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Quetiapine Abuse Common in Prison Populations

Major Finding: An estimated 30% of inmates in the Los Angeles County Jail malingered to obtain quetiapine; many of the malingerers were substance abusers who would snort the crushed tablets.

Data Source: Review of case reports from the medical literature.

Disclosures: The study was internally funded. Dr. Mulbry and Dr. Roper each reported that they had no relevant financial disclosures.


 

FROM THE ANNUAL MEETING OF THE AMERICAN ACADEMY OF PSYCHIATRY AND THE LAW

BOSTON – Quetiapine might be a drug of choice among substance abusers behind bars, said researchers at the annual meeting of the American Academy of Psychiatry and the Law.

An atypical antipsychotic with potent sedative and anxiolytic properties, quetiapine (Seroquel) is, along with olanzapine (Zyprexa), one of only two agents in its class to have a "street value," said Dr. Amanda Pearce Roper and Dr. Leonard Mulbry Jr., from the Medical University of South Carolina, Charleston.

"In any given institution where Seroquel is available, there will be hundreds of guys trying to get it," Dr. Mulbry said in an interview.

He said he also has heard anecdotal reports of quetiapine misuse and abuse in the community but has seen little in the way of evidence to support it.

"We had seen so much desire for it in the correctional system, but then when we did the literature search, there was virtually nothing there," he said.

Quetiapine is an antagonist of dopamine, serotonin, and adrenergic receptors, and it is a potent antihistamine with only negligible anticholinergic effects. It strongly binds serotonin receptors but is rapidly dissociated from D2 receptors, which minimizes its effects on the nigrostriatal and tuberoinfundibular pathways, said Dr. Roper.

Stopping the drug abruptly can lead to withdrawal symptoms because of compensatory changes in the aforementioned receptors. The British National formulary recommends that patients on quetiapine be gradually withdrawn from the drug to avoid withdrawal symptoms, Dr. Roper noted.

"In any given institution where Seroquel is available, there will be hundreds of guys trying to get it."

The drug is approved by the Food and Drug Administration for the treatment of bipolar affective disorder in the depressed phase and in mania maintenance, schizophrenia, and as an adjunct to treatment for major depressive disorder.

"Its impact on these symptoms may explain why its misuse is so widespread institutionally and on the street," Dr. Roper commented.

She pointed to a 2004 report that found that about 30% of inmates in the Los Angeles County Jail faked symptoms in order to obtain quetiapine, and that many of the malingerers were substance abusers who would snort the crushed tablets (Am. J. Psychiatry 2004;161:1718).

Other observers reported inmates or patients intravenously injecting crushed tablets or inserting them into the rectum (Am. J. Psychiatry 2005;162:1755-6; Pain Med. 2007;8:171-83).

"We have also gotten anecdotal reports of people using quetiapine on the outside and mixing it with other drugs, particularly cocaine," Dr. Mulbry said.

Dr. Roper noted that several correctional facilities have reported either removing quetiapine from their formulary or restricting its access in attempts to reduce abuse of the drug.

For example, the Santa Rita, Calif., jail removed quetiapine and several other drugs from its formulary out of concerns about abuse. The result was a drop in both medication abuse case reports and the cost of psychotropic agents for the jail, as well as a stabilizing of overall medication costs.

The prescribing information for quetiapine extended-release formulation states in part that "patients should be evaluated carefully for a history of drug abuse, and such patients should be observed closely for signs of misuse or abuse of SEROQUEL, e.g., development of tolerance, increases in dose, drug-seeking behavior."

The study was internally funded. Dr. Mulbry and Dr. Roper each reported that they had no relevant financial disclosures.

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