Atypical drug abuse: a case report involving clonidine

American Family Physician,  Sept 1, 1996  by Edmund C. Dy,  William R. Yates

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Prescription drug abuse can involve medications not usually considered to have addictive potential. Clonidine is a rare, but important, atypical drug of abuse. Atypical prescription abuse was discovered in a patient who had a history of alcohol and drug abuse. Clonidine produced a state that the patient identified as similar to the condition resulting from the use of opioids. This article offers a framework for identifying atypical prescription drug abuse and suggests guidelines for prevention and management.

Clonidine (Catapres) is a centrally acting [alpha.sub.2]-adrenergic agonist. It is traditionally used as an antihypertensive agent and, to a lesser extent, to alleviate the symptoms of opioid withdrawal. Clonidine is not a scheduled drug and is not generally considered to have significant addictive potential. Cases of clonidine abuse have been reported, however, suggesting that high doses of the drug may have sedative or euphoric effects.[1-3] Awareness of atypical prescription drug abuse can aid family physicians in the prevention, detection and management of the problem.

Illustrative Case

A 42-year-old man who had recently been admitted to a medical inpatient unit was referred for psychiatric consultation because he threatened to overdose with antihypertensive medication. This patient had a long history of polysubstance abuse, including amphetamines, heroin, opioids, benzodiazepines, cocaine and marijuana. Over the past several years, the patient had developed primary hypertension. About three years before, he had started taking clonidine, 0.3 mg daily, to control his blood pressure.

The patient gradually developed a pattern of clonidine prescription abuse. His abuse was prompted by a stressful social situation. In an attempt to relieve his distress, he impulsively took eight to 10 clonidine tablets, 0.3 mg each (2.4 mg to 3.0 mg total), at one time. He did not think this was likely to relieve his distress but did not know what else to do. He was pleasantly surprised when he found that this dosage produced what he described as a "nod" effect, similar to what he had experienced with morphine. He described this effect as a state in which the user becomes "sleepy and in dreamland, like floating on a cloud but still not unconscious--Nirvana." He insisted it was better to use clonidine than heroin, because clonidine did not make him feel sick afterward. Even better was the fact that the effect lasted up to one-half day. While taking this high dosage of clonidine, he reported experiencing fatigue, decreased appetite, drowsiness, blurred vision, slurred speech and euphoria. He denied any withdrawal symptoms except for insomnia.

Following his initial experience with a high dosage of clonidine, he developed a pattern of behavior that maximized his supply of the drug. He found a way to have two different pharmacies fill prescriptions. He would use a month's supply of clonidine in a week. Because clonidine was an atypical drug of abuse, he found it easy to persuade his physician to give him replacement prescriptions for ones that he claimed were lost. When he was out of money to purchase illicit drugs, he used clonidine to moderate the withdrawal symptoms. When he was unable to secure clonidine, he increased his use of opiates and cocaine. He was so satisfied with this method of using clonidine that he introduced two of his friends to the practice. He reported that these friends are now regular users of high dosages of clonidine.

Eventually, the man's physician discovered his abuse of clonidine and switched him to a patch form. The patient found that this route of drug administration failed to produce the desired effect. He tried applying several patches at a time, but that also failed to give him the same effect. Unfortunately, the patch form also failed to control his hypertension, probably because of problems with compliance.

The patient was admitted to an inpatient drug treatment program several days before his medical hospitalization. His transfer to a medical facility was precipitated by the sudden onset of night sweats, fever, chills, hypertension and bleeding gums. In the course of the workup, the medical staff decided to switch the patient from clonidine patches to a calcium channel blocker. In an attempt to persuade his physician to put him back on clonidine, the patient threatened to take all of the calcium channel blocker pills at one time. The medical team considered this a suicide threat and requested psychiatric consultation.

Psychiatric consultation confirmed the clonidine abuse. In addition, the patient's psychiatric history included multiple nonserious suicide attempts, incarcerations for drug violations and domestic abuse directed toward live-in companions. He had a long history of cocaine and opiate dependence. In addition, his history was consistent with the diagnosis of borderline personality disorder. Psychiatric consultation confirmed that there was no serious suicide risk, major depression or need for psychiatric hospitalization. It was recommended that the patient not be prescribed clonidine again because of his pattern of abuse and the possible medical complications of clonidine abuse.