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Changing Trends in Diet Pill Use, from Weight Loss Agent to Recreational Drug

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Changing Trends in Diet Pill Use, from Weight Loss Agent to Recreational Drug Residents’ Voices Changing trends in diet pill use, from weight loss agent to recreational drug Samidha Tripathi, MD, and Carolina Retamero, MD he prevalence of obesity and obesity- plements are some of the modalities used to related conditions in the United States address this epidemic. Tis increasing. Many weight-loss prod- Most so-called supplements for weight ucts and dietary supplements are used in an loss are exempt from FDA regulation. They attempt to combat this epidemic, but little evi- do not undergo rigorous testing for safety. dence exists of their efficacy and safety. Furthermore, many contain controlled sub- We present a case report of a middle-age stances; some supplements are anti-seizure woman who developed severe psychotic medications or other prescription drugs; and Dr. Tripathi a Fellow in Psychosomatic Medicine, University of Pennsylvania, symptoms while taking phentermine hydro- some are drugs not approved in the United Philadelphia, Pennsylvania. When this chloride (HCl), a psychostimulant similar States.2 Since the 1930s, such drugs as dini- article was written, she was a PGY-4 Resident, Department of Psychiatry to amphetamine that is used as a weight- trophenol, ephedrine, amphetamine, fenflu- and Behavioral Science, Einstein loss agent and for recreational purposes. ramine, and phentermine have flooded the Healthcare Network, Philadelphia, Phentermine has been associated with mood market with the promise of quick weight Pennsylvania, where Dr. Retamero is Associate Program Director. and psychotic symptoms and has a tendency loss.3,4 to cause psychological dependence and Disclosures The authors report no financial tolerance. Phentermine, a contraction of relationships with any company whose To investigate the risks and potential effects “phenyltertiary-butylamine,” and its products are mentioned in this article or with manufacturers of competing of using this drug, we searched OVID and various types (Table, e4) is a psychostimu- products. PubMed databases using the search string lant of the phenethylamine class, with a This unfunded study was presented “phentermine + psychosis.” We conclude pharmacologic profile similar to that of as a case report poster at the that there is a need for awareness about early amphetamine. It is known to yield false- Annual Meeting of the Academy of Psychosomatic Medicine, November detection and treatment of reversible psy- positive immunoassay screening results 2013, Tucson, Arizona, and at the chotic and mood symptoms caused by what for amphetamines. Colloquium of Scholars of the might appear to be harmless weight-loss and Medically, phentermine is used as an Philadelphia Psychiatric Society, March 2014, Philadelphia, Pennsylvania. energy pills. appetite suppressant because of its activity on dopaminergic and adrenergic systems. It is a Schedule-IV drug, by prescription Obesity epidemic, wide-ranging only. When used illicitly, it is associated with weight-loss efforts acute-onset psychosis and mood changes.5-13 There has been a dramatic increase in obesity continued in the United States in the past 20 years: More than one-third of adults and approximately 17% of children and adolescents are obese. LET YOUR VOICE BE HEARD Obesity-related conditions, such as heart dis- CURRENT PSYCHIATRY invites psychiatry residents ease, stroke, and type 2 diabetes mellitus, are to share their views on professional or clinical leading causes of preventable death.1 Weight topics for publication in Residents’ Voices. E-mail [email protected] monitoring, a healthy lifestyle, surgical inter- for author guidelines. Current Psychiatry vention, traditional herbs, and diet-pill sup- Vol. 14, No. 11 e3 Residents’ Voices Table Phentermine and its branded formulations Generic compound Brand names and formulations Phentermine HCl Adipex-P Dosages: 15 mg, 30 mg, and 37.5 mg Available as 37.5-mg pill Phentermine HCl, 37.5 mg = phentermine resin, 30 mg Suprenza Phentermine HCl, 30 mg = phentermine resin, 24 mg Orally disintegrating tablet Phentermine HCl, 15 mg = phentermine resin, 12 mg Dosages include 15-mg, and 30-mg pill Qsymia Previously known as Qnexa Combination of phentermine and extended- release topiramate Limited distribution in the United States Clinical Point Dosage forms: 3.75 mg/23 mg ER; Medically, 7.5 mg/46 mg ER; 11.25 mg/69 mg ER; 15 mg/92 mg ER phentermine is Fen-Phen used as an appetite Combination of fenfluramine and phentermine Withdrawn from the U.S. market in September suppressant because 1997 because of reports of potentially of its activity on fatal valvular heart disease and pulmonary hypertension, secondary to fenfluramine dopaminergic and ER: extended release; HCl: hydrochloride adrenergic systems CASE REPORT Her medical history, physical examination, Acute psychotic break and a CT scan of the head are unremarkable. Ms. B, age 37, with a history of postpar- The components of a comprehensive meta- tum depression, arrives at the emergency bolic panel and complete blood count are room reporting auditory hallucinations within normal limits. of her son and boyfriend; vivid visual hal- lucinations; and persecutory ideas toward After admission, in-depth assessment her boyfriend, whom she believes had reveals that Ms. B has been taking phen- kidnapped her son. She also complains of termine, 37.5 mg (under the brand name insomnia and intermittent confusion for the Adipex-P), once daily since age 16 for weight past week. loss. She recently discontinued the drug, Speech is pressured, fast, and difficult to abruptly, for 1 month, then resumed taking it comprehend at times; affect is labile and irri- at an unspecified higher dosage 1 week before table. Ms. B denies suicidal ideation and is she came to the emergency room, for what oriented to time, place, and person. she said was recreational use and to meet the A urine drug screen is positive for demands of her job, which required shift work amphetamine. and long hours. Pre-admission medications include alpra- Over the next few days in the hospital, Discuss this article at zolam, 1 mg as needed, and zolpidem, 10 mg Ms. B’s symptoms resolve as the drug is www.facebook.com/ at bedtime, prescribed by Ms. B’s primary eliminated from her body. Speech becomes CurrentPsychiatry care physician for anxiety and insomnia. comprehensible and sleep improves. She discontinued these medications 3 weeks Affective distress diminishes considerably ago because of increased drowsiness at after admission; slight mood lability per- work. She denies other substance use and is sists. She no longer reports perceptual dis- unable to account for the positive urine drug turbances or distress secondary to intrusive Current Psychiatry e4 November 2015 screen. thoughts. Residents’ Voices Ms. B is discharged 1 week after admis- Drug Brand Names sion, with instructions to follow up at a dual- Alprazolam • Xanax Topiramate • Topamax, diagnosis outpatient program. Fenfluramine • Pondimin Trokendi XR Phentermine HCl • Adipex-P, Zolpidem • Ambien Fen-Phen, Qsymia, Suprenza Pharmacologic profile Phentermine acts through sympathomi- substance of abuse and has catastrophic metic pathways by increasing brain nor- effects on the user’s psyche, the need for adrenaline and dopamine. The drug has no stronger warnings and guidelines might be effect on serotonin.4,5 Phentermine can lead warranted to allow consumers to make an to elevated blood pressure and heart rate, informed choice about using the drug. palpitations, restlessness, and insomnia, and can suppress appetite. Increased sympatho- Clinical Point mimetic activity has been implicated in the Call for awareness Not only are diet ability of phentermine to induce psychotic The case we presented here exemplifies the symptoms. importance of tighter regulation of both pills used by people over-the-counter and prescription stimu- with an eating The literature. Our PubMed search of lant analogs. There is a need for awareness disorder; their “phentermine + psychosis” produced among practitioners about early detection recreational use is 13 results, including 6 case reports of phen- and treatment of reversible psychotic and an emerging problem termine use. Five citations were more than mood symptoms secondary to what might 4 decades old5-12; only 1 could be considered be promoted as, or appear to be, “harmless” recent (2011).13 weight loss and energy pills. Patients in these reports developed psy- chotic or manic features after chronic or References 1. Center for Disease Control. Division of nutrition, physical acute phentermine use, mainly for weight activity, and obesity. http://www.cdc.gov/obesity/data/adult. reduction. The most recent article13 men- html. Updated September 14, 2015. Accessed October 27, 2015. 2. Retamero C, Rivera T, Murphy K. “Ephedra-free” diet pill- tioned 4 patients who were abusing diet pills induced psychosis. Psychosomatics. 2011;52(6):579-582. recreationally (including “for lethargy”). As 3. Cohen PA, Goday A, Swann JP. The return of rainbow diet pills. Am J Public Health. 2012;102(9):1676-1686. with Ms. B, in all 4 of those patients, phen- 4. Wellman PJ. Overview of adrenergic anorectic agents. Am J termine precipitated the primary pathol- Clin Nutr. 1992;55(suppl 1):193S-198S. ogy (mania in bipolar disorder; depression 5. Devan GS. Phentermine and psychosis. Br J Psychiatry. 1990;156:442-443. in postpartum depression and substance 6. Hoffman BF. Diet pill psychosis. Can Med Assoc J. abuse) or revealed underlying illness. 1977;116(4):351-355. 7. Hoffman BF. Diet pill psychosis: follow-up after 6 years. Can Med Assoc J. 1983;129(10):1077-1078. 8. Rubin RT. Acute psychotic reaction following ingestion of Changing landscape of use phentermine. Am J Psychiatry. 1964;120:1124-1125. 9. Schaffer CB, Pauli MW. Psychotic reaction caused by and abuse proprietary oral diet agent. Am J Psychiatry. 1980;137(10): There has been a trend observed in the 1256-12567. 10. Lee SH, Liu CY, Yang YY. Schizophreniform-like psychotic pattern of diet pill use: Initially marketed disorder induced by phentermine: a case report. Zhonghua Yi as an appetite suppressant, these pills are Xue Za Zhi (Taipei).
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