Clinical Insight – Misuse of Common Prescription Medications

Prescribed medications, though generally safe when taken as directed, can pose risks if taken in higher than prescribed doses or combined with other substances. This edition of Clinical Insight will highlight a few prescription medications that have been known to be misused: gabapentin, bupropion, and quetiapine.

Gabapentin (Neurontin®)

• • Gabapentin is a commonly prescribed drug for neuropathic pain and seizures and is often prescribed for off-label indications such as insomnia, anxiety, bipolar disorder, and migraines. 
  • It has become a sought-after drug of misuse, due to its low cost, classification as a federally non-controlled substance and its use as an alternative to opioids for pain management.
  • While misuse of gabapentin alone is concerning, a larger issue is the use of gabapentin in conjunction with other medications.
    • The majority of gabapentin misuse is in combination with other substances.  The most common class of drugs used in combination with gabapentin is benzodiazepines.  Other drugs found to be commonly misused with gabapentin include alcohol and opioids, among others.
    • Studies have found that misuse of gabapentin with opioids has been associated with a fourfold increased risk of respiratory depression and that gabapentin doses exceeding 900mg have led to a 60% increase in the odds of opioid related death. Gabapentin misuse with opioids is often as an adjunct to potentiate the “opioid high”.
  • Reasons for gabapentin misuse are varied and include recreational use, to control mood or anxiety, to potentiate the effects of substance abuse treatment, such as buprenorphine or methadone therapy, to treat pain, to reduce cravings or manage withdrawal from other abused drugs, or as a substitute for other drugs.
  • Effects experienced from gabapentin misuse include euphoria, sedation or relaxation, improved sociability, dissociation, increased energy and focus, and improvement in sleep quality. These effects were not dependent on a specific dose.
  • The majority of reports of individuals misusing gabapentin had prescriptions for it and did reveal taking higher doses than prescribed.
  • Street names of gabapentin include “Gabbies” or “Johnnies”.

Bupropion (Wellbutrin®, Zyban®)

• • Bupropion is a commonly prescribed antidepressant medication and also used for smoking cessation.
  • It shares some pharmacological properties with amphetamine, and abusers report a similar high to cocaine use, but with a lesser intensity. Misuse generally occurs in adolescents and young adults.
  • Individuals report ingesting it orally in doses much higher than prescribed, inhaling crushed tablets, or dissolving the crushed powder to inject it intravenously. Crushing the tablets bypasses the extended-release quality of the drug which causes a sudden rush of the drug to the brain, resulting in its desired stimulant effects.
  • Signs of bupropion misuse include extreme energy, loss of appetite, euphoria, insomnia, increased sense of self-esteem or excessive excitement.
  • Because bupropion is a drug that can lower the seizure threshold, even at therapeutic doses, seizures are a hallmark symptom of acute overdose with the drug. The onset of seizures can be delayed up to 24 hours in patients who take extended-release preparations.
  • Other signs of toxicity include fast heart rate, vomiting, hallucinations, agitation, lethargy, and tremors.  Cardiac toxicity can also occur in overdose situations.
  • Street names of bupropion include “Wellies”, “Dubs”, or “Barnies”.

Quetiapine (Seroquel®)

• • Quetiapine is an antipsychotic drug used to treat bipolar disorder and schizophrenia. It is also frequently prescribed to treat anxiety, depression, substance abuse disorder and to manage withdrawal symptoms from misused substances.
  • Misuse of this drug is often for its sedative effects and individuals will self-medicate symptoms of anxiety and insomnia. Other reasons for misuse include to reduce the crash from stimulant drugs such as cocaine, to substitute for other drugs, or to aid in withdrawal symptoms.
  • Studies found that 75% of quetiapine-related ER visits involved other substances, most commonly other prescription drugs. Benzodiazepines were the prescription drug class most often involved in these visits. Alcohol also played a role, and illicit drugs (primarily cocaine, heroin, and marijuana) found in combination with quetiapine accounted for approximately a quarter of quetiapine-related ER visits.
  • Most common toxic effects from misuse of quetiapine include lethargy, fast heart rate, slurred speech, agitation, dizziness, and confusion.
  • Street names of quetiapine include “Susie-Q”, “baby heroin”, “Quell” and “Squirrel”.  When used in combination with other drugs, it is referred to as “Maq-ball” (quetiapine and marijuana), or “Q-ball” (quetiapine plus cocaine or heroin).

Of note, the majority of misuse with these medications generally occurs in patients with a history of substance misuse or dependence.