1. Lorman, William J. JD, PhD, MSN, PMHNP/CNS-BC, CARN-AP

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Since the introduction of the first atypical antipsychotic medication, clozapine, in the 1970s, numerous atypical antipsychotic medications have been developed-each with its own set of neurobiologic effects (both therapeutic and adverse side effects) along with class effects found in all medications in this class (the serotonin-dopamine antagonists). These medications are relatively nontoxic compared with their predecessors, the phenothiazines, and prescribing of the atypical antipsychotics has increased both for approved indications and for off-label uses (Alexander et al., 2011; Rowe, 2007).


The misuse of prescribed medications is a major public health problem in the United States. Often, misuse occurs when the medication causes a state of euphoria, relaxation, alertness, or sedation or other side effects that the user is attempting to create. Quetiapine (Seroquel) meets these criteria, and as further proof, there are multiple case reports in the literature that suggest that this drug, a serotonin-dopamine antagonist (also known as an atypical antipsychotic)-which previously was not considered to have abuse potential-is being misused/abused by either being taken when it has not been prescribed to the individual or being taken in greater or more frequent amounts than prescribed to result in a euphoric or other state. Quetiapine has been approved by the U.S. Food and Drug Administration for the treatment of schizophrenia and also for the treatment of bipolar disorder and depressive disorder (AstraZeneca, 2013). Its use as an off-label medication for the treatment of multiple psychiatric disorders has sky-rocketed, and there are clinical studies establishing its effectiveness in treating obsessive-compulsive disorder, posttraumatic stress disorder, personality disorders, anxiety, and depression (Maher & Theodore, 2012). It has also been prescribed, with varying success, to treat withdrawal symptoms from abused substances (i.e., alcohol, cocaine, benzodiazepines, and opioids; Sattar et al., 2004). Quetiapine is most commonly prescribed off-label to treat insomnia in patients in early recovery from alcohol dependence. However, the results have been inconsistent (Chakravorty et al., 2014).


The most common adverse effect of quetiapine is somnolence-an effect that makes this medication a favorite for treatment of insomnia (off-label). Some of the other common side effects include dry mouth, dizziness, constipation, abdominal pain, sore throat, increased appetite, and dyspepsia. When taken over longer periods, there is an increased risk of metabolic syndrome, which includes significant weight gain, dyslipidemia, hyperglycemia, and diabetes.


Antipsychotics, in general, have not been typically viewed as drugs of abuse because they do not produce a state of euphoria and, in most cases, produce sedation. However, quetiapine has been noted to be significantly misused and is now considered by many as a drug of abuse. According to Mattson et al. (2015), signs that quetiapine has become a drug of abuse include the existence of street names and values for the drug, diversion in prisons and other institutionalized settings (such as inpatient and outpatient treatment centers), users seeking the drug by feigning symptoms, and reports of intravenous or intranasal use of the drug. Regulatory measures have been instituted to reduce the prescribing of quetiapine in custodial settings and, in some cases, to remove the drug from institutional formularies (Tamburello et al., 2012). In addition, there is anecdotal evidence that patients seen in emergency rooms are demanding quetiapine for malingering or fabricating psychotic symptoms such as hallucinations (Caniato et al., 2009).


Some street names for quetiapine include quell, Susie Q, baby heroin, squirrel, and jailhouse heroin. Combinations are referred to as Maq Ball (quetiapine and cannabis) and Q-Ball (quetiapine and cocaine or heroin; Bogart & Orr, 2011; Pinta & Taylor, 2007). Quetiapine is commonly diverted from prescribed users for its street value for use to self-medicate insomnia and anxiety, to get drunk without the hangover, to "zone out," to take the edge off, and to reduce the crash from stimulants such as cocaine (Tarasoff & Osti, 2007).


Multiple studies have been conducted looking at misuse and abuse of quetiapine with attempts at profiling users. Most users are men in their mid-30s with a history of substance use disorders-most were polydrug users who had numerous psychoactive drugs prescribed and also illegally obtained (Cubala & Springer, 2014; Fischer & Briggs, 2010). McLarnon et al. (2012) studied patients in a methadone maintenance program and found that individuals with a history of misuse of anxiolytics or sedatives were 8 times more likely to report quetiapine misuse. In addition, use of quetiapine in conjunction with alcohol use was often reported.


According to the Substance Abuse and Mental Health Data Archive (2015), quetiapine is the most common antipsychotic leading to an emergency room visit as a result of overdose. In addition, women seemed more prone than men to have an emergency department visit involving quetiapine-which placed women at a higher risk of acute medical emergencies involving quetiapine. One reason ascribed to the misuse and abuse of quetiapine is the increased prescription of this drug, which provides a greater opportunity for diversion. Furthermore, there seems to be increased quetiapine use among the illicit drug user population because anecdotal evidence in the relevant literature suggests that abusers take quetiapine for its sedative effects when coming down from cocaine or other stimulants. It is currently unknown from the drug's pharmacologic properties if quetiapine is intrinsically addictive, although intractable insomnia has been reported during cessation of the drug. Future research will determine whether quetiapine itself produces a pleasurable high as typical drugs of abuse do with other drug use (Sansone & Sansone, 2010).


In conclusion, nurses should be aware that quetiapine has emerged as a potential drug of abuse because it has features of more familiar recreational drugs such as having a street value and a street name. When used recreationally, quetiapine poses health risks, sometimes serious enough to warrant a visit to the emergency department (Mattson et al., 2015). These findings suggest the need for heightened vigilance when evaluating potential abuse. If the clinician is also a prescriber, be aware of the traditional signs of drug abuse such as requesting the drug by name, asking for early refills, stockpiling tablets, and prescriber shopping. In addition, clinicians should be especially concerned about abuse when prescribing quetiapine to patients with co-occurring mental health and substance use issues.




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