28 Addiction Psychiatry C LINICAL P SYCHIATRY N EWS • September 2007

Paroxetine Shows No E VIDENCE-BASED P SYCHIATRIC M EDICINE Effect on Drinking Abuse of Bupropion

BY MICHELE G. SULLIVAN The patients’ average age was 29 The Problem caloric intake, or sleep. On self-rating scales, Mid-Atlantic Bureau years; 50% were male. At base- You work in one of America’s contemporary bupropion was perceived as an active drug only line, their mean score on the Lei- long-term psychiatric treatment centers, also as often as placebo. The investigators con- C HICAGO — Paroxetine can bowitz Social Anxiety Scale (LSAS) known as a state prison. Inmates who come to cluded, “It is unlikely that bupropion will give take the anxiety out of the drinker, was about 90, indicating severe so- outpatient appointments and complain of de- rise to [amphetaminelike] patterns of abuse but it cannot take the drinking out cial anxiety. Anxiety had its onset pressive symptoms frequently request bupro- among normals or among those predisposed of the anxious person. at age 12 years in these patients; pion (Wellbutrin). The history they provide is to psychostimulant abuse.” (The study came The drug did uncouple anxiety the use of alcohol to cope with speciously similar: “It’s the only antidepressant from the Baylor College of Medicine, the and drinking in patients who use symptoms followed about a that’s ever worked.” You start to inquire about Houston Veterans Administration Medical alcohol to cope with severe gener- decade later. They were moder- how this medication is used in the prison Center, and the Burroughs Wellcome Research alized social anxiety, Dr. Sarah ately dependent on alcohol, con- yard, and some of your more frank patients Laboratories.) Book said at the annual meeting of suming about 15 drinks per week. say it is snorted to provide a methampheta- A double-blind, placebo-controlled, crossover the Research Society on Alco- By week 16, patients in the treat- minelike high. study conducted at the Medical University of holism. But compared with place- ment group had a far greater de- Innsbruck (Austria) bo, paroxetine (Paxil) had no effect crease in their LSAS scores than did The Question examined the abuse on overall alcohol consumption. those in the placebo group (53% vs. What is known liability of bupropi- “These patients were precon- 32%). But a different picture about the abuse po- on using caffeine as templators for their alcohol use emerged when Dr. Book examined tential of bupropion a positive control disorder,” said Dr. Book, a psychi- the drug’s effect on drinking. outside of the prison (Pharmacology atrist at the Medical University of All patients completed a study- environment? 2004;70:206-15). South Carolina, Charleston. “They specific questionnaire that asked In all, 60 male wanted us to fix their anxiety how often they drank to cope be- The Analysis smokers, aged 18-65 symptoms but weren’t interested fore and during social situations. At We looked at popu- years, were enrolled; in addressing their alcoholism.” week 16, those in the paroxetine lar culture first by 50 completed the tri- Her 16-week randomized con- group had significantly lower doing Google al. The subjects trolled trial, funded by the Nation- scores than did those in the place- searches for “Well- BY JAN LEARD- BY LAURENCE were given two dos- al Institute of Alcohol Abuse and bo group, with 20% (vs. 40%) say- butrin snort” and HANSSON, M.D. GUTTMACHER, M.D. es, 6 hours apart, of Alcoholism, pitted paroxetine (60 ing they still drank to cope with so- “snorting Well- placebo, caffeine mg) against placebo in 42 patients cial situations, and 30% (vs. 70%) butrin.” Some Web sites describe the effects (178 mg), or bupropion slow-release (Zyban, with severe generalized anxiety and saying they would avoid such situ- of snorting bupropion (www.erowid.org/ 150 mg). They completed standardized tele- comorbid alcohol use disorders. ations if they couldn’t drink. experiences/exp.php?ID=9266) and some give phone questionnaires at hourly intervals. Of The patients could have had no But when Dr. Book examined advice on extracting bupropion from Well- the 50 subjects, 50% were able to report “any previous alcohol detoxification the total overall drinking, no dif- butrin SR tablets for the purpose of insuffla- effect” to caffeine or bupropion. In those who treatment. “We wanted to examine ferences were found between the tion (http://bupropion.home.comcast.net). reported “any effect” to caffeine, bupropion was the effect of the drug in people groups in either frequency of Wondering what has been published on this reported as having essentially no effect. Subjects who were early in their alcoholism drinking or quantity consumed. topic in the medical literature, we first searched who reported effects from bupropion reported career, to see if we could intervene GlaxoSmithKline Inc. provided the Cochrane Database of Systematic Reviews “much more intense effects” after bupropion in the progression,” she said. the study medication. ■ (www.cochrane.org/reviews) without result. than caffeine. The authors concluded that We then searched Medline, combining “bupro- bupropion might be of some abuse liability. pion” and “abuse or misuse.” The authors of this study cited another study, not picked up by our search, which was Women Want One Doctor for The Evidence in part sponsored by a pharmaceutical com- Bupropion’s amphetaminelike abuse potential pany. That study compared bupropion with Substance Abuse, Obstetric Tx was suggested in preclinical trials in which an- dexamphetamine and showed essentially no imals substituted bupropion for amphetamine abuse liability of bupropion (Br. J. Clin. Phar- M IAMI — Women with prob- nity medicine, University of in a drug-discrimination task, and in another macol. 1979;7:469-78). lematic substance use during preg- Toronto. “The women like this study in which it was self-administered intra- Investigators at the University of Chicago nancy prefer integrated treatment [integrated] model,” she said. venously by monkeys. conducted a double-blind, placebo-controlled over separate obstetric and sub- “They have one doctor who treats We were able to find two case reports (N. crossover study examining the effects of d-am- stance use care, according to a pre- pregnancy and everything you’d Engl. J. Med. 2002;347:951; J. Child Adol. Psy- phetamine and bupropion on cigarette smok- sentation at the annual conference do for addiction.” chopharm. 2004;14:157-8) that described ado- ing (Psychopharmacology 2001;157:243-53). In of the American Society of Addic- In 2005, researchers used focus lescents who insufflated bupropion in an at- this study, 17 subjects, aged 19-54 years, re- tion Medicine. groups in Toronto to assess satis- tempt to obtain an amphetaminelike effect. ceived d-amphetamine (10 mg and 20 mg); The investigators found that faction among women attending One 16-year-old boy insufflated 600 mg of sus- bupropion (150 mg and 300 mg); and placebo. women attending one of two inte- one of two integrated programs— tained-release bupropion and experienced a Subjective, physiologic, and behavioral effects grated programs reported feeling the Toronto Center for Substance seizure. A 15-year-old girl snorted an unspeci- were monitored, and amphetamine and bupro- less stigmatization about their sub- Use in Pregnancy or the Herzl fied amount of sustained-release bupropion pion increased self-reports of arousal, mood, stance abuse. They also liked the Family Practice Centre. Tran- and reported a marijuanalike buzz that only and euphoria. care they received from consistent scripts of these sessions were cod- lasted a few seconds. providers. In contrast, those who ed for recurring themes. In a double-blind crossover study conducted The Conclusion received isolated substance abuse The researchers compared the to determine the amphetaminelike abuse po- The two university sponsored studies found an treatment at a traditional center subjects’ satisfaction with that of tential of bupropion, 13 male subjects (aged 22- abuse liability of bupropion, and the two stud- and obstetric care at a general hos- women recruited from the obstet- 31 years) with “substantial” histories of psy- ies that were partly sponsored by pharmaceu- pital reported harsh and punitive rics department at a general hos- chostimulant abuse were randomized to tical companies found no abuse liability. Our treatment from hospital staff that pital in 1995. Women in the latter receive, at intervals of at least 3 days, bupro- experience suggests that ingenious and deter- made them feel marginalized, Dr. group also attended a community pion (100 mg, 200 mg, and 400 mg); d-am- mined patients have found ways, overlooked by Lisa G. Lefebvre said during an in- substance use treatment center. phetamine (15 mg and 30 mg); and placebo (J. published studies, to bypass bupropion’s first- terview at a poster session. Women who attended separate Clin. Psychiatry 1983;44:206-8). pass metabolism and achieve highs similar to “Patients tour the maternity programs were less likely to report Drugs were administered at 8:00 a.m., with amphetamine. ward in advance, and everyone on a good birth experience. “Is it possi- physiologic measures taken a half hour before the staff is trained to be sensitive ble that the stigma of substance use administration and then hourly post dose. DR. LEARD-HANSSON is a forensic psychiatrist to their substance use,” said Dr. was worse in 1995? “Even in 2005, Bupropion had no measurable effect (relative who practices in San Diego. DR. GUTTMACHER Lefebvre, who is an addiction when they ended up in another fa- to placebo) on blood pressure, pulse rate, res- is chief of psychiatry at the Rochester (N.Y.) medicine consultant with the de- cility, they felt stigma,” she said. piratory rate, temperature, pupil size, appetite, Psychiatric Center. partment of family and commu- —Damian McNamara