Mephentermine dependence in a young Indian adult without psychosis

Background

Mephentermine, whose chemical name is N,2-dimethyl-1-phenylpropan-2-amine, bears close structural resemblance to amphetamine and methamphetamine.1 It is an alpha adrenergic receptor agonist and also causes release of endogenous norepinephrine. It is used to prevent or treat hypotension secondary to ganglionic blockade and hypotension accompanying spinal anaesthesia. It has also been used as a nasal decongestant in past. Notable adverse drug reactions include tachycardia, arrythmia, hypertension, nervousness, anxiety and seizures. Rarely, it could also lead to psychiatric manifestations in form of hallucinations and delusions.1 It is generally available as mephentermine sulphate in sterile solution of strength 15 and 30 mg/mL for parenteral use.1

Abuse of mephentermine has been known for a long time. First such report was published by Greenberg and Lustig.2 They had reported four cases where patients had developed visual hallucinations following ingestion of then available nasal decongestant preparation of mephentermine.2 More such cases were reported by Angrist et al.3 The cases reported in these publications did not have features of dependence to mephentermine. First case of dependence to mephentermine was reported by Joshi et al 1988.4 Thereafter, 10 more cases of mephentermine dependence have been reported.5–14 This report discusses one such case of mephentermine dependence in a young Indian adult male.

Case presentation

A 26-year-old man presented to psychiatry out patient services of this tertiary care hospital with regular use of and inability to stop injection Termin (mephentermine) for last 3 years. Background information and history was explored. Since his school days, the patient has been interested in athletics and had a passion for running. He had won several racing competitions held during intraschool and interschool sports competitions. He progressed in his athletic career and participated in national-level championships as well. However, he could not achieve more accolades. After completing 12 years of formal education, he did not pursue undergraduate courses. By the age of 22 years, he could secure a clerical job under state government through a special privilege available to sportsmen. He joined the same. However, his passion for running did not die and he continued to participate in various local and regional competitions. It was during this time, at an age of 23 years, he was introduced to mephentermine injections by a fellow athlete.

He was informed by his fellow athlete that he could easily gain significant improvement in his performance by use of this injection. He was initially reluctant to use mephentermine as he had never used any drug to augment his physical capabilities. However, he could not resist peer pressure and used the injection. At first instance, his peer injected 30 mg mephentermine in his arm (deltoid muscle of arm). After around half-an hour, he felt significantly energetic. He felt that he could run faster and for longer duration without getting any sense of fatigue or tiredness. He used this drug in same dose once a week for next 1 month. Thereafter, he learnt to administer injections himself (intramuscular). The frequency of taking injections also increased to two to three times every week. By end of around 6 months, he shifted to intravenous use as it produced physical effects quickly and also produced a sense of psychological well-being and peace of mind. After a year and half, he was taking multiple mephentermine injections in a day and his cumulative daily dose could be anything between 600 and 700 mg. During all this period, he never tried to return to professional athletic competitions but still continued to use mephentermine injections. Any attempt to decrease the dose or to discontinue the injections led to significant drowsiness, fatigue, cold and numb limbs and restlessness. These symptoms were relieved only after taking mephentermine injections. He always used fresh needles and syringes for taking injections. He had never shared needles or syringes with anyone. He always wore full sleeve shirts in order to hide scars due to repeated injections.

At the age of around 25 years, he got married. He could not hide his problem from his wife for long. His wife motivated him to abstain from use of his drug. He expressed his difficulty in doing the same. She advised him to seek medical help for the same which he refused and decided to make a strong attempt to gradually discontinue mephentermine use. Over next 1 year, with much difficulty, he could bring down the daily dose of mephentermine to 300 mg. Despite his continued effort, he could not decrease the dose further. It was at this point of time that he agreed to seek medical advice.

Detailed psychiatric assessment did not reveal any other psychiatric disorder or substance use (other than mephentermine) currently or in past. Developmental history was unremarkable. He was well adjusted in his personal and professional life. There were no features suggestive of any personality disorder. He satisfied diagnostic criteria for substance dependence as described in the International Classification of Diseases, 10th revision.15 Physical examination including examination of cardiovascular system was unremarkable except for multiple hypertrophic scars along veins of left arm. Reports of investigations viz. complete blood count, liver function tests, kidney function tests, tests for HIV, hepatitis B, hepatitis C and ECG were unremarkable. Urine was screened for natural opioids, benzodiazepines and cannabis and it was negative. Laboratory tests to confirm the presence of mephentermine in the body could not be conducted due to non-availability of the same. Currently, the patient was mainly concerned about dysphoria, restlessness and sleeplessness on attempts to discontinue mephentermine and repeatedly requested for help regarding the same.

Treatment

After taking note of all the clinical issues, he was offered inpatient management. However, he did not agree for the same. Therefore, home-based management was planned. He agreed to discontinue injections and stay under close supervision of his family members. He was advised to take rest, have normal diet, plenty of fluids and at least one litre oral rehydration solution daily. Measures to prevent postural hypotension were explained. He was advised to monitor his pulse and blood pressure with an automatic blood pressure monitor at least three times daily. The method and technique for blood pressure monitoring was demonstrated in the hospital. He was advised to contact this hospital or any locally available physician immediately in case significant drop in blood pressure is noted or if he feels cold, clammy, giddy, has black out or any other problem. For relief in anxiety and sleeplessness, tablet chlordiazepoxide 10 mg orally three times a day was prescribed. He was advised to follow up after 1 week or earlier if required. The patient reported at scheduled meeting after a week. He came to out patient department with his wife. He reported that he was able to stop injections completely for a week now. First 2 days were difficult but thereafter, he had rapid improvement in symptoms of fatigue, dysphoria and sleeplessness. He had mild dizziness too but that settled down by sixth day of abstinence. His wife was happy with the progress made and also confirmed that the patient has been under strict supervision at home. The patient had planned to join his duties next day onwards. The patient was allowed to resume his duties. He was advised to avoid driving for few more days and to stay watchful for symptoms of drop in blood pressure. Chlordiazepoxide was advised in tapering dose. Next appointment was scheduled 2 weeks later for assessment and initiation of psychotherapy and relapse prevention.

Outcome and follow-up

The patient came alone at the scheduled follow-up. He reported that he was abstinent and was happy to be free of drug use after a long time. However, he refused to go for psychotherapy as he felt that he was now in control of his problem and does not need continued clinical help. He could not be convinced to the contrary. He was advised to avoid cues that could lead to relapse and to follow up as and when required. Two months later, he was contacted through telephone. He reported himself to be abstinent and maintaining well. Further contacts were not made as patient was not willing.