An unusual case report: treatment of cocaine-dependent patient with an atypical antipsychotic

Um relato de caso incomum: tratamento de um paciente dependente de cocaína com antipsicótico atípico

CARTA AOS EDITORES

An unusual case report: treatment of cocaine-dependent patient with an atypical antipsychotic

Um relato de caso incomum: tratamento de um paciente dependente de cocaína com antipsicótico atípico

Dear Editor,

The patient is a 27-year-old, woman, who was diagnosed with dependence of cocaine as a teenager. She has a history of multiple admissions for clinical treatment and subsequent partial response to antipsychotic medication. Over time, she has been prescribed haloperidol and risperidone. The side effects included lethargy.

On admission, she was expressing rapid discourse, mainly of a persecutory nature. She was started on olanzapine at a dose of 2.5 mg daily, which was increased to 7.5 mg on day 7 and to 10 mg on day 14 (an oral dose administered at night). Her psychotic symptoms did not persist. Routine physical examination and investigations were all within normal limits including liver enzymes. After 6 weeks of a dose of 10 mg/day, her dependence symptoms had returned to their pre-morbid levels.¹

The neuropharmacological profile of the atypical antipsychotic olanzapine is consistent with a potentially useful medication for cocaine abuse, confirming the hypothesis that patients treated with olanzapine have reduced cocaine craving and abuse. The US FDA has approved a limited number of treatments for alcohol, nicotine and opioid dependence; however, no treatments for other abused drugs such as marijuana, cocaine or methamphetamine are approved.¹ Because cocaine delivers a particularly positive and reinforcing high, most users do not seek treatment voluntarily until the behavioral patterns have resulted in significant impairment in function or health problems. Craving for cocaine is often so intense that an individual needs to be initially entered into residential treatment in order to establish abstinence from the drug. Treatment must be multimodal, including medical, psychological, and social strategies to help the patient establish and maintain abstinence.²

The history of hypersensitivity to olanzapine in this patient was exclusio, included experiences of psychotic in this patients dementia and the use of other psychotropic medications. Baseline laboratory testing included a chemistry screen, complete blood count, and urinalysis. The patient received urinary pregnancy testing prior to starting medications, and at monthly intervals throughout the study.³

As a dopamine antagonist, olanzapine may worsen this hedonic deregulation and this may have made it difficult for olanzapine-treated subjects to remain abstinent.

Risperidone was found to be effective in reducing craving and relapse among cocaine-dependent schizophrenics in an open trial.²

Olanzapine was well tolerated. The adverse events reported included: weight gain (40%), drowsiness (40%), constipation (13%), dizziness (10%), dry mouth (7%), nausea (7%), restlessness (7%) and urticaria (3%). But in this case, there were not any of these events. The history of hypersensitivity to olanzapine in this patient was exclusion.⁴

Further studies to clarify this point and the precise pharmacology effect would be helpful. Olanzapine may be superior to traditional neuroleptics for the treatment of cocaine dependence due to its less severe side effect profile.⁵ This case was intended to determine if olanzapine showed any promise for the treatment of cocaine dependence. Further controlled research is warranted to more precisely determine the effect of olanzapine in this case.

Carlos Simon Guzman, José Ângelo Barletta Crescente Jr

Psychiatry Institute, Clinical Hospital, Medical School, Universidade de São Paulo (USP),

São Paulo (SP), Brazil

Arthur Guerra de Andrade

Psychiatry Institute, Clinical Hospital, Medical School, Universidade de São Paulo (USP),

São Paulo (SP), Brazil

Department of Psychiatry, Faculdade de Medicina do ABC,

Santo André (SP), Brazil

Financial support: None

Conflict of interests: None

• 1. Guardia J, Segura L, Gonzalvo B, Iglesias L, Roncero C, Cardús M, Casas M. A double-blind, placebo-controlled study of olanzapine in the treatment of alcohol-dependence disorder. Alcohol Clin Exp Res. 2004;28(5):736-45.
• 2. Smelson DA, Ziedonis D, Williams J, Losonczy MF, Williams J, Steinberg ML, Kaune M. The efficacy of olanzapine for decreasing cue-elicited craving in individuals with schizophrenia and cocaine dependence: a preliminary report. J Clin Psychopharmacol 2006;26(1):9-12.
• 3. Gasquet I, Haro JM, Novick D, Edgell ET, Kennedy L, Lepine JP; SOHO Study Group. Pharmacological treatment and other predictors of treatment outcomes in previously untreated patients with schizophrenia: results from the European Schizophrenia Outpatient Health Outcomes (SOHO) study. Int Clin Psychopharmacol 2005;20(4):199-205.
• 4.Kenna GA, Nielsen DM, Mello P, Schiesl A, Swift RM. Pharmacotherapy of dual substance abuse and dependence. CNS Drugs 2007;21(3):213-37.
• 5. Akerele E, Levin FR. Comparison of olanzapine to risperidone in substance-abusing individuals with schizophrenia. Am J Addict. 2007;16(4):260-8.

Publication Dates

• Publication in this collection
  23 June 2008
• Date of issue
  June 2008