SCOTTSDALE, Arizona — Atypical antipsychotics, though not typically considered drugs of abuse, are now being used to enhance the effects of other drugs or as a way to counter the adverse effects of illicit substances, new research suggests.
"Clinicians should screen their patients for substance use disorders before prescribing atypical antipsychotics for problems other than psychosis and closely monitor those who are taking them for psychosis who are known substance abusers," said senior author Deborah L. Haller, PhD, Columbia University College of Physicians and Surgeons and director of psychiatric research at St. Luke's and Roosevelt Hospitals in New York City.
With case reports of the misuse of atypical antipsychotics, quetiapine in particular, reported among substance abusers, Dr. Haller and colleagues sought to take a closer look at the role of antipsychotics in combination with alcohol and other drugs of abuse.
They found that of 429 patients from the detox and rehab units of the Addiction Institute of New York who were screened, 73 (17%) reported illegal or "nonmedical" use of prescribed atypical antipsychotics in combination with alcohol, opioids, cocaine/crack, methamphetamine, and/or cannabis.
The findings were presented here at the American Academy of Addiction Psychiatry (AAAP) 24th Annual Meeting & Symposium.
Quetiapine Most Abused
The majority of users of antipsychotics (88%) were polysubstance users. Quetiapine was, by far, the most abused antipsychotic (84.9%). Other atypical antipsychotics identified included olanzapine (17.8%), risperidone (24.7%), aripiprazole (20.5%), ziprasidone (8.1%), and asenapine (2.9%).
Most of the antipsychotics used came from friends or family, a pattern similar to that seen with prescription opioid abuse, Dr. Haller said.
"It is important to note that most of our participants obtained these drugs illegally ― from family/friends or from a drug dealer, indicating their street value. This is similar to what is seen with opioid analgesics," she told Medscape Medical News.
Among 25 of the 73 patients who agreed to be interviewed, atypical antipsychotics were reported to be most commonly used with alcohol, opioids, cocaine, or in combination.
The most common reasons reported for taking atypical antipsychotics were to recover from the side effects associated with using drugs and alcohol, followed by the desire to enhance the effects of other substances and "experimentation."
Patients listed the interest in "getting mellow" or "slowing down" as the leading desired effects obtained from mixing atypical antipsychotics with recreational drugs.
Long-term Effects Unknown
Whereas antipsychotics play an important role in the treatment of psychotic disorders, off-label uses may be especially risky with substance abuse patients, Dr. Haller said.
"Off-label use for problems including sleep, anxiety, and depression may help some substance abusers, but the risk for misuse may override any therapeutic benefit in these cases."
She noted that the vast majority of valid prescriptions for atypical antipsychotics were for sleep, anxiety, and mood symptoms, rather than psychosis.
"The question then is why prescribe a medication with high potential for misuse to 'at-risk' individuals? However, it is not clear that the prescribing doctors were even aware that their patients were addicted."
Atypical antipsychotics carry a host of potential side effects for psychiatric patients. Although some, including anticholinergic effects, were observed among the study sample, little is known of the potential longer-term effects from nonmedical use in substance abusers, Dr. Haller said.
"Possible long-term effects of use, such as weight gain or movement disorders, may not apply to individuals who are using these drugs sporadically or at lower doses, but this has not been studied."
Although the extent of atypical antipsychotic misuse is unclear, the trend has gained recognition, said Olivera Bogunovic, MD, an instructor of psychiatry at Harvard Medical School and associated program director of Partners Addiction Psychiatry Fellowship, in Belmont, Massachusetts, who was not involved in the research.
"Patients often misuse the antipsychotics in an attempt to self-detox," Dr. Bogunovi, told Medscape Medical News.
"In general, they abuse them in an effort to medicate the symptoms of withdrawal."
Commenting on the study for Medscape Medical News, psychiatrist Michael M. Miller, MD, University of Wisconsin School of Medicine and Public Health and medical director of Herrington Recovery Center at Rogers Memorial Hospital, in Oconomowoc, Wisconsin, noted that the reasons patients gave for misuse are consistent with substance abuse behaviors.
"If someone is taking a drug that can produce hallucinations or delusions, such as cocaine or methamphetamine, in addition to the euphoria the person desires, they may want to reduce the uncomfortable experience, and they may know an atypical antipsychotic can do that for them," he said.
"So they may take the antipsychotics to counteract the effects of the addicted drug, but I wouldn't say that's a novel finding," Dr. Miller added.
"On the other hand, even if a drug doesn't produce the kind of high that traditional addictive drugs do, it just has the ability to make them feel different, and that's enough for them to take it."
Potential Red Flag
Dr. Haller noted that as the marketing of atypical antipsychotics expands beyond the indication for psychosis, the potential for misuse could increase.
"As atypical antipsychotics are being promoted, including on TV, for problems other than psychosis ― such as aripipriazole for depression ― it seems likely that increasingly more of these drugs will be in circulation and thus available to those who might misuse them."
In the meantime, clinicians should keep the issue on their radar screen, Dr. Haller added.
"Requests for specific atypical antipsychotics should perk the clinician's interest, as patients obviously have had prior experience with them or have learned of their effects from other users. This is especially true if the patient has no history of a psychotic disorder."
Family and friends of substance abusers also should be made aware of the potential problem.
"As with opioid analgesics, family and friends who take these drugs should be mindful of their potential for misuse and should be cautious about their storage, especially if they have a family member or friend struggling with a substance use disorder," Dr. Haller concluded.
The authors, Dr. Bogunovic, and Dr. Miller report no relevant financial relationships.
American Academy of Addiction Psychiatry (AAAP) 24th Annual Meeting & Symposium: Abstract 16, presented December 7, 2013.
Medscape Medical News © 2013 WebMD, LLC
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Cite this: Atypical Antipsychotics New Drugs of Abuse - Medscape - Dec 17, 2013.