Case report A rare case of dependence on pemoline

AbstractThis is the first case to report about a patient dependent on the dopaminergic CNS-stimulant pemoline. Throughout the treatment of adultattention-deficit hyperactivity disorder (ADHD) with pemoline mental (e.g. craving, loss of control) and physical symptoms (e.g. tolerance,withdrawal symptoms) appeared that fulfill the DSM-IVor ICD-10 criteria for dependence on psychostimulants. However, the dependence wasregarded not to be induced by pemoline itself because the patient was prone to irregular and reinforced intake of amphetamines since heradolescence. Therefore, this case confirms the experience that in the treatment of ADHD the high risk to develop a dependence onpsychostimulants is combined with a history of stimulant abuse.© 2006 Elsevier Inc. All rights reserved. Keywords: ADHD; Dependence; Pemoline; Psychostimulants 1. IntroductionPemoline is a specific dopamine agonist indicated for thetreatment of attention-deficit hyperactivity disorder (ADHD).Also adults with this disorder benefit from this CNS-stimulantby a daily intake of up to 100 mg (Wilens et al., 1999). Clinicaleffects resemble those of methylphenidate with minimalsympathomimetic effects (Janowsky and Hauger, 1995). Areviewofadverseexperiencereportssuggeststhatpemoline hasa limited potential for abuse or dependence (Langer et al.,1986). Pemoline has been available for about three decades.During this time there have been only a few reports ofwithdrawal reactions and no reported cases of dependence onpemoline (Willy et al., 2002). Human experience indicates thatits use is limited and slowly increasing. Reports of intentionaloverdose of pemoline are seldom and no reports involvingabuse via intravenous injection are published (Langer et al.,1986; Willy et al., 2002). Here we report on a case of pemoline-dependence.2. Case reportA 42 year-old divorced female patient was admitted due to adetoxification primarily from pemoline. She was completelyexhausted and did not want to be controlled by pemoline anylonger.Shetoldaboutadaily intakeofupto 80tablets of20mgfor several years. This huge amount was received by visitingseveral doctors over the day. Signs of a central dopaminergicdysfunction, such as anxiety, paranoid psychosis and restless-ness,wouldquicklyeaseupwith1–2mglorazepam,whichwastaken occasionally only in the intention to limit these side-effects of pemoline-overdoses. On actual admission, a semi-quantitative drug screening revealed only low levels forbenzodiazepines in her urine without any traces on ampheta-mines. Physical and laboratory examinations including liverfunction were regular.Hermedicalhistoryrevealedadependenceonamphetaminesand other stimulants, such as prolintan, since her earlyadolescence, when she discovered amphetamines and amphet-amine-like drugs to control appetite and hyperactivity. In 1988and 1989 she was admitted due to a short-lasting amphetamine-induced psychosis. Pemoline was prescribed to her since themid 1990s both to substitute her amphetamine-dependence andalleged to treat symptoms reminiscent to adult ADHD (Wilenset al., 1999). As before with other stimulant medications she