Correspondence
A Case of Venlafaxine Abuse
N Engl J Med 2003; 348:764-765February 20, 2003
- Article
To the Editor:
Antidepressants are rarely abused except by persons who also abuse alcohol or other drugs.1,2 We describe a case of venlafaxine abuse, which to our knowledge has not been previously reported.
A 38-year-old man presented to the emergency department with chest pain. Cardiac problems were ruled out after thorough evaluation, including electrocardiography and measurement of cardiac enzymes. The patient reported a history of major depression and of amphetamine dependence in remission. Every three months, he saw a psychiatrist, who prescribed extended-release venlafaxine at a dose of 225 mg per day.
Six months before presentation, the patient had become unemployed. He had considered using amphetamines, but decided against it. Awaiting an appointment with his psychiatrist, he increased his daily dose of venlafaxine to 337.5 mg by taking one and a half pills, an amount that produced a sudden, amphetamine-like “high.” He then ingested two 225-mg pills. This higher dose did not produce a similar effect. Through experimentation, he discovered that crushing the venlafaxine pills produced quicker highs. He started ingesting crushed venlafaxine at doses of up to 3600 mg per day. When he ran out of the medication, he obtained early refills from the pharmacy and then contacted his primary care physician for another venlafaxine prescription. After consuming these pills he contacted the pharmacy for additional refills. When the pharmacist refused, the patient obtained another prescription from his primary care physician by claiming to have misplaced his pills and then purchased the drug at a different pharmacy. After he approached his physician for an additional supply of venlafaxine, the physician became suspicious and referred him to his psychiatrist. The patient instead acquired more venlafaxine illicitly. He continued to ingest increasing amounts of venlafaxine, until the ingestion of a 4050-mg dose produced chest pain, necessitating the visit to the emergency department.
On initial evaluation, the patient's pulse and blood pressure were elevated, but they normalized during the next few days without further medical intervention. His toxicology screen was negative for alcohol and drugs. After stabilization, he was transferred for inpatient psychiatric treatment for depression and substance dependence.
Venlafaxine and its active metabolite, O-desmethylvenlafaxine, block serotonin and norepinephrine reuptake and weakly inhibit dopamine reuptake.3,4 The mechanism of addiction is unknown, but large doses may produce effects that mimic amphetamine-like highs. Furthermore, extended-release pills contain spherules in coated or encapsulated form4 and, when broken, release the medication rapidly. This may explain the rapid highs experienced by the patient after he ingested crushed pills. The effect of venlafaxine in blocking norepinephrine reuptake may produce autonomic hyperactivity and, in overdoses, may raise the pulse and blood pressure and may cause chest pain.4 Most patients do not abuse venlafaxine. However, when treating patients with a history of alcohol or drug abuse, physicians should consider the potential of venlafaxine for abuse.
4 ReferencesS. Pirzada Sattar, M.D.
Kathleen M. Grant, M.D.
Subhash C. Bhatia, M.D.
Omaha Veterans Affairs Medical Center, Omaha, NE 68131
shrink@prodigy.net 1
Tinsley JA ,Olsen MW ,Laroche RR ,Palmen MA . Fluoxetine abuse. Mayo Clin Proc 1994;69:166-168
Web of Science | Medline2
Delisle JD . A case of amitriptyline abuse. Am J Psychiatry 1990;147:1377-1378
Web of Science | Medline3
Andrews JM ,Ninan PT ,Nemeroff CB . Venlafaxine: a novel antidepressant that has a dual mechanism of action. Depression 1996;4:48-56
CrossRef | Medline4
Physicians' desk reference. 56th ed. Montvale, N.J.: Medical Economics, 2002:3499.
Author/Editor Response
We concur with Sattar and colleagues' statement, “Antidepressants are rarely abused except by persons who also abuse alcohol or other drugs.” A review of the safety data base for venlafaxine, which comprises trial data and worldwide, spontaneous postmarketing reports, reinforces published information on antidepressants and indicates that spontaneous reports of venlafaxine abuse are rare and, in all cases, that such abuse has been associated with a current or past history of alcohol or other drug abuse. Sattar and colleagues' report of this extreme case should serve as a reminder to all physicians that, when treating patients who have psychiatric disorders with appropriate medications, they should pay careful attention to patients who have a history of substance abuse.
Victoria Kusiak, M.D.
Wyeth Pharmaceuticals, Saint Davids, PA 19087- Citing Articles (3)
Citing Articles
1
Ji-Hye Song, Bum-Hee Yu, Dongsoo Lee, Se Chang Yoon, Hong Jin Jeon. (2011) Uncontrolled Self-Medication with Venlafaxine in a Patient with Major Depressive Disorder. Psychiatry Investigation 8:1, 74
CrossRef2
Gianluca Quaglio, Fabrizio Schifano, Fabio Lugoboni. (2008) Venlafaxine dependence in a patient with a history of alcohol and amineptine misuse. Addiction 103:9, 1572-1574
CrossRef3
&NA;. (2003) Venlafaxine abuse. Reactions Weekly &NA;:941, 15
CrossRef
