To the Editor: We have noted recent reports of quetiapine diversion and misuse among inmates in correctional settings where it is also called “quell” or “baby heroin” (1, 2). It is used orally, intranasally, and intravenously for its potent sedative and anxiolytic properties (1, 2). Inmates obtain quetiapine for illegitimate use by malingering of psychotic symptoms or obtaining it from other inmates. The high prevalence of substance use disorders in corrections and the secondary gain of serving out “easy time” with pharmacological assistance contribute to an underground economy of diverted psychoactive medications (3). Anecdotal reports from colleagues—as well as online testimonials—support the existence of quetiapine diversion and misuse in noncorrectional settings as well (4). The following case is an example of prescription medication diversion with concomitant illicit substance use seen in the local county hospital emergency room.
A 33-year-old married Caucasian male with a history of polysubstance dependence (cocaine, heroin, alcohol, benzodiazepines) reported to the local county hospital emergency room requesting assistance with drug detoxification and rehabilitation. The patient endorsed daily use of intravenous cocaine mixed with 400 mg–800 mg of quetiapine. Quetiapine was surreptitiously diverted from his wife’s prescription. He reported crushing the quetiapine tablets and mixing the resulting powder with cocaine and water. He subsequently heated the mixture and drew the supernatant through a cotton swab into a syringe to administer intravenously. When asked why he engaged in this drug mixture, he stated that it achieved desired “hallucinogenic” effects.
Combining prescription medications and/or illicit drugs is a common practice to synergistically heighten the intoxication from the substances while potentially reducing undesirable side effects. The combination of intravenous heroin and cocaine (also known as “speedball”) is a well-known strategy to both maximize the cocaine “rush,” while mitigating its “crash” (5). It may be hypothesized that quetiapine was substituted for heroin in our case (to form a “Q-ball”) because the sedative/anxiolytic effects of quetiapine may mitigate the dysphoria associated with cocaine withdrawal and to possibly provide a “hallucinogenic” effect.
The case presented highlights the unknown effects (such as a “hallucinogenic” experience) of combining substances with different pharmacological properties and subsequently circumventing first-pass metabolism through intravenous administration. Individuals who use oral medications intravenously have the potential to develop significant pulmonary complications secondary to the deposition of medication binders in lung parenchyma. Furthermore, the cardiovascular and arrhythmogenic properties of cocaine may be amplified in combination with quetiapine (which has a risk of QTc prolongation). Physicians should remain cognizant of potential medication diversion and misuse in noncorrectional settings.
1.Hussain MZ, Waheed W, Hussain S: Intravenous quetiapine abuse (letter). Am J Psychiatry 2005; 162:1755–1756
2.Del Paggio D: Psychotropic medication abuse in correctional facilities. The Bay Area Psychopharmacology Newsletter 2005; 8:1, 5
3.Della Volpe K: Intervention reduces abuse of psychotropic medications in correctional facility. Pharmacy Practice News, July 2005
4.The Vaults of Erowid. http://www.erowid.org/ (accessed April 2006)
5.Smith JE, Co C, Coller MD, Hemby SE, Martin TJ: Self-administered heroin and cocaine combinations in the rat: additive reinforcing effects-supra-additive effects on nucleus accumbens extracellular dopamine. Neuropsychopharmacol 2006; 31: 139–150
The authors report no competing interests.