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PSYCHIATRIC COMPLICATIONS OF ERIMIN ABUSE

L H Peh, R Maherid.ran

SYNOPSIS:

Nimetazepam (Erimin) is a benzodiazepine which has become a new of abuse in Singapore. Three cases presenting With psychiatric complications had been treated as inpatients over a period of one and a half years (1986 to 1987) in Woodbridge Hospital and Tan lock Seng Hospital. Their clinical presentations which included drug dependency, withdrawal and transient drug psychosis are described and dismissed.

Key words: ; Erimin; psychiatric complications

SING MED J. 1989; No 30: 72 - 73

INTRODUCTION 2. WITHDRAWAL PSYCHOSIS A 34 year old unemployed Chinese bachelor was with a one day history of Nimetazepam (trade name Erimin) is becoming a widely admitted to Woodbridge Hospital and visual hal- prescribed benzodiazepine in Singapore. Indication for its , agitation, poor concentration "Lilliputian" figures of 10 to 20 usage is for the relief of insomnia, but as with other ben- lucinations. He saw and running about. zodiazepines, its pharmacologic profile includes , Chinese men on the floor, talking they disappeared but reap- , , amnesic and When he shouted at them, A known addict with three properties. It claims to have earlier efficacy in onset. As peared five to six times. centre, he was with all other benzodiazepine compounds, it has potential past admissions to the started abusing for dependence even in therapeutic dosages (1). just released a month earlier. He then tablets daily, which he obtained Just a few years ago, another of the benzodiazepines, Erimin, taking two or three week before admission , popularly known as Rohypnol or Roche 2, from various clinics, However one drug abuse but was re- became a drug of abuse in Singapore. Some cases with he was arrested for suspected just two days psychiatric complications had been reported (2). leased from Drug Rehabilitation Centre Hospital. Blood and The clinical presentations of three patients following before admission to Woodbridge reveal any toxic Erimin abuse are described. Although they are anecdotal, urine samples taken for toxicology did not was treated with 50 mg it is hoped that they will alert doctors to the potential of substances. He leading to his Erimin for psychiatric complications. for 2 nights and his symptoms improved, discharge.

CASE REPORTS 3. TRANSIENT DRUG PSYCHOSIS A 27 year old male Chinese, a "bookie runner", was which occurred three 1. DEPENDENCY admitted for aggressive behaviour tablets of Erimin (50 A 20 year old Malay bachelor, doing National Service hours after he had consumed ten refused to let him use the in the special constabulary, was taking Erimin tablets of mg). When his neighbour and flower pots. On up to 20 mg (4 tablets) a day for 2 years. He began with a telephone, he smashed the windows in time and had audi- history of and presented with free-floating examination he was disorientated He also noted to have multiple as well as attacks. He started to take Erimin tory hallucinations. was a of glue sniffing. One for relief of his symptoms, gradually noticed an increase tattoos on his body. He gave history he had an episode of ab- in his tolerance to Erimin and had to increase his intake, year prior to this admission, one tablet of Erimin to- His attempts to decrease or stop taking the drug resulted normal behaviour after taking he ran half -naked from in withdrawal symptoms in the form of increased anxiety. gether with , in which about of it, but was not admitted He was admitted and treated for his agoraphobia with a nightclub without being aware for this admission showed behavioural . and were to hospital. Urine toxicology per ml urine. Blood used instead of benzodiazepines and he was successfully that there was 2 ug/dI of taken did not show any presence of . His symp- weaned off his dependence on Erimin. toms cleared up one day after admission without any . Woodbridge Hospital Jalan Woodbridge Singapore 1954 DISCUSSION

L H Peh, MBBS, M Med (Psych) The three cases described are interesting as they reflect R Mahendran, MBBS, DPM, M Med (Psych) the variety of clinical features of Erimin abuse. A literature search revealed no reports or studies on Erimin use or Correspondence to: Dr Peh abuse. There are however clinical studies on its phar- macology (3).

72 Erimin has suppressive action on the central nervous and disorientation. The Lilliputian type of visual hallu- system; like other benzodiazepines it inhibits the limbic cinations have been described in delirious states, eg. system. In tests with mice, it was observed that Erimin Tremens. In the third patient, although there was might be more actively distributed in the brain than nitra- morphine in his urine sample, an earlier episode of ab- zepam. Also its rate in man is slower than in normal behaviour after taking Erimin indicated that his animals (4). transient psychotic episode was more likely to be related Benzodiazepine dependence was recognised early to Erimin rather than to morphine. but was thought to occur only with doses above thera- Non -drug strategies have been recommended as peutic range. It has been demonstrated however that alternatives to for the treatment of anxiety and in- benzodiazepines in therapeutic dosage can produce somnia. These include anxiety management techniques significant withdrawal symptoms when stopped (5). such as using relaxation tapes, cognitive -behavioural Erimin taken excessively over an extended period can therapy and hygiene (6). In preventing dependence, cause habituation and dependence. the prescription of benzodiazepines should be as low a Early symptoms of withdrawal include anxiety and dose as possible and for limited short periods only. The rebound insomnia which may be mistaken as a return of patient should be warned of possible withdrawal symp- the original symptoms. This happened in the first case toms to expect and a tapering -off regime is recommended where the dependence which had developed insiduously to minimise rebound (7). had features of both an increase in tolerance as well as Awareness of possible abuse of Erimin and psychia- withdrawal symptoms. He did not have the typical pattern tric complications arising as a result of such abuse should of dependence on which include drug -seeking lead to more careful prescribing by the clinician. behaviour, rapid tolerance and escalation of dosage. Other possible withdrawal symptoms in benzodiazepine dependence eg. perceptual disturbances, unusual soma- ACKNOWLEDGEMENTS tic symptoms, muscle stiffness, twitching, paraesthesiae, dysphonia, psychotic disturbance and epileptic fits may We wish to thank Dr Chee Kuan Tsee, Senior Consultant mimic a wide variety of disorders (1). Psychiatrist and Head of Unit Ill, Woodbridge Hospital for The second and third cases had a history of multiple his help in preparing this article. We also wish to thank Mr . The psychotic disturbance, in the Ng Chen Wee of National University of Singapore Medical former as a feature of abstinence and in the latter while on Library for help in the literature search, and Mdm Zohora the drug, had signs of organicity, viz visual hallucinations Begum for typing the manuscript.

REFERENCES

1. TYRER P.J. Benzodiazepines on trial. British Medical Journal 1984; 288: 1101-2. Journal 1979; 2. TED S.H., CHEF K.T. AND TAN C.T. Psychiatric Complications of Rohypnol Abuse. Singapore Medical 20: 270-3. 3. Lit. on Erimin, Sumitomo Chemical Co. Ltd, Japan page 1-20. 4. Medicine for Insomnia, Erimin Tablets, Sumitomo Chemical Co. Ltd, Japan page 6. 1987; 151: 5. TYRER R AND MURPHY S. Place of Benzodiazepines in Psychiatric Practice. British Journal of Psychiatry 719-23. 6. Lessening the Use of Benzodiazepines. Drug and Therapeutics Bulletin July 1987; 25 (15). of the 7. PRIEST R.G. AND MONTGOMERY S.A. Benzodiazepines and Dependence: A College Statement. Bulletin Royal College of Psychiatrists 1988, Vol 12.

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