Prescribing trends to watch: Psychotropics

Jailhouse heroin, Suzie Qs, Squirrel, Quell, Baby heroin, Maq-Ball (marijuana + quetiapine) or Q-ball (cocaine + quetiapine) – these are all street names for a prescription drug called quetiapine. Quetiapine is an antipsychotic medication that antagonizes serotonin, dopamine, histamine and the alpha-1 receptor, and it is used for the treatment of bipolar disorder, major depressive disorder and schizophrenia.

Psychotropic agents like quetiapine have been traditionally used for the treatment of schizophrenia or bipolar disorder. Although they are beneficial in the treatment of refractory depression as an adjunct therapy, the risks they carry outweigh the benefits. In recent months, there has been an increase in the number of these drugs that are being prescribed for pain and sleep disorders in workers’ compensation claims. Data supporting their use are subpar, yet medical providers continue to prescribe these potentially dangerous medications. Users have abused psychotropic drugs to help augment the euphoric effects obtained by snorting cocaine or heroin, which has resulted in a growing market of the drug being sold illegally.

Quetiapine (Seroquel®) is the most frequently abused psychotropic agent. Quetiapine has fewer side effects compared to other abused agents in its category. It has been reported to be crushed and mixed with cocaine and water. This mixture can be inhaled or injected for a rapid effect. It puts a concentration of the drug in the body  and users experience the “heroin high” and hallucinogenic effects.

Research is still ongoing to determine what makes quetiapine so addictive. There are two theories, but no definitive evidence.

The Drug Abuse Warning Network (DAWN) is a public health surveillance system that monitors drug-related emergency room visits. DAWN conducted a multicenter study from 2005-2011 at 300 different hospitals across the nation. The study found that, out of 143,598 antipsychotic-related emergency room visits, 52,635 patients were admitted due to misuse or abuse and 27,114 of them were related to quetiapine. It also revealed that quetiapine misuse and abuse is more common in females than males and those between 40-59 years old. There has also been an increase in combining quetiapine with other drugs such as cocaine, marijuana and barbiturates, which is another reason for the increase in emergency room visits related to quetiapine misuse and abuse. Patients who misused and abused quetiapine in combination with other drugs were more likely to be hospitalized than patients using quetiapine alone (52% vs. 44%). Of the patients who combined quetiapine with other drugs, 27% used it with alcohol and 22% used it with other illicit drugs (12% cocaine or Q-ball). What’s interesting is that in 46% of the total quetiapine cases, the drug was taken in conjunction with a benzodiazepine or another muscle relaxer commonly prescribed in workers’ compensation claims.

Identifying and accepting issues with the prescribing trends of psychotropics is the first step toward resolution. The next step is to start decreasing the number of quetiapine-related emergency room visits. Medical providers need to be more observant of their patients’ conditions and limit the number of scripts written for this medication. In addition, medical providers need to keep their eyes and ears open for signs of potential abuse. Key indicators include patients with a history of polysubstance or benzodiazepine abuse, and those who pressure clinicians for this drug. If a patient must receive quetiapine as a part of their medical treatment, then they need to be monitored regularly.

While focusing on the workers’ compensation injury, we can always look at the patient’s current condition and past medical history to see if all medications are appropriate, including quetiapine and other antipsychotics. To avoid medication misuse and abuse, and related costs and health problems, it’s best to confirm that each prescribed medication matches the indications and specific treatment needs of the patient. By carefully monitoring prescribing patterns, and then intervening with guidance and alternative recommendations when necessary, we are able to support better health and better outcomes for the people we are caring for and help set them on the right path to recovery.

Resources

  • Seroquel (quetiapine) [prescribing information]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; February 2017.
  • Seroquel XR (quetiapine) [prescribing information]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; February 2017.
  • Mattson, Albright, V., Council, C. and Yoon, J. (2015). Emergency Department Visits Involving Misuse and Abuse of the Antipsychotic Quetiapine: Results from the Drug Abuse Warning Network (DAWN). Substance Abuse: Research and Treatment, p.39.
  • Ahearn EP, Mussey M, Johnson C, Krohn A, Krahn D. Quetiapine as an adjunctive treatment for post-traumatic stress disorder: an 8-week open-label study. Int Clin Psychopharmacol. 2006;21(1):29-33. [PubMed 16317314]
  • Healthy Canadians Recalls & Alerts: Summary Safety Review - Atypical antipsychotics - assessing the potential risk of sleep apnea. Health Canada website. Available at: http://www.hc-sc.gc.ca/dhp-mps/medeff/reviews-examens/antipsycho2-eng.php. Published August 16, 2016. Accessed August 31, 2018.
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