Additional evidence of the abuse potential of quetiapine

Quetiapine is an atypical antipsychotic agent approved by the FDA for the treatment of schizophrenia, acute mania, and bipolar depression. Recently, reports of medication abuse, particularly intranasal and i.v. abuse, have been described. Three cases of oral misuse of quetiapine are presented and clinical implications are discussed. Clinicians should exercise caution when prescribing quetiapine to patients at risk for substance abuse.     

Substance use disorders in Saudi Arabia: review article

Objective: The objective was to review all the available published studies and reports with particular reference to substance abuse in Saudi Arabia.

Methods: Data were collected from a PubMed search and reviewing national journals, the United Nations Office on Drug and Crime (UNODC) reports, World Health Organization (WHO) reports and conference presentations over the last two decades.

Results: Among Saudi patients in addiction treatment settings, the most commonly abused substances were amphetamine (4–70.7%,), heroin (6.6–83.6%), alcohol (9–70.3%) and cannabis (1–60%). Over the past decade, there was an increase in the use of cannabis and amphetamine and decrease in the use of heroin and volatile substances. Peer pressure and psychosocial stresses were risk factors for initiation as well as relapse of substance abuse. Anxiety, depression and hepatitis were the most common co-morbid disorders among the Saudi patients.

Conclusion: Substance abuse is a public health problem in Saudi Arabia. It was associated with many psychiatric disorders, medical diseases and educational, occupational, legal and social consequences. School- and community-based prevention programmes are highly required in Saudi Arabia as a first-line strategy in the fight against substance abuse.     

Substance-abusing women in a medium secure psychiatric setting: characteristics and psychometric test performance

Background: There have been few assessments of women with substance misuse problem in secure psychiatric settings.

Aims: The aim is to describe the characteristics and psychometric test performance of women admitted to a medium secure hospital.

Method: Consecutive admission was classified into risk-relevant categories using case note data. Responses to psychometric measures of dependence, substance-related problems, self-efficacy, motivation for change, craving and coping were assessed.

Results: Forty-four out of 55 consecutive admissions had a risk-relevant pattern of substance use before admission. Analysis of psychometric test performance produced two groups of patients differentiated according to self-efficacy, craving and belief in the benefits of change.

Conclusions: Although further work needs to be done in assessing the applicability of specific psychometrics to specialist populations, findings reinforce the importance of matching treatment interventions to stages of readiness to change.     

Media reviews

Aims: To examine the occurrence of comorbid non‐substance abuse axis‐1 disorders among patients being treated for substance abuse.

Design, setting and participants: Prospective study of patients admitted to a Norwegian clinic for substance abuse treatment. All patients in treatment during a 3‐month period were invited to participate.

Measurements: Patients were clinically interviewed and MINI and GAF were scored. Data were analysed with Chi‐square tests and multiple regression analyses.

Findings: Twenty‐four patients (77.4%) participated, of whom 91.7% had at least one comorbid non‐substance abuse axis‐1 disorder. Of the patients, 70.8% had suffered a psychotic episode and prior episodes of psychosis occurred significantly more often among those who had a main abuse of amphetamines. Many patients also abused benzodiazepines and/or cannabis as secondary substances.

Conclusions: A high level of prior psychotic episodes could be related to a high use of amphetamine and cannabis, and possibly to a shortage of low‐threshold treatment for substance abuse in the catchment area.     

Associations of age at cannabis first use and later substance abuse with mental health and depression in young men

Purpose: This study aimed to determine if the associations between age at cannabis first use and mental health and depression persist after controlling for the misuse of cannabis, other illicit drugs, alcohol and cigarettes.

Methods: Baseline data from an ongoing cohort study on substance use risk factors were used (N?=?5521). The association between age at cannabis first use and the frequency of cannabis use was assessed using a Cox proportional hazard model. Associations with other illicit drug use, alcohol dependence, nicotine dependence, mental health and depression were tested using linear regressions and logistic regressions.

Results: Participants using cannabis “almost every day” were on an average two years younger at cannabis first use than those using cannabis “once a month or less”. Age at cannabis first use was also associated with other illicit drug use, alcohol dependence and nicotine dependence. Associations with mental health and depression were substantially attenuated after adjustment for the misuse of cannabis and other substances.

Conclusions: These findings show that early cannabis onset is associated with later impairments in mental health and depression; however, these are largely explained by later substance abuse. Effective preventive measures are needed to delay cannabis onset and to avoid the progression from cannabis to using other drugs.     

Behavioral misuse among clients in substance abuse treatment: an interview study

Background: The co-occurrence of substance misuse and behavioral misuse such as excessive food intake, sexual activities, gambling and exercise has been increasingly acknowledged in both research and treatment practice during the last decades. It has also been showed that behavioral misuse complicates substance abuse treatment, and that clients with such co-occurring difficulties have considerable treatment needs.

Methodology: This study is based on interviews with six clients in substance abuse treatment, who also had a history of behavioral misuse. The interviews concerned the participants’ perception of their behavioral misuse and of themselves, and were analyzed using interpretative phenomenological analysis.

Findings and clinical implications: The participants perceived behavioral misuse as an escape from self-criticism and experiences of non-coherence. They also perceived relations and affects as overwhelming. Through behavioral misuse, relational and affective needs, as well as distressing self-experiences, were mitigated. The participants also described the efforts they had made to comprehend themselves. Their experiences were interpreted with respect to dissociation and concretization. It is suggested that during treatment, practitioners need to support client’s comprehension and their capacity to approach affects and relational needs, and in this process, dissociation and concretization need to be handled.     

Pain medication beliefs and medication misuse in chronic pain.

This study assessed the influence of medication beliefs, symptom severity, disability, mood, and psychiatric history on opiate medication misuse behaviors in 288 chronic pain patients. Data were gathered by questionnaires and systematic reviews of electronic medical records. The results demonstrate that patients with a history of substance abuse, compared to those without, showed greater medication misuse despite similar dosages and self-rated opiate effectiveness. Misusers believed more strongly in the potential for opiate addiction and that they required higher doses than others, but also had greater belief in opiate effectiveness and the importance of free access. Although both anxiety and substance abuse history are related to medication misuse, a multivariate analysis indicated that these factors can be seen as mediated by medication beliefs. These data suggest important roles for historical, affective, and cognitive variables in understanding medication misuse. Patients with a history of substance abuse report stronger beliefs in opiate effectiveness while simultaneously showing awareness of their addiction potential. Providers may help patients by addressing these issues prior to prescribing opiates. PERSPECTIVE: History of substance abuse is associated with increased opiate medication misuse independent of differences in reported opiate effectiveness. Self-attributions regarding opiate treatment related to need for higher doses, dose control, and addiction potential, may be important mediators of this relationship and interact with anxiety to produce heightened risk of opiate misuse.     

Gastric pharmacobezoars in quetiapine extended-release overdose: A case series

Abstract

Objective. Although extended-release (XR) formulations are recognized to bear some risk of pharmacobezoar formation in overdose, there are no previously documented reports of this phenomenon with quetiapine. We describe nine cases of pharmacobezoar formation in acute quetiapine XR overdose. Methods. Observational case series of all patients who underwent gastroscopy after quetiapine XR overdose, which were reported by physicians to the Swiss Toxicological Information Centre between January 2010 and December 2012, with detailed analysis of cases with documented pharmacobezoar. Results. Gastric pharmacobezoars were detected in 9 out of 19 gastroscopic evaluations performed during the study period. All these patients ingested a large dose of quetiapine XR (10–61 tablets; 6–24.4 g quetiapine). All patients but one also coingested at least one other substance, and in three cases another XR drug formulation. Gastroscopic pharmacobezoar removal was achieved without complications in all patients, but was difficult due to the particular “gelatinous-sticky-pasty” consistency of the concretion. The subsequent clinical course was favorable. Conclusions. The possibility of pharmacobezoar formation following a large quetiapine XR overdose should be considered, as this may influence acute patient management. Complete endoscopic pharmacobezoar removal may be a promising approach in selected cases, but further studies are needed to define its role.     

The influence of family and social problems on treatment outcomes of persons with co-occurring substance use disorders and PTSD

Objective: Family and social problems may contribute to negative recovery outcomes in patients with co-occurring substance use and psychiatric disorders, yet few studies have empirically examined this relationship. This study investigates the impact of family and social problems on treatment outcomes among patients with co-occurring substance use and posttraumatic stress disorder (PTSD).

Method: A secondary analysis was conducted using data collected from a randomized controlled trial of an integrated therapy for patients with co-occurring substance use and PTSD. Substance use, psychiatric symptoms and social problems were assessed. Longitudinal outcomes were analyzed using generalized estimating equations (GEEs) and multiple linear regression.

Results: At baseline, increased family and social problems were associated with more severe substance use and psychiatric symptoms. Over time, all participants had comparable decreases in substance use and psychiatric problem severity. However, changes in family and social problem severity were predictive of PTSD symptom severity, alcohol use and psychiatric severity at follow-up.

Conclusions: For patients with co-occurring substance use and PTSD, family and social problem severity is associated with substance use and psychiatric problem severity at baseline and over time. Targeted treatment for social and family problems may be optimal.     

Chronic promethazine misuse and the possibility of dependence: a brief review of antihistamine abuse and dependence

Objective: Misuse of centrally acting antihistamines is potentially a significant under-recognised issue contributing to problems of abuse and dependence, with the potential to complicate management of other mental disorders. This article considers this problem with the aim of increasing practitioner awareness.

Method: This article considers the literature relating to abuse of centrally acting antihistamines and presents a unique case, with features suggesting of psychological and physiological dependence following prolonged misuse of promethazine.

Results: Increased understanding of the potential problem of centrally acting antihistamine abuse and consideration of the possibility of a dependence syndrome associated with promethazine.

Conclusions: The need for vigilance for abuse potential of promethazine and other centrally acting antihistamines by doctors and pharmacists is emphasised.     

Contacts related to psychiatry and substance abuse in Norwegian casualty clinics: A cross-sectional study

Objective

To provide quantitative measurement and analysis of the frequency with which patients contact emergency primary healthcare services in Norway for psychiatric illness, including substance misuse. Characteristics of the patient group and their contact times were also addressed.

Design

Cross-sectional observational study.

Setting

Data were collected from one district-based and one city-based casualty clinic in Norway.

Subjects

Patients seeking medical care during the whole of 2006.

Main outcome measures

Patients’ diagnoses, age, gender, and time of contact.

Results

Diagnoses related to psychiatric illness were found in 2.7% of all events at the casualty clinics, but were relatively more frequent at night (5.6%) and for home visits and out-of-office emergency responses combined (8.4%). Prevalence was almost doubled during the July holiday month. Prevalence remained relatively constant between ages 15 and 59. The most frequently diagnosed subgroups were depression/suicidal behaviour, anxiety, and substance abuse (21.3%) of which 76.8% was alcohol-related. Gender and age differences within diagnostic subgroups were identified. For example, substance abuse was more prevalent for men, while anxiety was more prevalent for women.

Conclusion

Psychiatric illness and substance misuse have relatively low presentation rates at Norwegian casualty clinics, compared with established daytime attendance at general practitioners. However, the prevalence increases during periods with lowered availability of primary and specialist psychiatric healthcare. These data have implications for the allocation of resources to patient treatment and provide a foundation for future research into provision of emergency healthcare services for this group of patients.     

Acute Hyponatremia,Seizure, and Rhabdomyolysis After Ecstasy Use

Abstract

Objective.?Inhalant misuse is the intentional inhalation of volatile substances in order to obtain euphoric, disinhibiting, and exciting effects. Solvents, glues, adhesives, paints, varnishes, paint removers, dry cleaning agents, spray paints, nail polish removers, typewriter correction fluids, and aerosol propellants are common sources of volatile substance abuse. In recent years the abuse of inhalant substances, not only among those who abuse other drugs but also in teenagers and younger children, has been reported. We reviewed retrospectively the cases of inhalant misuse reported to the Spanish Poison Control Center. Methods.?Human intoxications from abuse of inhalant substances registered by our service from 1991 to 2000 were studied. Data analyzed were relative to age, gender, signs and symptoms, drug dependence antecedents, and severity of symptoms of the patients. The type of product and composition were also investigated. Results.?During the study period 109 cases of patients aged from 8 to 50 years were collected. A percentage of 36.6% was less or equal to 20 years old. Seventy percent corresponded to males. Of the patients, 11% presented dependence antecedents to other abuse drugs and 72.5% were symptomatic. In the symptomatic exposures clinical features affected the following systems: CNS (62.8%), gastrointestinal (8.1%), cardiovascular (8.1%), respiratory (2.9%), peripheral nervous system (1.1%), renal (1.1%), haematological (1.1%), hepatic (1.7%), and other (13.1%). The commercial products more frequently inhaled were solvents (34.9%) and glues/adhesives (22.9%). We noted the use of medicines with ethyl chloride–local anaesthetic (8.3%), three cases with aerosol bronchodilator (with fluorocarbons as propellants), and one case of xylazine inhalation. The composition most often involved was aromatic hydrocarbons (46.9%), halogenated hydrocarbons (16.5%), aliphatic hydrocarbons (11.4%), ketones (10.1%), local anaesthetic (ethyl chloride) (8.4%), ethers (2.5%), nitrous oxides (2.5%), and aliphatic nitrites (1.7%). The calls received were 59.6% from health care units and 22% from general public. Only 14% of cases were at home and 48% had moderate to severe clinical effects. Acute intoxications occurred in 82% of cases. Conclusions.?Inhalation of volatile substance as abuse drugs has been detected in different age groups, including very young people. Although the principal source was industrial products, the use of drugs such as local anaesthetics and aerosol broncodilators was also detected. Based on epidemiological studies in the Spanish population (essentially adolescents and childhood) together with the ability of a Poison Center to detect sentinel‐events, the community and authorities should develop strategies to prevent these exposures and the later use of other substances of abuse. In fact, recently a Law on Drug Dependences and Other Addictive Alterations has been approved in Madrid in order to take precautionary measures.     

Childhood sexual abuse and substance abuse in relation to depression and coping

Objectives: To examine relationships between childhood sexual abuse (CSA), substance abuse, substance abuse relapse, depression and coping styles in an Australian sample. Methods: Participants were 79 adults actively seeking treatment for substance abuse or CSA. CSA and substance use history were assessed using a purpose built questionnaire. Depression was assessed using the Beck Depression Inventory Second Edition (BDI‐II), and coping styles were evaluated using the Coping Scale for Adults.

Results: Among substance abusers, self‐reported CSA history was associated with (1) severe depression; (2) less optimistic coping; (3) longer duration of substance abuse; and (4) the use of drugs to alleviate negative moods. A non‐substance‐abusing CSA group was remarkably similar to the CSA substance‐abusing group on all measures. Penetrative abuse, younger age at CSA onset, and lack of confidence in dealing with CSA were associated with more severe depression in CSA victims.

Conclusions: Despite several limitations of the present study, these findings have implications for treatment of substance abusing CSA victims and suggest directions for future research on the CSA‐substance disorder relationship.     

Demographic and clinical features of patients with substance-induced mental disorders admitted to the psychiatric hospital in Kermanshah,Iran

Background: Evaluating the prevalence and clinical features of substance induced mental disorders leading hospitalization is important in programming for better management of these disorders. There is a lack of studies investigated the pattern of drugs leading admission in mental hospitals.

Objectives: To evaluate demographic and clinical features of patients with substance induced mental disorders admitted to Farabi psychiatric hospital in Kermanshah, Iran.

Methods: This is a cross-sectional study conducted in 2013. 359 patients whom admitted with substance related psychiatric disorders were evaluated using demographic questionnaire, clinical and paraclinical exams. patients diagnosed with primary mental disorders, and mental disorders due to other medical condition were excluded.

Results: The participant's mean age was 31.44 years. The most of the patients were unemployed males with low education living in urban areas. Amphetamines in 289 (80.5%), opioids in 57 (15.8%), cannabis in 11(3.1%), and benzodiazepines in 2 (0.6%) patients were the main drugs leading admission. Amphetamine induced psychotic disorder with hallucination (40.4%) were the most common diagnosis among the study subjects.

Discussion: Amphetamines was the most problematic drug in our setting and amphetamine induced mental disorders were the most prevalent causes of hospitalization. Opioids induced psychiatric disorders were in the second rank.     

Anxiety and depression in substance abuse: clinical implications

Accurate diagnosis in patients presenting with anxiety and/or depressive symptoms requires that the contribution of substance abuse be carefully considered. When chemical dependence is identified, detoxification may be all that is necessary. However, if indicated, specific treatment of the mood or anxiety disorder may reduce substance use as well.