Savvy Psychopharmacology

Abuse of second-generation antipsychotics: What prescribers need to know

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References

Practice Points

• Antipsychotics have been abused and misused by inpatients and outpatients.

• Most published case reports of antipsychotic abuse involve quetiapine, although some describe misuse of other agents, including olanzapine.

Serotonin, histamine, and α-adrenergic neurotransmitter systems may play a role in second-generation antipsychotics’ abuse potential.

• Although individuals have misused quetiapine and olanzapine, evidence indicates that these drugs may be effective for treating substance use disorders.

Mr. Z, age 27, seeks treatment for substance abuse at a mental health clinic. He has a 7-year substance use history and his last urine drug screen 1 month ago was positive for marijuana, opiates, and benzodiazepines. Mr. Z reveals that he purchases prescription drugs on the street, including hydrocodone, diazepam, and quetiapine. He states that when he takes a 100-mg dose of quetiapine, he feels happy, relaxed, and “drunk without the mind-numbing effects that you get with alcohol.” Mr. Z often takes quetiapine while smoking marijuana. He sleeps well with this and does not experience a hangover effect.

Although clinicians always are vigilant about patients’ misuse of psychoactive substances, recent case reports have described abuse of antipsychotics, particularly second-generation antipsychotics (SGAs). A PubMed and PsycINFO literature search revealed several case reports of quetiapine abuse (Table)1-6 and 2 case reports of olanzapine misuse.

Table

Case reports of quetiapine abuse

ReferencePatientSettingDescription of abuse
Hussain et al, 20051Woman, age 34, with history of polysubstance abuse, depression, and borderline personality traitsPrisonCrushed tablets dissolved in water and injected intravenously
Morin, 20072Woman, age 28, with history of schizoaffective disorder, polysubstance abuse, and personality disorder not otherwise specifiedHospitalTablets crushed with aspirin and inhaled intranasally
Waters et al, 20073Man, age 33, with history of polysubstance abuseOutpatientCrushed tablets dissolved in water and injected intravenously
Reeves et al, 20074Man, age 49, with history of alcohol dependence and benzodiazepine abuseOutpatientMisuse without psychiatric symptoms or a diagnosed psychiatric disorder
Man, age 23, with history of benzodiazepine dependenceOutpatientMisuse without psychiatric symptoms or a diagnosed psychiatric disorder
Man, age 39, with history of bipolar disorderOutpatientOral use in doses more than the prescribed amount
Murphy et al, 20085Man, age 29, with unclear history of schizophreniaPsychiatric walk-in clinicMalingering psychiatric symptoms to obtain an oral dose and overnight stay
Fischer et al, 20096Man, age 53, with history of depressive symptomsCourt-mandated outpatient clinicMalingering psychiatric symptoms to obtain higher oral doses

Quetiapine

Methods of quetiapine misuse include ingesting pills, inhaling crushed tablets, and injecting a solution of dissolved tablets.1-7 In case studies, patients report abusing quetiapine for its sedative, anxiolytic, and calming effects.1,2,4-7 One patient reported snorting crushed quetiapine tablets combined with cocaine for “hallucinogenic” effects.3 Street names for quetiapine include “quell,” “Susie-Q,” and “baby heroin,” and “Q-ball” refers to a combination of cocaine and quetiapine.8 Quetiapine tablets have a street value of $3 to $8 for doses ranging from 25 mg to 100 mg.9 Although outpatient misuse of quetiapine is common, abuse in correctional settings also is becoming more frequent.10 Residents of jails and prisons misuse quetiapine for reasons similar to those cited by outpatients: sedation, relief of anxiety, and hallucinogenic effects or “getting high.”1,2,10 Clinicians must differentiate inmates who have legitimate psychiatric symptoms that require antipsychotic treatment from those who are malingering to obtain the drug. Efforts to treat inmates for substance use disorders may be thwarted by the easy availability of drugs in correctional settings.10

Other SGAs

The incidence of misuse of olanzapine and other SGAs is more difficult to ascertain. Only 2 case reports describe olanzapine abuse, both in outpatient settings. One describes a patient treated for depression with psychosis who was using increasingly higher doses of olanzapine to obtain euphoric effects.11 Switching to aripiprazole effectively treated her illness and addressed her olanzapine misuse.

In the other case, a patient with bipolar disorder was able to obtain olanzapine, 40 mg/d, by complaining of worsened manic symptoms.12 He described the experience of misusing olanzapine as getting a “buzz,” feeling “very relaxed,” and blunting the negative jitteriness he felt when he used cocaine.12 This patient stated that he had observed others abusing olanzapine, both orally and intravenously.

Although the literature lacks reports on the risks of antipsychotic abuse, numerous Web sites purport to sell these drugs without a prescription and some describe the experience of illicit use of drugs such as haloperidol, risperidone, quetiapine, and olanzapine and ways to “enhance” the experience by combining drugs.13 Reported experiences with risperidone tend to be negative, citing extrapyramidal side effects and feeling “numb,” whereas olanzapine and quetiapine users describe feeling “drunk without the bad effects of alcohol” and “really happy, calm.” These sites also describe hallucinogenic effects of these agents.13

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