Is There a Potential of Misuse for Venlafaxine and Bupropion?

A comprehensive review and meta-analysis of neurological side effects related to second-generation antidepressants in individuals with major depressive disorder

Second-generation antidepressants (SGADs) often cause neurological side effects (SEs). This meta-analysis seeks to quantify the short-term rates of neurological SEs related to routinely used second-generation antidepressants used to treat major depressive disorder (MDD). A search of the PubMed, EMBASE,Cochrane Library databases and Web of Science was done to uncover double-blind, randomized, placebo-controlled studies evaluating the effectiveness of frequently used SGADs medicines in people with MDD. Qualifying studies were required to concentrate on the use of SGADs routinely used in MDD and to uncover data on treatment-emergent neurological SEs occurring within 12 weeks of therapy. Overall, 143 RCT studies containing 188 treatment arms were included in the meta-analyses. Most SGADs increased the risk of neurological SEs compared to placebo. The least tolerated antidepressants on the neurological tract were desvenlafaxine (OR=1.98; CI 0.85-4.65; p-value=0.12) and venlafaxine (OR=1.15; CI 0.96-1.38; p-value=0.13). Agomelatine, bupropion and vortioxetine exhibited reduced neurological SEs, showing diminished risk in insomnia (OR=0.56; CI 0.36-0.88; p-value=0.01), somnolence (OR=0.46; CI 0.27-0.79; p-value=0.01), vision blurred (OR=0.43; CI 0.19-0.96; p-value=0.04), respectively. Most SGADs did not or just marginally increased the risk of headache compared to placebo. In conclusion, frequently used SGADs demonstrated distinct patterns of neurological SEs, which physicians should consider when prescribing antidepressants to promote treatment adherence and favorable outcomes in patients with MDD.

A Systematic Review of Abuse or Overprescription of Bupropion in American Prisons and a Synthesis of Case Reports on Bupropion Abuse in American Prison and Non-prison Systems

Illicit drug use is a huge problem in the US prison system. The objectives of this study are (1) to systematically investigate the prevalence of bupropion abuse in American prisons along with associated problems, and (2) to synthesize available case reports on this topic in both prison and non-prison settings. Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses, we searched five databases (PubMed, Embase, Scopus, CINAHL, and PsycINFO) and used Covidence software for screening and reviewing identified articles. The final search date was February 21, 2023. Newcastle-Ottawa Scale and ROBINS-I tool were used for risk of bias assessment. We included original studies of populations aged 18 years and above in American prisons. We found 77 unique articles, none of which met our eligibility criteria. A synthesis of 22 case reports that we found showed bupropion abuse to be more common in young males, and intranasal administration was the most common method of abuse. More frequent desired and adverse effects were "cocaine-like highs" and seizures, respectively. Although several cases of bupropion abuse have been reported in US prisons, no study has been done to understand its prevalence and associated effects. The absence of original studies on bupropion abuse in US prisons and the observed patterns in this case report synthesis further highlight the need for a study to investigate the prevalence of bupropion abuse in US prisons. The limitations of this study include that it is an empty systematic review and the absence of all pertinent data in many of the included case reports. The authors did not receive any funding for this work. This systematic review was registered in PROSPERO with registration number CRD42021227561.

Survey of noncontrolled medication misuse patterns

Introduction

The abuse potential of opioids and other controlled substances is well-known; however, reports of noncontrolled prescription medication (NCPM) misuse deserves further attention. Whereas several studies investigate patterns, motivations, and biochemical mechanisms underlying the misuse potential of NCPM, the clinical significance of NCPM misuse is not well-understood. The primary objectives of this project were to identify prescriber perceptions of NCPM misuse and evaluate patient reported patterns of misuse through survey responses.

Methods

Adult patients admitted to psychiatry services and prescribers working in psychiatry or on a general medicine service during the study time frame were invited to participate. Surveys were collected anonymously for both patients and prescribers.

Results

NCPM misuse was reported by 38.4% of patients. Trazodone (35%) and quetiapine (30%) were most commonly reported as being misused. Opioid (24.1% vs 4.3%; P = .023) and cannabis use disorders (13.8% vs 0%; P = .019) were reported more frequently in patients who misuse NCPM, whereas no difference was seen for other SUDs (P > .05). There was no difference between psychiatric and general medicine prescribers regarding familiarity with NCPM misuse (n = 21 [87.5%] vs n = 13 [81.3%]; P = .668).

Discussion

High rates of NCPM misuse were seen in this patient population. Our findings confirm previous reports of quetiapine misuse and also reveal that trazodone is frequently misused. Based on the observations in this study, the misuse of NCPM is identified as prevalent and noteworthy at our institution, warranting provider education and future studies.

A Focus on Abuse/Misuse and Withdrawal Issues with Selective Serotonin Reuptake Inhibitors (SSRIs): Analysis of Both the European EMA and the US FAERS Pharmacovigilance Databases

Despite increasing reports, antidepressant (AD) misuse and dependence remain underestimated issues, possibly due to limited epidemiological and pharmacovigilance evidence. Thus, here we aimed to determine available pharmacovigilance misuse/abuse/dependence/withdrawal signals relating to the Selective Serotonin Reuptake Inhibitors (SSRI) citalopram, escitalopram, paroxetine, fluoxetine, and sertraline. Both EudraVigilance (EV) and Food and Drug Administration-FDA Adverse Events Reporting System (FAERS) datasets were analysed to identify AD misuse/abuse/dependence/withdrawal issues. A descriptive analysis was performed; moreover, pharmacovigilance measures, including the reporting odds ratio (ROR), the proportional reporting ratio (PRR), the information component (IC), and the empirical Bayesian geometric mean (EBGM) were calculated. Both datasets showed increasing trends of yearly reporting and similar signals regarding abuse and dependence. From the EV, a total of 5335 individual ADR reports were analysed, of which 30% corresponded to paroxetine (n = 1592), 27% citalopram (n = 1419), 22% sertraline (n = 1149), 14% fluoxetine (n = 771), and 8% escitalopram (n = 404). From FAERS, a total of 144,395 individual ADR reports were analysed, of which 27% were related to paroxetine, 27% sertraline, 18% citalopram, 16% fluoxetine, and 13% escitalopram. Comparing SSRIs, the EV misuse/abuse-related ADRs were mostly recorded for citalopram, fluoxetine, and sertraline; conversely, dependence was mostly associated with paroxetine, and withdrawal to escitalopram. Similarly, in the FAERS dataset, dependence/withdrawal-related signals were more frequently reported for paroxetine. Although SSRIs are considered non-addictive pharmacological agents, a range of proper withdrawal symptoms can occur well after discontinuation, especially with paroxetine. Prescribers should be aware of the potential for dependence and withdrawal associated with SSRIs.

Antidepressants as Endocrine Disrupting Compounds in Fish

As antidepressant usage by the global population continues to increase, their persistent detection in aquatic habitats from municipal wastewater effluent release has led to concerns of possible impacts on non-target organisms, including fish. These pharmaceuticals have been marketed as mood-altering drugs, specifically targeting the monoaminergic signaling in the brain of humans. However, the monoaminergic systems are highly conserved and involved in the modulation of a multitude of endocrine functions in vertebrates. While most studies exploring possible impact of antidepressants on fish have focused on behavioural perturbations, a smaller spotlight has been placed on the endocrine functions, especially related to reproduction, growth, and the stress response. The purpose of this review is to highlight the possible role of antidepressants as endocrine disruptors in fish. While studies linking the effects of environmentally relevant levels of antidepressant on the endocrine system in fish are sparse, the emerging evidence suggests that early-life exposure to these compounds have the potential to alter the developmental programming of the endocrine system, which could persist as long-term and multigenerational effects in teleosts.

Bupropion Use Disorder by Chewing

INTRODUCTION

Bupropion is a widely used antidepressant that plays an essential role in treating mental disorders. Due to its structural similarities with psychostimulants, bupropion is suggested to have addictive potential. Several case reports have been published addressing its misuse in recent years, mainly through nasal insufflation and intravenous administration. Most of the reported cases cited a history of substance use disorder.

METHODS

Written informed consent was obtained from the patient to write this case report.

CASE PRESENTATION

We present a case with alcohol use disorder and attention deficit hyperactivity disorder, who developed a substance use disorder to bupropion while chewing it in doses up to 2250 mg, in an attempt to get "high" with no history of seizures.

DISCUSSION

Our case suggests that bupropion can also be misused by chewing even at high doses and that it can lead to a substance use disorder. Its use in various indications in treating mental disorders and its over-the-counter accessibility, along with a lower risk of stigmatization, could increase the prevalence of bupropion misuse. It is essential to know the medical consequences of bupropion misuse as there is increasing data on its addictive potential. More information is needed to clarify the impact of the route of administration on drug metabolism and adverse effects.

The Timing of Clinical Effects of Bupropion Misuse Via Insufflation Reported to a Regional Poison Center

BACKGROUND

Bupropion is an antidepressant medication with expanding indications including smoking cessation, weight loss, attention-deficit/hyperactivity disorder, seasonal affective disorder, and amphetamine dependence. Despite its increasing popularity among providers, it has a well-known narrow therapeutic window that can lead to delayed onset of symptoms with extended-release formulations and devastating consequences in overdose. We have noticed some patients misusing bupropion via insufflation, which added a layer of complexity with regards to the therapeutic application of the drug. This route of use created difficult decisions regarding clinical monitoring in these patients.

OBJECTIVES

To determine if prolonged observation is required after insufflation of bupropion and to further describe effects from this route of use.

METHODS

This is a retrospective observational study reviewing all the cases of insufflated bupropion use reported to a single poison center without any other coingestants.

RESULTS

The majority (85.7%) of patients had mild or moderate effects, and seizures occurred in 19.6% of cases; and the vast majority of patients were symptomatic by the time of the initial call to the poison center. We did not encounter any delayed effects after this route of use.

CONCLUSIONS

This report describes the clinical effects reported, and the timing of these effects, after insufflation of bupropion.

Beyond the 'purple drank': Study of promethazine abuse according to the European Medicines Agency adverse drug reaction reports

BACKGROUND

Promethazine is a medicinal product, available on its own or in combination with other ingredients including dextromethorphan, paracetamol and/or expectorants. Anecdotal reports have however indicated that promethazine may have a misuse potential, especially in adolescents.

OBJECTIVE

We here aimed at studying how this phenomenon has been reported to the European Monitoring Agency Adverse Drug Reactions database.

METHODS

After a formal request to the European Monitoring Agency, the promethazine-specific dataset has been studied, performing a descriptive analysis of misuse/abuse/dependence-related adverse drug reaction reports. The study was approved by the University of Hertfordshire (LMS/PGR/UH/03234).

RESULTS

The analysis of promethazine data showed increasing levels of misuse/abuse/ dependence issues over time (2003-2019). Out of a total number of 1543 cases of adverse drug reactions, the abuse/misuse/dependence-related cases reported were 557, with 'drug abuse' (300/557: 53.8%) and 'intentional product misuse' (117/557: 21.0%). being the most represented adverse drug reactions. A high number of fatalities were described (310/557: 55.6%), mostly recorded as 'drug toxicity/drug abuse' cases, with opiates/opioids having been the most commonly reported concomitant drugs used.

CONCLUSION

Anecdotal promethazine misuse/abuse reports have been confirmed by European Monitoring Agency data. Promethazine misuse/abuse appears to be an alarming issue, being associated with drug-related fatalities. Thus, healthcare professionals should be warned about a possible misuse of promethazine and be vigilant, as in some countries medicinal products containing promethazine can be purchased over the counter. Since promethazine is often available in association with opioids, its abuse may be considered a public health issue, with huge implications for clinical practice.

Stimulant use in patients presenting with psychocutaneous disorders

BACKGROUND

Psychocutaneous disorders are often attributed to stimulant medications, yet this relationship has never been fully elucidated. Literature on psychocutaneous disorders largely focuses on clinical presentation and treatment rather than disease etiology or exacerbation.

OBJECTIVE

To determine whether patients presenting with psychocutaneous disorders display high rates of stimulant use and psychiatric comorbidity.

METHODS

We undertook a retrospective cohort study of patients with psychocutaneous disorders presenting to a single center. It was hypothesized that these patients would have high rates of stimulant use and psychiatric comorbidity. Following analysis of baseline demographics, the patients were assigned to 1 of 2 groups: those with a psychotic disorder and those with a neurotic disorder.

RESULTS

Sixty percent of the patients (n = 317) with psychocutaneous disease had recently used a stimulant and more than 80% (270 of 317) carried an additional psychiatric diagnosis. The neurotic disorder group (n = 237) was younger and had higher rates of stimulant use. The psychotic disorder group (n = 80) had higher rates of psychosis, medical comorbidity, and illicit stimulant drug use.

LIMITATIONS

The predominantly Caucasian population may limit generalizability of findings as may the retrospective nature.

CONCLUSIONS

Patients with psychocutaneous disease have high rates of stimulant use and most have at least 1 psychiatric comorbidity.

Clinical effects of intravenous bupropion misuse reported to a regional poison center

Bupropion is an antidepressant medication with expanding indications including smoking cessation, weight loss, attention-deficit/hyperactivity disorder, seasonal affective disorder, and amphetamine dependence. Despite its increasing popularity among providers, it has a well-known narrow therapeutic window which can lead to delayed onset of symptoms with extended-release formulations and devastating consequences in overdose. We have noticed some patients misusing bupropion via intravenous use and had difficulty guiding decisions regarding clinical monitoring in these patients. As this route entirely changes the kinetics of bupropion, this has caused concern within our group. We reviewed all the cases of intravenous bupropion use reported to a single poison center without any other coingestants. The majority (66.7%) of patients had moderate effects and one patient had a seizure. No deaths were reported. All patients were symptomatic by the time of initial call to the poison center if they had any reported symptoms due to bupropion. This case series describes the clinical effects reported, and the timing of these effects, after intravenous bupropion use.

The e-psychonaut drugs' psychopharmacology

The focus here was on the pharmacological and clinical pharmacological issues pertaining to the vast range of drugs (e.g. synthetic cannabimimetics, synthetic opioids, novel stimulants, novel psychedelics, PCP/ketamine-like compounds, prescribed medicinal compounds and popular psychotropic herbs/plants) discussed by Internet-based enthusiasts of new/novel psychoactive substances (NPS), 'e-psychonauts'. Currently ongoing related in silico studies, followed by further in vitro and in vivo/preclinical studies, will hopefully provide important findings in terms of which molecules within each given NPS class may present with higher levels of receptor affinities, and hence clinical potency. Understanding the pharmacological characteristics/potency of those novel recreational molecules will hopefully help in predicting related NPS diffusion, morbidity and possible lethality data.

New psychoactive substances (NPS) and serotonin syndrome onset: A systematic review

The use of several new psychoactive substances (NPS) has become very popular and is posing global health risks. Chemically and pharmacologically diverse molecules are constantly emerging and are presenting with a wide range of clinical implications. Serotonin toxicity, and specifically Serotonin Syndrome (SS), might develop as a result of an over-activation of the serotoninergic system caused by several mechanisms resulting in a classic triad of altered mental status, neuromuscular effects, and autonomic hyperactivity. In the present systematic review, we have investigated and summarized the available evidence related to the association between SS and NPS intake. Three retrospective studies, two case series and five case reports were included in this systematic review; several NPS were found to be implicated in SS occurrence These include psychedelic phenethylamines, e.g. 2, 5-dimethoxy-4-iodophenethylamine (2C-I); 2-(4-Iodo-2,5-dimethoxyphenyl)- N-I[(2-methyoxyphenyl)methyl]ethanamine (25I-NBOMe); and 5-(2-aminopropyl)indole (5-IT); and synthetic cathinones, e.g. mephedrone; 3,4-methylenedioxypyrovalerone (MDPV); methylone; butylone; NRG3; alpha-methyltryptamine (AMT); methoxphenidine (MXP); and the antidepressant bupropion. Bupropion was here misused at high dosages and/or in combination with other licit/illicit serotonergic drugs. Whilst most substances were ingested orally, nasal insufflation (with both 5-IT and 2C-I) and sublingual administration of blotter paper (with 25I-NBOMe) were reported as well. Interestingly, the psychiatric history was negative for most subjects, apart from two cases. Clinicians should be aware of NPS potential risks and the severe consequences of their recreational use, including SS. Also, due to their undetectability in routine and common drug screenings, the diagnostic challenges posed by NPS should not be underestimated during the treatment of such patients.

Educational Intervention for Bupropion Abuse Prevention

BACKGROUND

Bupropion is being abused due to effects that are comparable with methamphetamine and cocaine. Current research indicates several interventions that can prevent prescription medication abuse.

OBJECTIVES

A research study was performed at two healthcare organizations to evaluate whether education on prevention-based interventions increased self-efficacy of healthcare staff in addressing potential and ongoing bupropion abuse and whether the education reduced the rate of bupropion prescribing.

METHODS

The study sample consisted of 43 staff members who completed a paper-based preeducation survey, attended a 1-hour educational session, and completed a paper-based posteducation survey.

RESULTS

There was a 42% increase in total staff self-efficacy scores along with significant differences between pre-/postsurvey scores (p ≤ .001). After education prescribers answered they plan to change prescribing practices and the number of bupropion prescriptions filled decreased.

IMPLICATIONS FOR NURSING

Future practice recommendations should include education on bupropion abuse and implementation of prevention interventions to reduce the occurrence of the abuse of bupropion.

CONCLUSIONS

The research findings suggested that education on interventions for bupropion abuse prevention improved healthcare staff self-efficacy in the management of potential and ongoing bupropion abuse, influenced prescribing practices of prescribers, and decreased the number of bupropion prescriptions. This research can be used to continue providing education to help prevent further cases of bupropion abuse.

New/emerging psychoactive substances and associated psychopathological consequences

BACKGROUND

The present paper provides an updated review of both the large number of new/novel/emerging psychoactive substances (NPS) and their associated psychopathological consequences. Focus was here given on identification of those NPS being commented in specialised online sources and the related short-/long-term psychopathological and medical ill-health effects.

METHODS

NPS have been identified through an innovative crawling/navigating software, called the 'NPS.Finder®', created in order to facilitate the process of early recognition of NPS online. A range of information regarding NPS, including chemical and street names; chemical formula; three-dimensional image and anecdotally reported clinical/psychoactive effects, were here made available.

RESULTS

Using the 'NPS.Finder®' approach, a few thousand NPS were here preliminarily identified, a number which is about 4-fold higher than those figures suggested by European and international drug agencies. NPS most commonly associated with the onset of psychopathological consequences included here synthetic cannabinoids/cannabimimetics; new synthetic opioids; ketamine-like dissociatives; novel stimulants; novel psychedelics and several prescription and over-the-counter medicines.

CONCLUSIONS

The ever-increasing changes in terms of recreational psychotropics' availability represent a relatively new challenge for psychiatry, as the pharmacodynamics and pharmacokinetics of many NPS have not been thoroughly understood. Health/mental health professionals should be informed about the range of NPS; their intake modalities; their psychoactive sought-after effects; the idiosyncratic psychotropics' combinations and finally, their medical and psychopathological risks.

Zygotic Venlafaxine Exposure Impacts Behavioral Programming by Disrupting Brain Serotonin in Zebrafish

The antidepressant venlafaxine, a selective serotonin and norepinephrine reuptake inhibitor, is present in surface waters downstream of wastewater treatment plants. We previously showed that zygotic venlafaxine deposition alters larval behavior in zebrafish (Danio rerio), but the mechanisms were unknown. Here we tested the hypothesis that venlafaxine disrupts central serotonergic development, leading to impaired behavioral responses in zebrafish larvae. This was tested by microinjecting embryos with venlafaxine immediately after fertilization and performing spatial distribution of serotonin immunoreactivity, as well as characterizing target genes involved in serotonin turnover in the zebrafish brain. We provide evidence that venlafaxine exposure reduces serotonin immunoreactivity and tyrosine hydroxylase-positive cell populations in specific larval brain regions, and this corresponded with reduced larval activity observed in the drug-exposed group. Lowered serotonin was not due to either reduced synthesis or increased breakdown capacity. However, co-injection of serotonin alongside venlafaxine in embryos recovered brain serotonin immunoreactivity, tyrosine hydroxylase-positive cell populations, and rescued venlafaxine-mediated behavioral changes. Overall, our results demonstrate for the first time that early life exposure to venlafaxine perturbs brain development, which may be due to reduced serotonin, leading to altered larval behavior in zebrafish.

Environmental levels of venlafaxine impact larval behavioural performance in fathead minnows

Venlafaxine, a selective serotonin and norepinephrine reuptake inhibitor, is one of the most abundant antidepressants in municipal wastewater effluents (MWWE). The early life stages are particularly sensitive to contaminant exposure, but few studies have examined whether persistent exposure to venlafaxine impart adverse developmental outcomes. The fathead minnow (Pimephales promelas) is a widely used model for ecotoxicological studies, and this fish is native to Alberta, Canada. We tested the hypothesis that environmental levels of venlafaxine compromises early developmental behavioural performances in fathead minnows. Embryos were exposed to waterborne venlafaxine at either 0, 0.06, 0.33, 0.66, 1.37 or 3 μg L^-1 concentration for 7 days. Environmental levels of venlafaxine did not impact the survival, hatch rate or heart rate of fathead minnow embryos and larvae but reduced the growth of larvae even at concentrations as low as 0.06 μg L^-1. We validated thigmotaxis as a screen for anxiolytic and anxiogenic behaviour in fathead minnow larvae by exposing them to concentrations of ethanol and caffeine, respectively. Behavioural analyses revealed that early developmental exposure to venlafaxine does not alter thigmotaxis but reduced the activity of fathead minnows. The larval behavioural assays reported here for fathead minnow have the potential to be used as screening tools for the risk assessment of neurotoxic contaminants in MWWE. Overall, we demonstrate for the first time that exposure to environmental levels of venlafaxine during the critical early developmental window does not elicit an anxiogenic response but may adversely affect the larval growth performance of fathead minnows.

Is medicinal ketamine associated with urinary dysfunction issues? Assessment of both the European Medicines Agency (EMA) and the UK Yellow Card Scheme pharmacovigilance database-related reports

OBJECTIVE

A range of ketamine-induced uropathy (KIU) issues have been typically described in ketamine misusers. Conversely, more knowledge is needed in terms of medicinal ketamine-related urological disturbances, since ketamine prescribing is being increasingly considered for a range of medical and psychopathological conditions.

METHODS

To assess medicinal KIU issues, we aimed at analyzing both the 2005-2017 European Medicines Agency (EMA) and the 2006-2018 UK Yellow Card Scheme (YCS) pharmacovigilance databases.

RESULTS

A total number (eg, all categories) of 11 632 EMA ketamine-related adverse drug reaction (ADR) reports were here identified. Out of these, some 9971 ADRs (eg, 85.7% of the total) were judged as "suspect" and were here analyzed. Some 1758 ADRs (17.7% of 9971, corresponding to 194 individual patients) referred to urological issues, relating to either kidney/ureter (922 ADRs) or bladder/urethra (837 ADRs). Ketamine was the sole drug administered in 156/194 (80.4%) cases/patients. Although most cases occurred in the 1 month-1 year time frame following the start of ketamine prescribing, in 30 cases the ADR occurred within 48 hours. Most ADR-related cases resolved, although both sequelae (18 cases) and fatalities (79/1758; 4.5%) were recorded. Overall, YCS data were consistent with EMA findings, with some 50/217 (23%) ADRs referring to renal/urinary disorders.

CONCLUSIONS

Current data may only represent a gross underestimate of the KIU real prevalence issues. It is here suggested that chronic treatment involving higher doses/repeated exposure to ketamine be restricted to the context of controlled trials or clinical audits.

Exploring the Baseline Knowledge and Experience of Healthcare Professionals in the United Kingdom on Novel Psychoactive Substances

Objective: This survey aimed to explore knowledge and experience on novel psychoactive substances (NPS) of healthcare professionals (HCPs). The study also aimed to assess how HCPs would like to improve their knowledge of NPS. Methods: Seventy paper questionnaires were disseminated in 2017 within continuing education events to pharmacists, nurses and general practitioners (GPs). Additionally, 127 online surveys were completed using the Qualtrics platform by other HCPs and mental health nurses in six United Kingdom (UK) independent mental health hospitals long-stay in-patient rehabilitation services. Two educational sessions involving pharmacists and GPs were also held in late 2017 and mid-2018. Knowledge of NPS by HCPs was evaluated prior to the start of the educational events. Evaluation forms were handed out post-sessions to garner feedback, especially on areas for improvement for future sessions. Statistical analysis of data was undertaken using SPSS (V.25). Results: Most HCPs reported only ‘basic’ to ‘intermediate’ NPS knowledge. Substance misuse service staff felt more informed, were more often consulted and had greater confidence regarding NPS compared to hospital and primary care professionals. A negative association was found between the age of the HCP and knowledge of NPS. Most participants expressed a need for regular training and updates as insufficient NPS-related information is currently received. Conclusions: An improvement within the self-reported knowledge of HCPs on NPS is evident in comparison to previous studies. Continued education of HCPs on NPS is fundamental for the provision of improved harm reduction services, which can enhance overall care for NPS service users.

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.

Characterization of intentional-abuse venlafaxine exposures reported to poison control centers in the United States

Background: Venlafaxine use to achieve an amphetamine-like high has been described but data regarding the epidemiology and clinical effects are sparse. Objectives: Describe the prevalence and toxicity of venlafaxine abuse reported to US poison control centers. Methods: This was a retrospective review of venlafaxine exposures reported to the National Poison Data System (NPDS) from 2000 to 2016. Inclusion criteria were: age 12 years and older, reason for exposure intentional-abuse, and either single-substance exposure or venlafaxine was the first substance. The primary outcome was prevalence of intentional-abuse of venlafaxine. Secondary outcomes characterized demographics, geographic distribution, toxicity, and outcomes. Results: Intentional-abuse accounted for 752 of 85,621 venlafaxine exposures. Overall prevalence was 87.8 intentional-abuse exposures/10,000 venlafaxine exposures reported to NPDS (range, 59.3-117.6/10,000). Prevalence decreased from 107/10,000 in 2000 to 59.3/10,000 in 2016. Median age was 23 years and 50% were female. Primary route was ingestion (90.8%) with 4.7% using venlafaxine via inhalation/intranasal insufflation, and 3.7% both routes. There were 227 venlafaxine-only exposures; 54.0% were treated/released from the emergency department, 20% were admitted for medical management, 9.0% to a psychiatric facility, and 17.0% managed at home. Known medical outcomes for single-substance exposures were: no effect (24.0%), minor (39.0%), moderate (33.0%), and major (4.0%); no deaths occurred. Most frequent clinical effects were tachycardia (33.9%), drowsiness (20.7%), and agitation (11.5%). Conclusion: The prevalence of venlafaxine abuse reported to poison control centers has decreased. Medical outcomes are usually not serious. Clinicians should be aware that non-medical use is possible but infrequently reported to poison control centers.

An Insight into Z-Drug Abuse and Dependence: An Examination of Reports to the European Medicines Agency Database of Suspected Adverse Drug Reactions

BACKGROUND

Although originally marketed as safe alternatives to the habit-forming benzodiazepines, growing numbers of zaleplon, zolpidem, and zopiclone ("Z-drugs") clinical concerns relating to their potential of abuse, dependence, and withdrawal have been reported over time. We aimed here at assessing these issues analyzing datasets of adverse drug reactions provided by the European Medicines Agency through the EudraVigilance system.

METHODS

Analyzing the adverse drug reactions databases of each Z-drug, descriptive analyses have been performed on cases and proportional reporting ratios (PRRs) computed.

RESULTS

An overall number of 33 240 (e.g., 23 420 zolpidem; 9283 zopiclone; and 537 zaleplon) misuse-, abuse-, dependence-, and withdrawal-related adverse drug reactions, corresponding to some 6246 unique patients given Z-drugs, were here identified. Cases were studied and described, including demographic characteristics and clinical data such as concomitant drugs, doses, routes of administration, and outcomes of the reactions (being fatalities recorded). Considering PRR values and in comparison with zopiclone, zolpidem was more frequently involved in both misuse/abuse and withdrawal issues. Zolpidem and zopiclone presented with the same dependence risk, but zopiclone was most involved in overdose adverse drug reactions. Compared with zaleplon, zopiclone presented higher dependence and overdose-related issues but slightly lower misuse/abuse and withdrawal PRR values.

CONCLUSION

Current data may only represent a gross underestimate of the real prevalence of Z-drug misuse. Caution should be exercised when prescribing those molecules, especially for patients with psychiatric illnesses and/or history of drug abuse. We recommend the need to invest in proactive pharmacovigilance activities to better and promptly detect, understand, and prevent any possible misuse potential of prescribed medications.

Is there such a thing as a 'lope' dope? Analysis of loperamide-related European Medicines Agency (EMA) pharmacovigilance database reports

Background

Among over-the-counter (OTC) drugs, loperamide has recently emerged for its potential of misuse and cardiotoxicity issues. Hence, we aimed here at assessing the loperamide-related cases being reported to the EMA's EudraVigilance (EV) database.

Methods

All spontaneous EV reports relating to loperamide misuse/abuse/dependence/withdrawal and cardiotoxicity issues were here retrieved, performing a descriptive analysis.

Findings

During the years 2005–2017, EV collected a number of 1,983 (out of a total of 7,895; 25.11%) loperamide-related misuse/abuse/dependence/withdrawal adverse drug reaction (ADR) reports, with a progressively increasing trend since 2014. Most cases were classified as drug use disorder (37.4%) or intentional overdose (25.4%). Loperamide was used on its own in 41.9% of cases; remaining, polydrug, cases included antidepressants; benzodiazepines; and other OTCs. Some 1,085 (1,085/7,895 = 13.7%) cardiovascular ADRs were reported, being conduction abnormalities and EKG alterations the most frequently identified.

Conclusions

EV data may support the levels of concern relating to loperamide potential of abuse and associated cardiotoxicity issues.

Abuse of Prescription Drugs in the Context of Novel Psychoactive Substances (NPS): A Systematic Review

Recently, a range of prescription and over-the-counter drugs have been reportedly used as Novel Psychoactive Substances (NPS), due to their potential for abuse resulting from their high dosage/idiosyncratic methods of self-administration. This paper provides a systematic review of the topic, focusing on a range of medications which have emerged as being used recreationally, either on their own or in combination with NPS. Among gabapentinoids, pregabalin may present with higher addictive liability levels than gabapentin, with pregabalin being mostly identified in the context of opioid, polydrug intake. For antidepressants, their dopaminergic, stimulant-like, bupropion activities may explain their recreational value and diversion from the therapeutic intended use. In some vulnerable clients, a high dosage of venlafaxine (‘baby ecstasy’) is ingested for recreational purposes, whilst the occurrence of a clinically-relevant withdrawal syndrome may be a significant issue for all venlafaxine-treated patients. Considering second generation antipsychotics, olanzapine appears to be ingested at very large dosages as an ‘ideal trip terminator’, whilst the immediate-release quetiapine formulation may possess proper abuse liability levels. Within the image- and performance- enhancing drugs (IPEDs) group, the beta-2 agonist clenbuterol (‘size zero pill’) is reported to be self-administered for aggressive slimming purposes. Finally, high/very high dosage ingestion of the antidiarrhoeal loperamide has shown recent increasing levels of popularity due to its central recreational, anti-withdrawal, opiatergic effects. The emerging abuse of prescription drugs within the context of a rapidly modifying drug scenario represents a challenge for psychiatry, public health and drug-control policies.