Intranasal Quetiapine Abuse

To the Editor: We would like to report on the widespread “abuse” of quetiapine among inmates in the Los Angeles County Jail—“the largest mental health institution in the world.” Anecdotal reports from clinicians and staff estimate that as many as 30% of the inmates seen in psychiatric services report malingered psychotic symptoms (typically endorsing “hearing voices” or ill-defined “paranoia”) in order to specifically obtain quetiapine. A history of substance dependence is common among those engaging in this practice. In addition to oral administration, the drug is also taken intranasally by snorting pulverized tablets. Such abusive self-administration seems to be driven by quetiapine’s sedative and anxiolytic effects (to help with sleep or to “calm down”) rather than by its antipsychotic properties. Accordingly, the drug has a “street value” (it is sold to other inmates for money) and is sometimes referred to simply as “quell.”

Although the prevalence of this behavior beyond this narrow forensic population is unknown, the possibility of such an abuse potential is both curious and clinically pertinent. For example, it suggests that quetiapine is indeed associated with a better subjective response than its conventional antipsychotic counterparts (1). It also appears to give lie to the clinical myth that only psychotic patients will ask for and take antipsychotic medications. In our collective clinical experience, many patients (in particular, those with substance dependence) complain of “hearing voices” in order to procure hospital admission, disability income, or psychotropic medications (2). The “voices” are usually vague, highly suggestive of malingering (3), and occur in the absence of other symptoms (such as clear-cut delusions or thought disorganization) that would warrant a diagnosis of schizophrenia. While antipsychotic medications are not typically recognized as drugs with abuse potential, the use of intranasal quetiapine suggests otherwise and underscores the importance of recognizing malingered psychosis in clinical settings. This phenomenon is reminiscent of the era before the widespread use of atypical antipsychotic compounds, when a select group of patients would inappropriately seek and self-administer not only anticholinergics, such as trihexyphenidyl (4), but also low-potency antipsychotics, such as thioridazine or chlorpromazine. Finally, since the monosymptomatic “voices” endorsed by patients are often assumed to represent psychosis and therefore lead to reflexive prescription of antipsychotic medications, further investigative efforts aimed at distinguishing this clinical presentation from schizophrenia would be useful. If these entities could be reliably disentangled, it would help to reduce the diagnostic heterogeneity of schizophrenia and the unnecessary exposure of patients to the potentially harmful side effects of antipsychotic medications.