance (tianeptine), and the urgent need for regulatory oversight.