Seroquel Abuse?

[Ulquiorra]

Hi everybody. I'm currently a PGY-2 and my attending is taking a 2 week vacation in some exotic tropical location and as such I am having my first experiences as an attending physician. I am checking out to the three (!) attendings his patients are divided up upon, but their degree of supervision is generally minimal.

One of the patients on my team is a young man in the hospital for substance induced mood disorder and amphetamine dependence. During his entire hospital stay, he had had several behavioral issues (unscrewing the windows, smoking on the unit, banging the walls) and been pining for medicines. First it was narcotics for back pain, despite the fact that he looked comfortable and would sit and lie in positions that would make most folks with back pain as severe as he made it out to be writhe in pain. The next thing he focused on was being "locked up" and being anxious and agitated. One of the covering doctors put him on a low dose of a prn benzo.

I promptly discontinued that and he then went on about being anxious and needing Seroquel. He also upped the anty by claiming to hear voices. He did not appear the least bit psychotic, and I'm guessing a week is plenty of time to be out of the window for persisting psychosis due to amphetamines.

Eventually, since he wasn't getting what he wanted from me (ie medicating him so that he wouldn't have to be awake and deal with his amphetamine dependence), he opted to go to a shelter. I discharged him.

Now here are my questions:

1) Was I too harsh in dealing with this patient? I've seen patients like him before and my read was that he was not really ready to face his addiction and on top of that he was wanting to medicate any and every little bad emotion or thought that came his way.

2) I know there have been a few case reports of Seroquel abuse, but is there any new literature on the subject? I've looked and found nada.

Thanks for reading this long post

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[Faebinder]

Hi everybody. I'm currently a PGY-2 and my attending is taking a 2 week vacation in some exotic tropical location and as such I am having my first experiences as an attending physician. I am checking out to the three (!) attendings his patients are divided up upon, but their degree of supervision is generally minimal.

One of the patients on my team is a young man in the hospital for substance induced mood disorder and amphetamine dependence. During his entire hospital stay, he had had several behavioral issues (unscrewing the windows, smoking on the unit, banging the walls) and been pining for medicines. First it was narcotics for back pain, despite the fact that he looked comfortable and would sit and lie in positions that would make most folks with back pain as severe as he made it out to be writhe in pain. The next thing he focused on was being "locked up" and being anxious and agitated. One of the covering doctors put him on a low dose of a prn benzo.

I promptly discontinued that and he then went on about being anxious and needing Seroquel. He also upped the anty by claiming to hear voices. He did not appear the least bit psychotic, and I'm guessing a week is plenty of time to be out of the window for persisting psychosis due to amphetamines.

Eventually, since he wasn't getting what he wanted from me (ie medicating him so that he wouldn't have to be awake and deal with his amphetamine dependence), he opted to go to a shelter. I discharged him.

Now here are my questions:

1) Was I too harsh in dealing with this patient? I've seen patients like him before and my read was that he was not really ready to face his addiction and on top of that he was wanting to medicate any and every little bad emotion or thought that came his way.

2) I know there have been a few case reports of Seroquel abuse, but is there any new literature on the subject? I've looked and found nada.

Thanks for reading this long post

1) You did very well and should have even discharged him earlier.

2) Seroquel is a drug that is sold on the street to get high, don't give it out if you don't need it.

 

[Ulquiorra]

1) Thanks. Today was actually my first day as the boss. I'd say the attending and I were more than patient with him last week, but his shenanigans made me have to bring the hammer down.

2) Yeah, it irks me how folks prescribe it so literally for things other than true psychosis.

 

[whopper]

There are case reports of people using it to get high by insufflating it.

It is known that mixing opioids with anti-histamines enhance the effect of the opioid. Seroquel is a strong antihistamine. This actually may explain a lot with the above case because the person you mentioned is on "narcotics" for pain.

There are also reports that Seroquel eases a cocaine crash.

I've heard certain people say they love Seroquel when doing a speed-ball--a mix of heroine & cocaine. Makes sense, think about it. It heightens the high of the heroine, it eases the crash of the cocaine.

Mixing Seroquel with Cocaine has a street name: "Rosemary's Dolly"

Several psychiatrists working in a forensic or prison setting I know will not prescribe Seroquel for the above reasons. Also think about it. Seroquel per the CATIE trial was the least efficacious of the atypical antipsychotics, and its side effect profile was the 3rd worst. In terms of metabolic problems it was right behind Zyprexa. There was also a lot of hypotension & sedation with the medication. It also had the worst QT prolongation profile per CATIE.

Aripiprazole (Abilify) while not in the CATIE trial does not have metabolic problems. Geodon doesn't, has less side effects vs Seroquel & was more efficacious in the CATIE trial. Risperdal had better efficacy, & less metabolic effects, though it did have worse prolactin elevation.

Overall, for that reason, I find very little reason to give out Seroquel. I'd give it out if I knew for a fact that it was the only antipsychotic that worked on the patient, but I've yet to see a patient where only Seroquel worked for them & not another atypical. I have seen several patients where only a certain atypical worked for them--just never Seroquel. Only times where I've seen a need to give Seroquel is if the person is so sensitive to D2 blockers that they get severe EPS or TD from any other atypical. Seroquel is theorized to have weaker D2 binding and binds to D2 receptors & releases more quickly than the other atypicals. I've only had 1 case of that so far in my entire career. Just a small dose of an antipsychotic gave him such bad EPS his muscles locked up and he was in extreme pain. An IM doc had to be called. He's on megadoses of Seroquel (1200mg/day) because the normal 800mg max wasn't working for him. The guy had a massive history of abuse, but I doubt he's malingering. He hates the sedation from the med, though he overcame after a few weeks. He's also pretty much going to be trapped in a forensic facility for years since he was NGRI for multiple murder.

Only other cases were for Parkinson's, though even in this category, I've been able to try something else such as Geodon, or Abilify with success without having to use Seroquel.

 

[OldPsychDoc]

Two thoughts:
1) why the reticence about medicating an agitated patient on a locked unit? Judicious use of prns can ease the milieu and prevent all sorts of bad escalations. Yeah the guy's an addict and probably got ASPD as well...but what are you gaining by being all righteous about keeping him anxious and agitated? In my experience the akathesia and general sensory hyperreactivity following habitual meth use will persist for weeks following detox. (Some authors have suggested that a meth addict needs at least 6 months of clean time before they are able to cognitively benefit from rehab!) It might be the most compassionate thing one could do to medicate some of the symptoms. If you're on an anti-atypical crusade, then use thorazine and benedryl, but I really don't believe that prolonging suffering does anything to enhance the motivation to become sober.

2) as pointed out, Seroquel can modulate the effects of illegal drugs, but its stand-alone addictive potential is pretty negligible. Yeah, I know there are extreme stories out there--but people huff aerosols and chug cough syrup, too. Dogmatic refusal to treat a patient who could reasonably benefit from a targeted intervention is just as bad as being a "Dr. Feelgood" prescribing benzos like candy.

 

[Solideliquid]

Would somebody mind posting a PDF of the full CATIE study? Or PMing it to me I think I'd like to browse it over again as it's been a while.

 

[whopper]

http://content.nejm.org/cgi/content/full/353/12/1209

but its stand-alone addictive potential is pretty negligible. Yeah, I know there are extreme stories out there--but people huff aerosols and chug cough syrup, too. Dogmatic refusal to treat a patient who could reasonably benefit from a targeted intervention is just as bad as being a "Dr. Feelgood" prescribing benzos like candy.

Agree, but like I mentioned, there are several alternatives, which by the studies are actually better than Seroquel. I think it may also differ in what part of the country you're in. Where I was, in Atlantic City, where heroine & cocaine use was rampant, giving out Seroquel, to the typical patient who was homeless was not a good idea IMHO. Even if that person had bona fide mental illness, he/she had a good oppurtunity to sell it for a quick buck.

If I were in an area where the locals didn't know about the non-approved uses of Seroquel, I still don't think I've be giving it out much. Other atypicals are more efficacious for psychosis. As for Bipolar, I haven't seen any head to head studies, but Aripiprazole & Olanzapine both have approval in mania & bipolar maintenance, while Quietapine has it for mania & Bipolar Depression.

The few times I do consider use of Seroquel, its for Bipolar Depression or a patient with extreme EPS or TD sensitivity.

 

[Ulquiorra]

Would somebody mind posting a PDF of the full CATIE study? Or PMing it to me I think I'd like to browse it over again as it's been a while.

http://content.nejm.org/cgi/content...INDEX=0&sortspec=relevance&resourcetype=HWCIT

 

[swingerofbirch]

You're a doctor. Did you take his vitals? This sounds incredibly unscientific. He was having withdrawal symptoms and you are basing your assessment purely on observation. Did he have tachycardia? You said he was quite agitated, so he may have. There is too little information to go on to give advice. Generally meth withdrawal will cause depression, anxiety, violent and agitated behavior. Seroquel may have been a good choice temporarily if only for its strong sedating effects (which in my experience don't last long, the drug is only useful as such for 1-2 weeks).

 

[Doc Samson]

You're a doctor.

And you're not.

 

[PsyDGrrrl]

I work in a forensic facility and our patients definitely stockpile and sell Seroquel. Some of the psychiatrists are cautious about using it for this reason. One of my patients just got caught the other day snorting one of his Seroquels...now he only gets them crushed in juice. Of course, this guy tries to get high off of anything he can and was caught with talcum powder he was apparently trying to snort, and got caught trying to eat mushrooms in the courtyard a couple of weeks ago...

 

[swingerofbirch]

And you're not.

In all fairness you're not a super hero. Maybe something more like Dr. Jonathan Crane.

 

[OldPsychDoc]

In all fairness you're not a super hero. Maybe something more like Dr. Jonathan Crane.

Is that Frasier's other brother?

 

[OldPsychDoc]

I work in a forensic facility and our patients definitely stockpile and sell Seroquel. Some of the psychiatrists are cautious about using it for this reason. One of my patients just got caught the other day snorting one of his Seroquels...now he only gets them crushed in juice. Of course, this guy tries to get high off of anything he can and was caught with talcum powder he was apparently trying to snort, and got caught trying to eat mushrooms in the courtyard a couple of weeks ago...

"The Rules", whatever they are, are completely different in these populations, dontcha think?

 

[billypilgrim37]

In all fairness you're not a super hero. Maybe something more like Dr. Jonathan Crane.

You're right. In some issues, he's actually the super villain. Just depends how Eric Bana/Ed Norton is feeling that day.

 

[Doc Samson]

You're right. In some issues, he's actually the super villain. Just depends how Eric Bana/Ed Norton is feeling that day.

Which is pretty typical of the ambivalent relationship between the chronically mentally ill and their psychiatrists, right? One day we're helping them to health, the next we're colluding with "the man" to have them locked down against their will.

BTW, Crane/Scarecrow is a psychologist. If you wanted to pick a villainous psychiatrist, you could've gone for Harlequin, Faustus, Moonstone (second version), or Amadeus Arkham.

 

[whopper]

Dr. Faustus....

Now there's a villian that is truly evil. Several of the Marvel villians are along the lines of Dr. Evil from Austin Powers--evil in a 2 dimensional, even silly manner.

The current creative team on Captain America has been very good. Great story & art, very true to the characteristics that made Cap great, and Faustus is just so so so evil & complex.

You wouldn't expect Harley Quinn from Batman to be a psychiatrist. She is portrayed as a young 20s Cluster B girl. However I'm too big a fan of the Bruce Timm, Paul Dini-verse to complain much about it.

But I digress....This thread's about psychiatry, not comics.

 

[swingerofbirch]

Which is pretty typical of the ambivalent relationship between the chronically mentally ill and their psychiatrists, right? One day we're helping them to health, the next we're colluding with "the man" to have them locked down against their will.

BTW, Crane/Scarecrow is a psychologist. If you wanted to pick a villainous psychiatrist, you could've gone for Harlequin, Faustus, Moonstone (second version), or Amadeus Arkham.

Chronically drugging a person doesn't mean that they are mentally ill. I think calling someone mentally ill is quite offensive and untrue. We are all human beings. If you look at history, there have been more and less barbaric ways of saying some people are not quite right and treating them for not being like the rest of us. None of them is right. And of course, some people are involuntarily committed against their will; I'm not sure what your point was regarding that. Are you saying people aren't? I do think that some psychiatrists probably think they are helping some of their patients; although I do empathize with the realization that for those in the field with insight into their patients the job could be frustrating. And for a limited period of time certain medications do alleviate some symptoms. But helping patients to health? That's a big claim to make. A state of health would mean that you first identified an illness and helped to actually treat the illness or cure it. With the notions of mental illness you have, you could say that psychiatrists describe sets of symptoms, vote on how to categorize those symptoms, and prescribe drugs that can somewhat alleviate those symptoms. In all of that there is no actual disease, no actual treatment of that disease, and no cure. There are theories, but the theory basically says that if you alter brain chemistry and a person feels better, there was a brain chemistry problem to begin with. It's a logical fallacy though. It would be as if you were having a bad day and suddenly your favorite TV show came and you became enraptured in it and then concluded your bad day was from not having watched that TV show 24 hours a day. (Like medicine, you might develop a tolerance to the enjoyment of that show when watching it indefinitely.)

The human brain is special and has existed for about 200,000 years. You can't tell me that these drugs that started coming out in the 1950s are the end-all answer to human suffering, that psychiatrists are the authority on what they call mental illness. It's arrogant. You can't look back on history, the majesty of humans and the world and say suddenly in all of world and the history of people the answer to human suffering was Paxil, or Ativan, or Seroquel. It's preposterous. Look at the trees and flowers and oceans of the world and see if they speak those names. But medicine does help people. Real medicine. We look now at developed countries and see people living into their 80s and beyond. And we can say that is because of modern medicine. And we can look back in history and see people living into their 30s on average and say, wow, if they had access to the nutrition and medicines we do now, we could have helped those people live longer. But what do you say now about how well adjusted we are, how happy we are, our level of human suffering? Do we look back in history and think, look at how much suffering we could have solved throughout the hundreds of thousands of years with these psychiatric drugs? Or do we look at ourselves now and think human suffering in wealthy countries with access to these drugs is still rampant? We have so many people who aren't being helped, who aren't feeling better and who even die as a result of iatrogenic psychiatric drug addiction. You can look at famous celebrities, such as Anna Nicole Smith whose psychiatrist was prescribing her 11 drugs all legally. People suffer still in modern times with these drugs. If psychiatric drugs were a ticket to health, Anna Nicole Smith should still be alive and swinging.

And also when you look at biospychiatry it's a very short-lived field which has yielded very few answers. It's mired in problems and the commitment to it borders on insane. You move from chloryl hydrate to barbiturates to benzos, and each time they say this one is safe, this one's not addictive. And thirty years after it comes out that they are addictive, you still have doctors giving them to kids saying they're not addictive. You've just got to give it up. This is so big. This is human beings' lives we're talking about. Psychiatrists I guess, if I were to pin a responsibility on them, would be to protect patients from the misuse of controlled substances they are charged with prescribing. Given what they do, that could be the best I would hope for. And in my experience, I was failed of that. And I'm not the only one.

BTW, Crane is a psychiatrist. http://en.wikipedia.org/wiki/Scarecrow_(comics)

 

[Doc Samson]

I'm not going to respond to your anti-psychiatry diatribe because that's not what this board is for, and quite frankly you're harshing the buzz of the funnest day of the year for many people posting here.

I won't let you slide on questioning my comic book geekhood with an F-ing wikipedia reference. Crane was on the tenure track in the Department of Psychology at Gotham State.

From the DC comics website:

http://www.dccomics.com/dcdirect/?dcd=3119

 

[swingerofbirch]

I'm not going to respond to your anti-psychiatry diatribe because that's not what this board is for, and quite frankly you're harshing the buzz of the funnest day of the year for many people posting here.

I won't let you slide on questioning my comic book geekhood with an F-ing wikipedia reference. Crane was on the tenure track in the Department of Psychology at Gotham State.

From the DC comics website:

http://www.dccomics.com/dcdirect/?dcd=3119

Heaven forbid I harshen the buzz. I spent another day trying to taper my Ativan dosage (which is why I originally found this board, to find out about studies of the use of l theanine during benzodiazepine withdrawal, the posts of which were deleted, ironically the nicest ones I posted). I guess I just stayed for the good company. I know it's scramble week, I have friends in med school who are graduating (they share my opinions on psychiatry and are even harsher at times). But I was simply responding to your anti-patient diatribe suggesting that your patients are paranoid in thinking you are somehow out to put them away while not recognizing your greatness in returning them to health. My original post in this thread was on topic and I actually answered the OP's question regarding the use of seroquel.

 

[Doc Samson]

Heaven forbid I harshen the buzz. I spent another day trying to taper my Ativan dosage (which is why I originally found this board, to find out about studies of the use of l theanine during benzodiazepine withdrawal, the posts of which were deleted, ironically the nicest ones I posted). I guess I just stayed for the good company. I know it's scramble week, I have friends in med school who are graduating (they share my opinions on psychiatry and are even harsher at times). But I was simply responding to your anti-patient diatribe suggesting that your patients are paranoid in thinking you are somehow out to put them away while not recognizing your greatness in returning them to health. My original post in this thread was on topic and I actually answered the OP's question regarding the use of seroquel.

One of the hardest things a psychiatrist has to do is to act against their patient's wishes in order to maintain their health and/or safety. We do not take such a decision lightly. My comment vis-a-vis the ambivalence of the Doc Samson character was simpy commenting on how well it mirrored the oft-changing relationship I've had with my patients with chronic and persistent serious mental illness. I am in no way "anti-patient", but sometimes I do hospitalize my patients against their will only after careful consideration of the alternatives. If my job satisfaction was based on recognition of "greatness" then I'd be in another field entirely.

 

[billypilgrim37]

I won't let you slide on questioning my comic book geekhood with an F-ing wikipedia reference. Crane was on the tenure track in the Department of Psychology at Gotham State.

To be fair, he might have been a psychologist in New Mexico, where could prescribe that green stuff to people before making his way to Gotham...

 

[Regnvejr]

Chronically drugging a person doesn't mean that they are mentally ill. I think calling someone mentally ill is quite offensive and untrue. ...

Ah, Scientology wannabe. Unsubstantiated attacks based on personal dislike really doesn't give you much credibility, especially in the fact of what we experience with our patients. If they are not happy, then they don't come back, and I am WAYYY to busy.

So your argument is essentially junk; you are junk.

 

[PsyDGrrrl]

Have the Scientologists and/or the New World Order/Illuminati Conspiracy crazies invaded this thread?

 

[PsyDGrrrl]

"The Rules", whatever they are, are completely different in these populations, dontcha think?

Ha ha. My patients are very...unique individuals. I have a long list of "you can't make this stuff up" quotes and incidents.

 

[swingerofbirch]

Ah, Scientology wannabe. Unsubstantiated attacks based on personal dislike really doesn't give you much credibility, especially in the fact of what we experience with our patients. If they are not happy, then they don't come back, and I am WAYYY to busy.

So your argument is essentially junk; you are junk.

Given the comprehensive comments I've written, I'm not sure what you're saying is unsubstantiated that I've said; you only quoted a small snippet. I have been saying that the major tenants of biopsychiatry are unsubstantiated. I find it ironic that you say I am making personal attacks when I am writing about the field of psychiatry and when you attack me as being a Scientologist wannabe and that I myself am junk. I knew I hated what psychiatry had done to my life before I even had heard of Scientology. I am not a Scientologist. My personal belief is that Scientology is a cult that uses hypnosis and fear to keep people caught in its web. I've even read articles that they use psychiatric drugs in their narconon programs when they've been investigated, so if anything I find them quite hypocritical. Why in the world would I need to be a member of a cult to disagree with psychiatry's tenants?

Please remember I came to this forum looking for help with my benzodiazepine withdrawal as I have not been able to find help from psychiatrists. I wrote very politely with pointed questions. The rudeness and arrogance with which I was privately messaged was not appropriate, especially given the fact that psychiatrists regularly seek medical advice for their patients on this site without in any way confirming they are in fact psychiatrists and not patients. So, I was told I could not post seeking medical advice. And I haven't. I have simply posted my opinion. You are the one who is making a personal attack calling me a Scientologist and junk. It's not a surprising attitude to me given the attitudes I have seen from psychiatrists and the one psychiatrist I saw who was actually abusive.

 

[whopper]

I have not been able to find help from psychiatrists.

Which is why I referred you to NAMI. If someone you sought help from did not give you the help needed, it could be for a myriad of reasons why. It is considered inappropriate for a doctor to investigate your particular case and look into what happened, without there being some official stamp on it such as your permission which creates a binding contract between the 2 entities..and as such we cannot do that.

From your own admission your own experience with a psychiatrist left a bad impression on you. We're not the people to talk to, just as much as you getting a bad pizza does not make the next pizza joint culpable for the original restaurant's bad pizza. The people to talk to are NAMI, getting a 2nd opinion from another doctor where you've established an official relationship or perhaps even a lawyer or consumer advocate.

And if you think that's a one sided defense of psychiatry-its not. I would personally love to see any bad psychiatrist or any doctor for that matter get caught in an investigation. I don't know you but I am still considering the possibility that your frustration from your situation you experienced is valid, but that does not make the entire field bad, just as much as the ER doctor that prescribed my father in law the wrong medication make all ER doctors bad (I was the one that had to correct that situation).

Now, since your presence on the forum is becoming disruptive, and at times still seeking medical advice, I hate saying it but I would reccomend that the forum lock your account.

 

[billypilgrim37]

Please remember I came to this forum looking for help with my benzodiazepine withdrawal as I have not been able to find help from psychiatrists.

Exactly. You have an excellent question, you've obviously read a lot, and this simply isn't the right venue for your question. By our definition, you just described what we would call "asking for medical advice" precisely. You may disagree with that definition, and that's fine. But this isn't some egalitarian forum where the opinion of anyone else but the moderators matters.

 

[whopper]

Oh by the way--Scarecrow was referred to as a psychiatrist in some texts. I think it depended on the writer & editor of the issue of Batman at the time who may have not known the difference, though I agree with Doc Samson that the official answer would be better as a psychologist, since more comics have portrayed him as such. This occasionally happens in comics-Doc Samson-the Marvel character, not our own Doc Samson for example is identified as a having a "Doctorate in Psychiatry", and some of the writers who handled his character didn't seem to get that psychiatrists need to go to medical school first before becoming a psychiatrist.

 

[Doc Samson]

Oh by the way--Scarecrow was referred to as a psychiatrist in some texts. I think it depended on the writer & editor of the issue of Batman at the time who may have not known the difference, though I agree with Doc Samson that the official answer would be better as a psychologist, since more comics have portrayed him as such. This occasionally happens in comics-Doc Samson-the Marvel character, not our own Doc Samson for example is identified as a having a "Doctorate in Psychiatry", and some of the writers who handled his character didn't seem to get that psychiatrists need to go to medical school first before becoming a psychiatrist.

Totally agree, I just wasn't in the mood to concede the point. In general though, the back story of Scarecrow is most fitting with a psychologist (on tenure track in major university department doing research on the fear response) and Samson's is that of a psychiatrist (med school graduate in private practice, some military consultation on the side). Also agree that some of the writers just don't know the difference and use the two interchangeably.

 

[Regnvejr]

....And if you think that's a one sided defense of psychiatry-its not. I would personally love to see any bad psychiatrist or any doctor for that matter get caught in an investigation....

Agreed. Those guys leave a mess for the rest of us to clean up.
And every profession have those, not just psychiatry/medicine.

 

[whopper]

Scarecrow was referred to as a psychiatrist in some texts

Agree that he's a psychologist. However when people ask me what do I do as a profession, and I say "Forensic Psychiatrist", I get asked what exactly is that?

And to keep it short & sweet I say, "Did you see Batman Begins? I do what Scarecrow does--if he were legit & not scraring people with the gas."

 

[jennieloo]

I have the answer to this question...

Seroquel is used in an institutional setting to zombie out while someone is getting over opiate withdrawals under the radar. It is also used to remove one's consciousness from the institutional setting altogether especially if the inmate, addict, and or patient is under substantial stress like life losses or legal charges. It is not used to get high just to get away and burn up time sleeping instead of thinking.

When someone is begging for Seroquel, they are saying I am dealing with things I cannot physically or mentally or emotionally handle, and I do not want to suffer so I would rather sleep. You can manage their dose so they get good sleep at night but have to deal with their self induced burdens during the day. The night of good rest can also help them handle their pain so they do not become suicidal from being constantly overwhelmed from the life they chose.

On the streets, this drug is not used for much of getting high, it is just basically an instant sedative. If they snort it, they are just being stupid. The most that will happen is they will pass out before they wipe their nose.

 

[whopper]

Hmm,

I got to point out some issues I have with your post.

especially if the inmate, addict, and or patient is under substantial stress like life losses or legal charges. It is not used to get high just to get away and burn up time sleeping instead of thinking.

In several places it is used to augment the effects of substances of abuse. This is well recorded in several case studies, and the pharmacology behind Seroquel support that this effect is likely. There are reports in prisons of prisoners obsessively demanding seroquel but not other antipychotic as was mentioned in the last AAPL convention.

Just one example out of several...
http://ajp.psychiatryonline.org/cgi/content/short/161/9/1718

As for the substantial stress, it's not indicated for the treatment of adjustment disorder.

When someone is begging for Seroquel, they are saying I am dealing with things I cannot physically or mentally or emotionally handle, and I do not want to suffer so I would rather sleep.

Seroquel is not indicated for sleeping purposes. It's sleep effect is based on it's antihistimanic properties, so if you give someone Seroquel just to make them sleep, you're bascally given them $400 benadryl. That only creates an argument to consider giving the person a sleep medication, not Seroquel which is not indicated for such.

You can manage their dose so they get good sleep at night but have to deal with their self induced burdens during the day. The night of good rest can also help them handle their pain so they do not become suicidal from being constantly overwhelmed from the life they chose.

Then why give the person a medication that is not for sleeping purposes that happens to be an antipsychotic? Why not just give the person a sleep medication? Antipsychotic medications are associated with several side-effects. Many of those side effects are dangerous and can be permanent.

On the streets, this drug is not used for much of getting high, it is just basically an instant sedative. If they snort it, they are just being stupid. The most that will happen is they will pass out before they wipe their nose

This likely varies per region, though as I said, it is published that antihistamines boost the effect of opioids. So then why are people willing to pay for Seroquel off the street (an illegal practice) if all they want to do is sleep, when they can legally get a sleep medication for a cheaper price? Why are there published case reports of Seroquel abuse? Why pay hundreds of dollars to a drug dealer when you can get an OTC sleep med for $5? I hate saying it, but the reason is highly transparent.

The most that will happen is they will pass out before they wipe their nose

Uh no. If they snort it, they can get nasal damage, possibly even epistaxis to levels that may require hospital intervention. Ever hear of cocaine abusers with nose problems? Some of them, their noses bled to the point where they required a surgeon to intervene. Any powder inhaled through the nose could cause the same problems. In fact, going through the list of published reports, insufflating anything, even if done appropriately, can cause several medical problems.

There are reports of people begging for Seroquel claiming they just want it to go to sleep? Uh yeah, and there are several patients begging for another script of Xanax because their dog ate the first one. Just because one begs for a medication, we still have to give it appropriately.

I hope you aren't advocating we give out Seroquel simply for sleep purposes. That, by the way, is illegal under certain circumstances (e.g. a drug rep advocating it for that use, why? Because it's not FDA approved for that use).

1) If you are a psychologist without medical training, it's outside your expertise.
2) Even if you do have medical training, you don't seem to be aware of the possible side-effects of this medication and it's lack of FDA approval for sleep, who someone with medical training should know before they advocate it's use.

I do respect what I believe is your compassion to help these people, but if all they really need is a decent night of sleep, I'll give them a dosage of something other than Seroquel. There's a difference between helping someone and enabling a problem, though with good intentions.

I think my tone is a bit terse. Please believe me that I only mean to express my differing opinions in a collegial manner. I felt I needed to counter you point-by-point despite that it creates terse tone only because there are medical students and residents who read these forums. I do not want them to get a wrong idea which can lead to disastrous consequences in their practice.

 

[Matteomm]

One of the patients on my team is a young man in the hospital for substance induced mood disorder and amphetamine dependence. During his entire hospital stay, he had had several behavioral issues (unscrewing the windows, smoking on the unit, banging the walls) and been pining for medicines. First it was narcotics for back pain, despite the fact that he looked comfortable and would sit and lie in positions that would make most folks with back pain as severe as he made it out to be writhe in pain. The next thing he focused on was being "locked up" and being anxious and agitated. One of the covering doctors put him on a low dose of a prn benzo.

I promptly discontinued that and he then went on about being anxious and needing Seroquel. He also upped the anty by claiming to hear voices. He did not appear the least bit psychotic, and I'm guessing a week is plenty of time to be out of the window for persisting psychosis due to amphetamines.

Eventually, since he wasn't getting what he wanted from me (ie medicating him so that he wouldn't have to be awake and deal with his amphetamine dependence), he opted to go to a shelter. I discharged him.

Now here are my questions:

1) Was I too harsh in dealing with this patient? I've seen patients like him before and my read was that he was not really ready to face his addiction and on top of that he was wanting to medicate any and every little bad emotion or thought that came his way.

2) I know there have been a few case reports of Seroquel abuse, but is there any new literature on the subject? I've looked and found nada.

Thanks for reading this long post

Apologies for bringing up an old thread. After scanning through related threads, this one peaked my interest.

If I was in your position, I would have given him seroquel.

Honestly, depending on the severity of his mood, low dose risperidone regardless of whether he was hearing voices or not could be good as well. The patient presented with substance induced mood disorder and amphetamine dependence. Besides agitation, were there other symptoms?

It sounds like it would have been pointless for him to stay in the psych ward anyways. Addicts ask for addictive medications. That's just the reality of it. A doctor overseeing a patient with substance abuse needs to have an introspective understanding and an ability to empathise with the struggles a patient is experiencing. If he wasn't going to receive any medications to relieve his restlessness and agitation, why bother to even keep him there. Might as discharge him.

Perhaps pretending to hear voices was the only way he knew that he could get a medication he felt might help. Why should he trust a doctor to prescribe him something that he wants, by asking for it in a more direct honest way. If he knows that a doctor is aware of his substance abuse, he wants to avoid the doctor from thinking that he would ever abuse such a medication. Despite how seroquel is meant for schizophrenia and bipolar, we can all attest that it's used off label much more often. Evidence suggests it's actually good in people with substance abuse.

Remeron is another good medication in this population I might add.

 

[OldPsychDoc]

Oh god--that Scarecrow--Doc Samson controversy...
I'm in tears.

The Golden Age of SDN Psych.

 

[MLT2MT2DO]

Oh god--that Scarecrow--Doc Samson controversy...
I'm in tears.

The Golden Age of SDN Psych.

Interesting, there's also a poster that was banned by the name of "swingerofbirsch" posts read a lot like "birschswing"

 

[OldPsychDoc]

Interesting, there's also a poster that was banned by the name of "swingerofbirsch" posts read a lot like "birschswing"

Couldn't be related. "birchswing" is much more well-behaved.

 

[wfamtwsch]

Just an anecdote, I had a psych NP who was managing my care try to prescribe seroquel because I said it was tough to fall asleep sometimes. I even said melatonin works fine... I assume this isn't standard practice.

 

[birchswing]

Couldn't be related. "birchswing" is much more well-behaved.

Hard to imagine an appreciation for Robert Frost's poetry isn't near universal.

Just an anecdote, I had a psych NP who was managing my care try to prescribe seroquel because I said it was tough to fall asleep sometimes. I even said melatonin works fine... I assume this isn't standard practice.

It seems common (based on message boards), not sure if it actually is. AstraZeneca settled a lawsuit with the government over pushing many off-label uses for Seroquel. It's not hard to imagine a drug rep advertising Seroquel as a non-addictive sleep aid. When a marketing rep walks into a medical office with a bucket of KFC, it's not hard to imagine all sorts of illustrative conversations take place.