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LETTERS TO EDITOR  
Year : 2020  |  Volume : 62  |  Issue : 6  |  Page : 740-741
A rare case of dicyclomine and mefenamic acid abuse fulfilling criteria of dependence syndrome


Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India

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Date of Submission20-Oct-2019
Date of Decision29-Dec-2019
Date of Acceptance20-Apr-2020
Date of Web Publication12-Dec-2020
 

How to cite this article:
Sinha SK, Dhiman S, Sidana A. A rare case of dicyclomine and mefenamic acid abuse fulfilling criteria of dependence syndrome. Indian J Psychiatry 2020;62:740-1

How to cite this URL:
Sinha SK, Dhiman S, Sidana A. A rare case of dicyclomine and mefenamic acid abuse fulfilling criteria of dependence syndrome. Indian J Psychiatry [serial online] 2020 [cited 2021 Jan 22];62:740-1. Available from: https://www.indianjpsychiatry.org/text.asp?2020/62/6/740/303177




Sir,

Dicyclomine is a tertiary amine anticholinergic drug indicated for morning sickness, dysmenorrhea, and irritable bowel syndrome.[1] Mefenamic acid is a nonsteroidal anti-inflammatory drug used primarily as an analgesic. It is quite effective in dysmenorrhea.[2] This is an extremely rare case of drug abuse of dicyclomine and mefenamic acid tablets fulfilling criteria of dependence syndrome.

A 30-year-old woman presented with a complaint of excessive use of dicyclomine and mefenamic acid tablets for the past 10 years. She started using it in 2007 for dysmenorrhea. After 1 year of initiation, she started using it to get relief from nervousness and headache because of any stress. From 2014, she started taking 2–3 tablet daily to get relief from stress of marital discord which increased to 10–15 tablets daily in 2018 suggesting tolerance. She reported an intense desire to take tablets suggesting craving. She would have apprehension, restlessness, and headache 2–3 days after stopping it suggesting withdrawal symptoms. In 2017, her husband got to know about it leading to conflict between her in-law family and her family. Because of this, she had low mood, intermittent headache, apprehension and disturbed sleep. During mental status examination, she subjectively reported low mood and had anxious affect. On cue exposure and extinction, she developed tachycardia, palpitation, and sweating suggesting objective craving. Her body mass index was 18.2 kg/m2 and hemoglobin was 10.4 g/dl, and rest of the general physical examination and investigations were within the normal limit. She was diagnosed with abuse of nondependence-producing substances with adjustment disorder (International Statistical Classification of Diseases-10). Initially, on outpatient basis and later during ward admission, she was treated with fluoxetine 20 mg per day and clonazepam 0.5 mg per day and advised abstinence. With these measures, she reverted to normal physiological state in a week during ward stay. During 1 year of follow-up, she denied any abuse of dicyclomine and mefenamic acid tablets but that could not be corroborated with her husband who suspected that she may have used it intermittently.

Our patient started using dicyclomine and mefenamic acid tablets for dysmenorrhea and later for stress relief. Since that caused therapeutic benefit, it acted as a positive reinforcement for drug use. Later, relief from withdrawal symptoms acted as a negative reinforcement for drug use. The transition from casual drug use to drug abuse may be neurobiologically conceptualized as a transition from positive to negative reinforcement mechanisms.[3] The abuse liability may have been because of dicyclomine's anticholinergic property and its property to cross blood–brain barrier.[4] Previous literature also reported abuse of dicyclomine[4],[5] though no literature on abuse of mefenamic acid has been found to the best of knowledge of authors. Our patient fulfilled the criteria of craving, withdrawal, and tolerance for substance use disorder. This suggests that nondependence-producing substance like dicyclomine may also cause dependence if not used judiciously. Hence, further study on abuse of anticholinergic drug, particularly dicyclomine, is needed. We also suggest that therapeutic use of anticholinergic drug, particularly dicyclomine, should be combined with strict vigilance and effective counseling of patients and family members to prevent abuse of such drugs.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent form. In the form, the patient has given her consent for clinical information to be reported in the journal. The patient understands that her name and initial will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Tripathi KD. Anticholinergic drugs and drugs acting on autonomic ganglia. In: Tripathi M, editor. Essentials of Medical Pharmacology. 6th ed. New Delhi: Jaypee Brothers Medical Publishers (p) Ltd.; 2008. p. 110.  Back to cited text no. 1
    
2.
Tripathi KD. Nonsteroidal antiinflammatory drugs and antipyretic-analgesics. In: Tripathi M, editor. Essentials of Medical Pharmacology. 6th ed. New Delhi: Jaypee Brothers Medical Publishers (p) Ltd.; 2008. p. 193.  Back to cited text no. 2
    
3.
Sadock BJ, Sadock VA, Ruiz P. Neuroscience of substance use disorders. In: Comprehensive Textbook of Psychiatry. 10th ed.. New Delhi: Wolters Kluver (India) Pvt., Ltd.; 2017. p. 370.  Back to cited text no. 3
    
4.
Das S, Mondal S, Datta A, Bandyopadhyay S. A rare case of dicyclomine abuse. J Young Pharm 2013;5:106-7.  Back to cited text no. 4
    
5.
Carlini EA. Preliminary note: Dangerous use of anticholinergic drugs in Brazil. Drug Alcohol Depend 1993;32:1-7.  Back to cited text no. 5
    

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Correspondence Address:
Santosh Kumar Sinha
Department of Psychiatry, Government Medical College and Hospital, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_562_19

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