Quetiapine Abuse Fourteen Years Later: Where Are We Now? A Systematic Review

Association between Prescribing and Intoxication Rates for Selected Psychotropic Drugs: A Longitudinal Observational Study

Psychotropic prescription drugs are commonly involved in intoxication events. The study's aim was to determine a comparative risk for intoxication in relation to prescribing rates for individual drugs. This was a nationwide observational study in Slovenian adults between 2015 and 2021. Intoxication events with psychotropic drugs were collected from the National Register of intoxications. Dispensing data, expressed in defined daily doses, were provided by the Health Insurance Institute of Slovenia. Intoxication/prescribing ratio values were calculated. The correlation between trends in prescribing and intoxication rates was assessed using the Pearson correlation coefficient. In total, 2640 intoxication cases with psychotropic prescription drugs were registered. Anxiolytics and antipsychotics were the predominant groups. Midazolam, chlormethiazole, clonazepam, sulpiride, and quetiapine demonstrated the highest risk of intoxication, while all antidepressants had a risk several times lower. The best trend correlation was found for the prescribing period of 2 years before the intoxication events. An increase of 1,000,000 defined daily doses prescribed resulted in an increase of fifty intoxication events for antipsychotics, twenty events for antiepileptics, and five events for antidepressants. Intoxication/prescribing ratio calculation allowed for a quantitative comparison of the risk for intoxication in relation to the prescribing rates for psychotropic drugs, providing additional understanding of their toxicoepidemiology.

Prescription patterns of quetiapine for multiple drug abuse, depression, and psychosis: A retrospective study

Background

Quetiapine is an atypical antipsychotic prescribed for schizophrenia, bipolar disorder, multiple drug abuse (MDA), generalized anxiety disorder, severe depression, dementia, and mood disorders. Prescription of quetiapine varies according to use, with side effects increasingly reported with higher doses. Many previous case reports highlighted the misuse of the drug. Here we studied the prescribing patterns of quetiapine in multiple drug abuse (MDA), depression, and psychosis patients in the Madinah region in Saudi Arabia.

Methods

This is a retrospective single-center study carried out in the main referral hospital for mental health in Madinah, Saudi Arabia for the period December 2020 till December 2021.

Results

A total of 158 patients were included in this study. The mean age of the patients was 30.5 ± 10.1 years. Male presented for 89.9 % of the patients. In terms of quetiapine indications, 46.2 % of patients used it for MDA, 29.7 % for psychosis, and 24.1 for depression. For all patients, quetiapine was used with a mean daily dose of 285.2 ± 222 mg and for a mean duration of 13.9 ± 15.4 weeks. Quetiapine was prescribed with a mean of 2.1 ± 2.2 prescriptions. Comparison between different indications shows that quetiapine was more frequently prescribed for MDA (p < 0.001). The MDA patients were significantly younger than in other groups (p = 0.001). All patients who received quetiapine for MDA were males. However, MDA patients received a smaller dose of quetiapine than other indications (p < 0.001). There were no significant differences between groups in terms of the number of prescriptions, duration, and whether the patient was on other medications or not. These results have been confirmed by regression analysis, where male and younger ages represented a significant contributing factor to MDA compared to psychosis, 95 % CI: 8 x107 (8 x107 - 8 x107) and 0.943 (0.900---0.987), respectively.

Conclusion

Quetiapine was prescribed more frequently in MDA patients and younger individuals. Low dose was predominant in those patients, indicating a probability of drug abuse.

Combined effects of quetiapine and opioids: A study of autopsy cases, drug users and sedation in rats

Fatal opioid poisonings often involve methadone or morphine. This study aimed to elucidate if quetiapine, a widely used sedative antipsychotic medication, may increase the risk of fatal opioid poisoning by additive inhibitory effects on the central nervous system. We used data from 323 cases of fatal methadone or/and morphine poisonings autopsied from 2013 to 2020, a survey of 34 drug users, and performed blinded placebo‐controlled studies in 75 Flinders Resistant Line rats receiving three cumulative intraperitoneal doses of vehicle, methadone (2.5, 10 and 15 mg/kg), morphine (3.75, 15 and 22.5 mg/kg), quetiapine (3, 10 and 30 mg/kg) or quetiapine combined with methadone or morphine. Quetiapine was detected in 20.4% of fatal opioid poisonings with a significantly increased frequency over time, primarily in low or therapeutic concentrations, and was not associated with methadone or morphine concentrations. Use of quetiapine, most commonly in low‐to‐moderate doses to obtain a sleep‐inducing or tranquillizing effect, was reported by 67.6% of survey respondents. In the animal studies, a significant impairment of sedation score, performance on the rotarod and open field mobility was observed in all treatment groups compared with vehicle. However, the effect of quetiapine plus the opioid was not significantly different from that of the opioid alone. Thus, no additive sedative effects were observed in rats. Our results suggest that quetiapine is more often an innocent bystander than a contributor to fatal opioid poisoning. However, the combined effects on other parameters, including blood pressure, cardiac rhythm and respiratory rate, need investigation.

Abuse and misuse of second-generation antipsychotics: an analysis using VigiBaseTM , the World Health Organisation pharmacovigilance database

The study aim was to assess the abuse/misuse potential of second-generation antipsychotics (SGAPs) using VigiBase^TM data. We extracted individual case safety reports (ICSRs) of 'Drug abuse, dependence, and withdrawal' involving SGAPs up to June 2018. We assessed disproportionate reporting by calculating the Information Component (IC), considering the lower end of the 95% credibility interval for IC (IC₀₂₅ ), and the Proportional Reporting Ratio (PRR). We identified 1,683 ICSRs recorded as 'abuse, dependence, and withdrawal' involving SGAPs, mainly quetiapine (n=1,089) and olanzapine (n=209). The disproportional reporting indicators highlighted an association between 'Drug abuse and dependence', and quetiapine, olanzapine, and ziprasidone, as indicated by the IC₀₂₅ (2.263, 0.259, and 1.051, respectively) and PRR values (3.929, 1.020, and 1.334, respectively). The abuse/misuse potential is confirmed for quetiapine and olanzapine and highlighted for the first time for ziprasidone. Physicians should consider these risks when prescribing these antipsychotics, especially to patients with history of drug abuse.

Who prescribes quetiapine in Denmark?

The second‐generation antipsychotic quetiapine is commonly used off‐label for its anxiolytic and hypnotic properties. However, quetiapine is associated with problematic side‐effects. We used Danish Medicinal Product Statistics and a 20% random sample of the Danish population's prescription fills (2001–2020) to describe the utilization of quetiapine and proportion of various prescriber types (general practitioner [GP], specialist in private practice, hospital physician and other prescribers) both in connection to first‐time and subsequent prescriptions. In 2020, 92% of all quetiapine was dispensed outside hospitals and the average daily dispensed quantity of quetiapine per user corresponded to 100 mg/user/d. A GP issued 53% of first‐time prescriptions and 75% of subsequent prescriptions for quetiapine in 2020. The proportion of quetiapine prescriptions issued by GPs varied by age group—from 14% among 0–17‐year‐olds to 93% among the ≥80‐year‐olds. Future initiatives on the rational use of quetiapine and related drugs, especially among adults, should target GPs.

Quetiapine, Misuse and Dependency: A Case-Series of Questions to a Norwegian Network of Drug Information Centers

Purpose

The second-generation antipsychotic quetiapine has been associated with misuse and dependency. We aimed to review questions to the Norwegian network of drug information centers concerning this potential drug safety problem.

Methods

We conducted a Boolean search in the database of the Regional Medicines Information and Pharmacovigilance Centres in Norway (RELIS) combining the indexed categories “quetiapine” and “adverse drug reaction” with the text words “misuse” or “dependency”. Question–answer pairs (Q/As) in the full-text, searchable RELIS database were defined as cases. Cases were analyzed for drug safety issues linked to use of quetiapine, including off-label use, polypharmacy and other patient risk factors.

Results

The search resulted in 54 cases. Forty-six cases (85%) were patient-related, and a majority came from physicians working in hospitals. Twenty-nine cases (54%) concerned patients with a history of addiction, 14 cases (26%) had polypharmacy, and off-label use of quetiapine for insomnia was identified in 14 of the cases (26%). Only three of the cases included a specific question about patient dependency of quetiapine, and these cases were all associated with insomnia.

Conclusion

We conclude that our case series from the Norwegian network of drug information centres reflects that quetiapine frequently involves clinical narratives of a history of addiction, polypharmacy or insomnia (off-label use). However, the case series did not reveal new information about the drug’s addictive potential.

Identification and Quantification of Antipsychotics in Blood Samples by LC-MS-MS: Case Reports and Data from Three Years of Routine Analysis

Antipsychotic drugs (AP) are widely prescribed for the treatment of schizophrenia and psychosis. The pharmacological treatment of schizophrenia is often performed with the simultaneous use of two or more antipsychotic agents to achieve the desired control of psychotic symptoms Available AP include both conventional (typical) and new (atypical) antipsychotic medications. Atypical AP, such as quetiapine, now account for the vast majority of AP prescriptions. In forensic toxicology, AP are of considerable interest because of their potential abuse and their involvement in intoxications and suicides. The authors retrospectively examined AP positive cases detected in samples collected during autopsies performed in the Forensic Clinical and Pathology Service of National Institute of Legal Medicine and Forensic Sciences Centre Branch or in other autopsies carried out in the central region of Portugal, between January 2016 and December 2018. A quantitative liquid chromatography-tandem mass spectrometry assay was developed for the simultaneous determination of 16 AP (amisulpride, aripiprazole, chlorpromazine, clozapine, cyamemazine, fluphenazine, haloperidol, levomepromazine, melperone, olanzapine, paliperidone, promethazine, quetiapine, risperidone, sulpiride and ziprasidone) in blood samples of postmortem cases. The Laboratory of Forensic Chemistry and Toxicology received 3,588 requests for toxicological analysis: 1,413 cases were positive for drugs from which 351 (24.8%) cases were positive for AP, 60.1% from male individuals and 39.9% from female. Quetiapine was the most prevalent AP (36.5%) followed by olanzapine (20.8%). During this period, there were 25 postmortem cases with AP blood concentrations above therapeutic range, in which 36% of those are in agreement with the information received (psychological history or acute intoxication suspicion) and the manner of death was suicide. Our results point that antipsychotics are an increasingly prevalent class of drugs. AP must be measured not only in toxic concentrations but also in therapeutic levels in postmortem cases; therefore, it is important to come up with a sensitive method to cover the low therapeutic range in which AP are usually present.

Focus on Clozapine Withdrawal- and Misuse-Related Cases as Reported to the European Medicines Agency (EMA) Pharmacovigilance Database

BACKGROUND

Clozapine is of high clinical relevance for the management of both treatment-resistant schizophrenia and psychotic disturbances with concurrent drug misuse. Although the molecule presents with a range of well-known side-effects, its discontinuation/withdrawal syndrome has been only anecdotally described.

AIMS

the 2005-2018 European Medicines Agency (EMA) dataset of Adverse Drug Reactions (ADRs) was analyzed to identify and describe possible clozapine withdrawal- and misuse-/abuse-/dependence-related issues.

METHOD

A descriptive analysis of clozapine-related ADRs was performed when available, data on ADRs' outcome, dosage, and possible concomitant drug(s) were considered.

RESULTS

Out of 11,847 clozapine-related ADRs, some 599 (5.05%) were related to misuse/abuse/dependence/withdrawal issues, including 258 withdrawal-related (43.1%); 241 abuse-related (40.2%); and 80 intentional product misuse-related (13.3%) ADRs. A small number of overdose- and suicide-related ADRs were reported as well. Clozapine was typically (69.2%) identified alone, and most (84.7%) fatalities/high-dosage intake instances were reported in association with a history of substance abuse.

CONCLUSIONS

Previous suggestions about the possibility of a clozapine discontinuation/withdrawal occurrence are here supported, but further studies are needed. However, the misuse/abuse cases here identified might be difficult to interpret, given the lack of studies highlighting the possible recreational use of clozapine. The high-dosage intake, fatal outcomes and clozapine/polydrug abuse issues reported here may, however, be a reason for concern.

Prescription Drug Misuse in "Clubbers" and Disco Goers in Ibiza

Background: Prescription drug misuse and its related risks are considered a worldwide public health issue. Current trends show that the extent of such phenomenon may not be limited to subjects with psychiatric disorders, as it also spreads to dance party and nightclub attendees, who often consume prescription drugs in combination with alcohol and psychoactive substances. This study aims to report the sociodemographic data and the psychiatric and clinical features of a sample of clubbers reporting prescription drugs use. Methods: Patients admitted to the psychiatry ward of the Can Misses Hospital in Ibiza were recruited for the study during a span of four consecutive years (2015-2018). The inclusion criteria were age 18-75 years old and the intake of psychoactive substances or more than five alcohol units during the previous 24 h. Substance use habits, psychopathological features, and use of unprescribed pharmaceuticals were investigated. Urine samples were collected and analyzed using gas chromatography/mass spectrometry. Results: A total of 110 subjects with psychoactive substance intoxication were recruited for the study. Among these, 37 (40%) disclosed the use of prescription drugs without medical supervision. The most common compounds were benzodiazepines (66%), antiepileptic drugs (8%), antidepressants (6%), opioids (6%), antipsychotics (6%), stimulants (6%), and non-steroidal anti-inflammatory drugs (NSAIDs, 2%). Prescription drug misuse was negatively associated with the use of psychodysleptics (two-tailed Fisher's exact test p = 0.018, ρ = -0.262). Conclusions: The use of prescription drugs is also common among clubbers, usually characterized by low propensity to be prescribed benzodiazepines, antipsychotics, or antidepressants. Prescription drugs may be an alternative to classic and novel psychoactive compounds or may be used to tamper and self-medicate the effects determined by the use of substances. Party goers should be adequately informed about possible risks of co-intake of psychoactive substances and prescription drugs to prevent serious medical and psychiatric consequences.