by Emily Forest
SDN Staff Writer
While some associate prescription drugs with expense and inconvenience, others seek out the drugs, lying to get prescriptions, and buying pills illegally. Such “drug seeking behavior,” familiar to medical professionals when it involves Ritalin, OxyContin, Xanax, or any number of drugs noted to increase productivity, sink patients into an opiate-induced haze, or sedate those wishing to evade the stresses of life, abuse of anticonvulsants, antipsychotics, antihistamines, and others, represents a new frontier of drug abuse.
One of the more well-known and well-documented drugs of abuse, diphenhydramine is an antagonist to the H1 receptor, which seems, given its over-the-counter status, to be innocuous. Like many sleep aids, including the more recently developed Ambien, the drug was at first touted as having low associated risk of dependency (1). However, there has been much evidence to the contrary. In low doses, the drug has its indicated sedating effects while in larger quantities it can produce a euphoric high and possible associated hallucinations (2). Diphenhydramine is particularly desirable as it is cheap and requires no prescription. Thus it is especially hazardous to adolescent populations unable to obtain more hard-core street drugs.
Some newer drugs, including Seroquel and Neurontin, have also demonstrated abuse potential. Seroquel, an atypical antipsychotic familiar to psychiatrists as a treatment for schizophrenia and bipolar disorder, is known on the streets as quell, Suzie Q, baby heroin, and, when combined with cocaine, a Q-ball. In the latter example, Seroquel replaces heroin in the usual cocaine-heroin speedball recipe (3). The abuse potential is thought to be due to its sedating effects, most likely secondary to histamine H1 receptor antagonism. There is much anecdotal evidence to bolster this theory as one patient reportedly took the drug to “mellow out” and another compared the drug to clonazepam.
Drug seeking and Seroquel abuse have been particularly problematic in prison populations. One report on the Los Angeles County Jail states that about a third of those prisoners seeking psychiatric help may be malingering to obtain Seroquel. Knowing that the drug is used to treat psychosis, prisoners mimic these symptoms, often reporting that they hear voices (4). Such drug-seeking behavior has also been noted outside of the prison population, including the case of one man who stole his girlfriend’s Seroquel. In another case, a patient who was prescribed the drug legitimately, for bipolar disorder, resorted to taking more than his prescribed dose.
While Seroquel has received much recent attention as an insidious drug of abuse, other drugs outside of the usual stimulants and benzodiazepines have been noted to have abuse potential. Neurontin, used to treat both epilepsy and neuropathic pain, has recently been noted as a potential drug of abuse.
The drug is known also to have a sedating effects with an accompanying high similar to that produced by marijuana (5). This is somewhat less well-documented. One patient, known to have a history of alcoholism, reported that it reduced his cravings (6) and another patient resorted to drug-seeking behaviors (5). Both experienced withdrawal symptoms upon cessation of the drug.
Abuse of diphenhydramine, Neurontin and Seroquel illustrates the point that doctors must proceed cautiously when dealing with patients who appear to exhibit drug-seeking behavior towards drugs not normally known to be abused.
(1) Roberts, K., Gruer, L., Gilhooly, T. Misuse of diphenhydramine soft gel capsules (Sleepia): a cautionary tale from Glasgow. Addiction. 94; 10, 1999.
(2) Halpert, AG., Olmsead, MC., Beninger, RJ. Mechanisms and Abuse Liability of the Anti Histamine Diphenhydramine. Neuroscience and Behavioral Reviews. 26, 2002
(3) Waters, BM., Joshi, KG. Intravenous Quetiapine- Cocaine Use (Q Ball). Am J Psychiatry 164:1, 2007.
(4) Pierre, JM., Shnayder, I., Wirshing, DA., Wirshing, WC. Intranasal Quetiapine Abuse. Am J Psychiatry. 161:9, 2004
(5) Vigneau, CV., Guerlials, M., Jolliet, P. Abuse, Dependency, and Withdrawal with Gabapentin: A first Case Report. Pharmacopsychiatry. 40, 2007.
(6) Pittenger, C, Desan, PH. Gabapentin Abuse and Delierium Tremens Upon Gabapentin Withdrawal. J. Clin. Psychiatry. 68:8. 2007.
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There should be a central database to monitor controlled substance prescriptions of the patients. Until then the abuse problem will be difficult to solve. Doctors are caught up between patients’ right to get treated for pain and other conditions and th tendency of dependence and abuse
The issue described in the article is more difficult- these are not even controlled substances.
Emily: very topical – in our ED we see Seroquel ODs nearly every day. These patients just sleep and sleep. I haven’t seen very many with negative effects from the OD other than long-lasting somnolence, however.
We certainly see Benadryl ODs as well, which can be a lot more interesting to treat as they have a very classic toxidrome as well as an antidote. For potential tox enthusiasts, Benadryl causes an anticholinergic toxidrome characterized by dilated pupils, tachycardia, and hallucinations, which classically causes patients to “pick feebly at their bedclothes”. The mnemonic is “red as a beet, dry as a bone, blind as a bat, mad as a hatter, and hot as a hare.” Some at my institution like to add “tacky (tachy) as a polyester suit!”
If you see one of these patients, in a daze, looking around the room with blank eyes as they neverendingly fuss with their clothing and sheets, you will not forget it. The other thing toxicologists often note is that if you suspect a diphenhydramine overdose, hold up your hands and pretend to be stretching an imaginary string in front of the patient’s eyes, asking “what color is this string?” When the patient answers the question, you know you were right about the Benadryl!
The antidote, physostigmine, is used at my institution and is fantastic to watch, because seconds after you push it, the staring and picking ceases and the person will clearly look at you and sensibly ask, “hey, what’s going on?” The use of ‘physo’ is limited because of a few reports that it has been associated with fatal arrhythmias.
You can learn more at the Erowid diphenhydramine vault: http://www.erowid.org/pharms/diphenhydramine/diphenhydramine.shtml
or my favorite free site for medical information, Emedicine:
http://www.emedicine.com/emerg/topic36.htm
Interesting article on cnn.com about at-home deaths from prescription drugs.
http://www.cnn.com/2008/HEALTH/07/28/fatal.drug.errors.ap/index.html
I’ve always wondered how pharmacudical companys would be affected if everyone in the U.S. stopped abusing the types of medications described in this article…
Seriously who cares if people abuse drugs?
This is all we need. Fantastic! Another hurdle for legitimate people to jump over. Now all of these lovely SDNers will start looking at normal people funny when they try to buy Benadryl for their allergies, Neurontin for nerve pain, and Seroquel for mental illness. Good job Emily, NOT!
“This is all we need. Fantastic! Another hurdle for legitimate people to jump over. Now all of these lovely SDNers will start looking at normal people funny when they try to buy Benadryl for their allergies, Neurontin for nerve pain, and Seroquel for mental illness. Good job Emily, NOT!”
That wasn’t the point of her article. Shedding light on some less commonly known drugs that are abused isn’t meant to be interpreted as you did. If everyone went the route that you did, we’d be a nation of presumptuous idiots.
This article is absurd. It’s not like you wrote about tramadol (http://www.deadiversion.usdoj.gov/drugs_concern/tramadol.htm) or carisoprodol (http://www.ncbi.nlm.nih.gov/pubmed/2860599)- which aren’t controlled for the most part. Those can be take as a muscle relaxer or an analgesic, and they have an effect that is actually abused. No. You write about diphenhydramine, which is indicated for allergies, motion sickness, insomnia, and mild cases of parkinsonism; Seroquel, which is for mental illness, and it is way more expensive than generic pain medications containing hydrocodone or tramadol; Neurontin, which is also way more expensive than other alternatives. Also, all of the drugs that you wrote about do not come up on the DEA’s website. Therefore, this article has no merit. If you had written about something that was more plausible, i.e. actually abused in the real world, then your write-up would be more credible.
You could have written about the over-the-counter cough suppressant dextromethorphan- (http://www.deadiversion.usdoj.gov/drugs_concern/dextro_m/dextro_m.htm) or pseudoephedrine
(http://www.deadiversion.usdoj.gov/pubs/brochures/pseudo/pseudo_notice.htm). Those two actually come up on the DEA’s Office of Diversion Control website. Those are drugs of concern!
I wanted to write about drugs of abuse that are more unusual. Dextromethorphan, pseudophedrine, and muscle relaxers are widely recognized as drugs of abuse. I wanted to shed light on drugs that people don’t normally think of. Drugs that would not necessarily make it to the DEA website. As far as the validity of my article- there are sources cited, which are listed right at the bottom of the article. Furthermore, if you do your own searches, you’ll come up with even more on the subject.
People will abuse what they want to abuse. Should we stop selling paint, because some addicts inhale the fumes to get high? No. Should we stop selling razors, because cutters may use them for self-mutilation purposes? No. Should we stop selling gallons of ice cream, because compulsive eaters can not control themselves? No. People will do what they want to do with the products that they buy and consume. Therefore, your point is moot, because unless these medications are controlled, nothing can be done about this “abuse”. There is no law or regulation saying that I can not buy a thousand Benadryl tablets if I wanted. The medications that are of concern are clearly noted on the DEA’s website. These “unusual” medications of “abuse” are not drugs of concern, and this is why your article is not convincing.
Good article. If anything it speaks to the fact that in certain patients and certain environments, any drug can be abused. I would emphasize that the majority of the references you provided are case reports, often from prison populations. The point being that drugs like seroquel and gabapentin are only likely to be desirable to specific populations in specific environments and these people often have dual diagnoses. These drugs are unlikely to produce “liking” effects in normal populations. Quite the contrary, actually. Plenty of patients hate the dizzy feeling they get from gabapentin. Similarly, the drowsiness and hangover effect from seroquel is unlikely to be enjoyed by those who aren’t experiencing severe agitation (say from cocaine abuse or a psychiatric illness) or those simply looking for a change in consciousness (prisoners). Drug, Set, and Setting must always be taken into account.
I agree. The setting makes a big difference. Too bad the introductory paragraph doesn’t state anything about the setting or specific populations. This leads the reader to assume that these medications of “abuse” occur amongst anyone who “[seeks] out… drugs, [lies] to get prescriptions, and [buys] pills illegally.”
People existing outside of prison systems and psychiatric institutions can demonstrate “[seeking]“, “lying”, or dishonest behaviors, but the drugs that they abuse actually circulate within “normal populations”, per the DEA’s website.
These drugs of “abuse”, like Andy says, are case-sensitive, which should have been outlined in the beginning to solidify the article.
(introductory paragraph: “While some associate prescription drugs with expense and inconvenience, others seek out the drugs, lying to get prescriptions, and buying pills illegally. Such “drug seeking behavior,” familiar to medical professionals when it involves Ritalin, OxyContin, Xanax, or any number of drugs noted to increase productivity, sink patients into an opiate-induced haze, or sedate those wishing to evade the stresses of life, abuse of anticonvulsants, antipsychotics, antihistamines, and others, represents a new frontier of drug abuse.”)
“This leads the reader to assume that these medications of “abuse” occur amongst anyone who ‘[seeks] out… drugs, [lies] to get prescriptions, and [buys] pills illegally.’”
Or they could just read the title of the article. I guess I should ask what you mean by “case-sensitive” since when a topic/article is titled with the word “Atypical”, I generally tend to not over-generalize what the article speaks about.
“Or they could just read the title of the article. I guess I should ask what you mean by “case-sensitive” since when a topic/article is titled with the word “Atypical”, I generally tend to not over-generalize what the article speaks about.”
The article is titled “Atypical Drugs of Abuse”, not “Atypical Abuse of Drugs”. The emphasis is supposed to be on the drugs and not the people who use them. Therefore, an “over-[generalized]” population should work, but it doesn’t, because the people who would “abuse” these drugs are “atypical”.
Patients need to be properly educated so that they don’t misuse or divert prescription medications. Patients are consumers and some are well-educated while others lack the necessary familiarity about what they can do with some of these substances. Just about any type of drug can be misused, abused, or inappropriately diverted. They don’t need to be controlled substances.
I found the article to be informative. I am a Correctional nurse and I knew about the abuse potential of Seroquel but not Neurontin (although inmates will take anything…) Our MD does not prescribe Neurontin except in exceptional cases. I was going to ask her why, but decided to do a web search before doing so. Emily gave me an answer!
Emily-Really appreciated the article; reflected my recent experiences in correctional institute pharmacy (many cases of male inmates working the system to get quetiapine, gabapentin, olanzapine, and topirimate for female inmates) then afterwards in a community pharmacy that served a large percentage of former inmates. For me, the most difficult part of dispensing very expensive atypical antipsychotics to former inmates (when CATIE has shown less expensive first generation antipsychotics are as effective) was the financial burden for the drug abusers’caregivers, who typically picked up the meds. People can’t afford dental care or basic hygeine supplies, but will continue to float their family money for quetiapine, lest they become agitated and possibly abusive.
Well, as an experienced emergency provider with a few years of primary care under my belt, too, I have to say that I’m as disgusted with providers who treat medication seeking patients as “druggies” and “scumbags” as I am with drug companies who tweak/twist proprietary substances in order to wring a few more years’ profit out of already-suffering public.
My view after all these years is that the real problem is/are the social ills that compel so many people from ALL walks of life (some are just better at maniupulating, functioning more highly, etc, than others) to seek out something…ANYTHING…to take away their pain, psychic or physical, to make them feel normal.
I don’t enable drug seekers, but surveying the “lay of the land,” I’m as saddened and discouraged by the close-mindedness of my colleagues as I am by fat-cat pharmaceutical companies and/or people willing to go down the road to ruin that is addiction.
We are a sick society…and developing countries that are adopting our Western/consumeristic ways of life are manifesting EXACTLY the same patterns of dysfunction and mental illness that we have been seeing in our own.
People, for the most part, aren’t abusing to feel euphoric or super-human…they are “abusing” because of the way that we define “abuse,” and they do “that” because they just want to feel, HUMAN, normal, again, somehow, someway, someday…
I’m a drug addict and alcoholic in recovery in Los Angeles. I take seroquel for some super fun mental illnesses. I hate the drug. it inhibits the ability to feel satiated and thus causes weight gain. it’s dangerous to the body in many ways. seroquel is not a “normal” drug of abuse. it’s not a substance i have ever “craved.” however… when i was still using, if i could not find my drug(s) of choice, i would settle for taking more than the prescribed amount of SQ. hands down. an addict will abuse anything that can change their state of mind. i have a friend who nearly ODed on the anticonvulsant/mood stablizer Depakote trying to get a high. Benadryl, phenadrine, fioicet, clariting, tylenol PM, nyquil AND dayquil, mouthwash, cologne, windex… in you need to get high, youll get high. try holding your breath until the second right before you pass out. all these things happen. even in affluent communities. i’ve seen it.
I am so frustrated with the goverment and the medical community. within the last 10 years I have been on oxycotin, tramadol, valium, and seroquel. I have valid medical reasons for all of these. The pain I experience every day is very hard to deal with, especially with 2 children. One day I decided to take myself off of oxycotin, no doctor ordered this. It took a year to become myself again but I did. My pain, due to a more recent injury has escalated, and now i am lucky to get 30 10/500 Lortabs for a month. This due to the abuse, What do patients like us do? My seroquel is currently at 800mg at night, and one durring day if neeeded. I get no high of this or any of the other medications i have listed. I have a very high tolerance with meds since i have been on them since i was 17years old. there has to be a way that patients like me can get the medication they need and not be considered drug seekers or abusers. The goverment has come up with a way to monitor and regulate everything else. This issue is just as important if not more so. I welcome any thoughts or feedback anyone else may have. I sure don’t no what to do anymore?.
I have seen people abuse Neurontin in Rehab. It is no secret on the street that the drug is often abused. It seems Dr’s don’t believe it, because they still prescribe large quantities with little or no discussion of abuse. Who cares if it is on the DEA’s list. If it looks like a duck……… T
I am an addict. I used heroin and prescription opiates/opioids IV for several years, in addition to abusing xanax, valium, etc etc.. Anyway, I tried tons of different treatments, inpatient programs, detox drugs, everything; until I finally resorted to methadone. I did not want to get into methadone maintenence treatment because I just wanted to be clean off of everything, but I was afraid of OD’ing or passing out while driving, etc., so I went into MMT. The reason I say all this is I have been clean for over 4 years with the help of methadone. I have been seeing a psychiatrist who says that while I should be on a benzo for anxiety and panic attacks, she will not (and I don’t want her to) prescribe xanax or valium or anything else like benzo’s.
So, I have just been prescribed Neurontin. I thought i was pretty well aware of all the little-known drugs with potential for abuse, but I guess not. I have no intention on abusing this drug, as I have two beautiful children and I’m incredibly thankful to have been clean for as long as I have. This is really just a note that even though my psychiatrist knows EVERYTHING about my past with substance abuse, she had no problem prescribing me neurontin on my first visit to her. Does this seem odd? Moreover, can someone please suggest anything that might help with anxiety/sleeplessness/panic attacks that I could talk with my doctor about that are NOT narcotics (and don’t have much potential for abuse)? Thanks everyone. Sorry for my wordiness.
Ash,
“Moreover, can someone please suggest anything that might help with anxiety/sleeplessness/panic attacks that I could talk with my doctor about that are NOT narcotics (and don’t have much potential for abuse)?”
Mirtazapine and trazodone are anti-anxiety/depression medications that are typically given at bedtime and promote sleep. Buspirone and hydroxyzine are other anti-anxiety medications, but are not used to induce sleep.
These medications have “low abuse” potential. As several have pointed out above, many medications may be abused. Some above have expressed disgust that “safe” medications have “inappropriately” been labeled drugs that have the potential for abuse.
I have bad news for you; drugs are bad period. Every medication (drug, including “natural” products and OTC’s) has risks and benefits. Drugs are labeled “prescription” because they are dangerous (this is a legal definition not opinion). ANY drug used inappropriately is harmful. All drugs should be used prudently. Ask your physician (doctor) or your pharmacist (often a doctor) what is the ultimate goal of medication therapy? I hope they respond by saying, “If possible to stop medication therapy.”
I am not against drugs or people that take them. I am a pharmacy student; I respect drugs. My job will be to ensure that medications are taken appropriately — to protect the public (this also law not my self-described job).
My only criticism is that pharmacists do not do more. Ensuring appropriate use of a blood pressure medication (or any other drug) deserves equal attention to use of drugs with high potential for abuse.
So next time you are at your pharmacy if your pharmacist does not ask tell them how you are taking your medications, for what disease and what side-effects you are having. Without respect dangerous drugs have greater potential for harm.
Interesting article.Abuse of drugs like diphenhydramine does indeed go on.I myself was addicted to diphenhydramine for several years,and that being many years ago.I do suffer from mental illness.I would take about 50 pills a day.It did produce a euphoric high,for several hours,but trust me,the negative effects far outweighed the positive effects.