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Black-Market Value

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350 Am J Psychiatry 164:2, February 2007LETTERS TO THE EDITORajp.psychiatryonline.orgBlack-Market Value of Antipsychotics, Antidepressants, and Hypnotics in Las Vegas, NevadaTO THE EDITOR: To our knowledge, this letter represents thefirst effort to document the monetary value of several antipsy-chotic and antidepressant medications outside of a custody set-ting on the black-market in a major U.S. city. The monetaryvalue of benzodiazepines and narcotics in Canada has beenpreviously published (1), and we include a few of these medica-tions in this letter as well. Stimulants are not included in this let-ter because of insufficient reports of street prices in our cohort.Several reports have documented the potential misuse ofmedications, not traditionally considered to be addictive, forrecreational purposes, primarily in custody settings. These in-clude quetiapine (2, 3), anticholinergics (4), and tricyclics (5).When publicly funded outpatient clinic staff memberswere asked if they had any suspicions about misuse of thesemedications, many said that they had heard of patients sell-ing their medications on the street, and several suspected thatsome patients feigned psychosis to obtain medications to sell.Between Oct. and Dec. of 2005, a variety of health profes-sionals were asked if they had heard the street prices of medi-cations. The results from sixty-one buyer and seller reportsare summarized in Table 1.Sellers reported that it was relatively easy to sell the medi-cations they had received free of charge from the clinics andconvert them into money for rent, utilities, food, illicit drugs,or alcohol. Buyers reported that they use these medicationsfor their sedative effect as a sleep aid, to “zone-out” or to “takethe edge off.” Buyers included individuals attempting to self-medicate, not having a third-party method of payment.More detailed studies should be performed to elucidate theabuse potential of these and other medications as well as theepidemiology of their misuse. The health effects of black-market use are as yet unstudied, and physicians should beaware that patients might be covertly taking psychotropicmedicines. Diversion of these medications may represent asignificant expense for public and private agencies, and sus-pected malingering or other requests for early refills shouldalert agencies to the possibility of black-market activity.References1. Sajan A, Corneil T, Grzybowski S: The street value of prescrip-tion drugs. CMAJ 1998; 159:139–1422. Pierre JM, Shnayder I, Wirshing DA, Wirshing WC: Intranasalquetiapine abuse (letter). Am J Psychiatry 2004; 161:17183. Hussain MZ, Waheed W, Hussain S: Intravenous quetiapineabuse (letter). Am J Psychiatry 2005; 162:1755–17564. Buhrich N, Weller A, Kevans P: Misuse of anticholinergic drugsby people with serious mental illness. Psychiatr Serv 2000; 51:928–9295. Hepburn S, Harden J, Grieve JHK, Hiscox J: Deliberate misuse oftricyclic antidepressants by intravenous drug users: case stud-ies and report. Scott Med J 2005; 50:131–133GREG TARASOFF, M.D.KATHRYN OSTILas Vegas, Nev.Physical Exercise as a Treatment for Non-Suicidal Self-Injury: Evidence From a Single-Case StudyTO THE EDITOR: Nonsuicidal self-injury refers to deliberatedamage to one’s own bodily tissue without suicidal intent.Nonsuicidal self-injury is a pervasive behavior problem, yet ef-fective treatments are lacking. Research has found that peopleengage in nonsuicidal self-injury for several different reasons,including tension relief and the induction of pleasurable affec-tive states (1). Preliminary evidence suggests that the release ofendogenous opioids may be central to this process of emo-tional regulation (2). We hypothesized that aerobic physical ex-ercise, which has been shown to regulate mood (3) and stimu-late the release of beta-endorphin (4), would decrease thefrequency of nonsuicidal self-injury. We report on the results ofa single-case study demonstrating the effectiveness of physicalexercise as a treatment for nonsuicidal self-injury.“Ms. A” was an overweight 26-year-old woman with a13-year history of ongoing psychological and pharmaco-logical treatment for persistent nonsuicidal self-injury, in-cluding one inpatient hospitalization for nonsuicidal self-injury within the past year. Ms. A was receiving twice-weekly outpatient psychotherapy for the duration of thisstudy. In an initial baseline assessment, she reported 2.25episodes of nonsuicidal self-injury per week over the pre-vious month, including self-hitting and head-banging.We provided Ms. A with a 60-minute workout video, in-structing her to exercise three times per week and to exer-cise in response to nonsuicidal self-injury urges at anytime. We also provided a daily assessment form in whichshe recorded mood and self-injurious urges (both on 0–9scales) and behaviors.The frequency of Ms. A’s nonsuicidal self-injury de-creased immediately after the introduction of exercise to0.37 times per week during a five-week experimentalphase. She then independently discontinued exercise.During this quasi-experimental return to baseline, nonsui-cidal self-injury increased to 2.33 times per week. Whenexercise was re-introduced, nonsuicidal self-injury de-creased to 0.00 times per week for the remainder of thestudy.Overall, nonsuicidal self-injury frequency was signifi-cantly lower during exercise phases (M=0.29, SD=0.49) rel-ative to nonexercise phases ([M=2.20, SD=0.45] t=6.93,df=10, p<0.001). Moreover, analysis of mood ratingsshowed an increase from before exercise (M=2.23, SD=TABLE 1. Results From Sixty-One Buyer and Seller ReportsMedication StrengthPrice Per Bottle (25–30 Doses)Single Dose PriceAntipsychoticsOlanzapine 10 mg $90–$150 $5–$12Quetiapine 25 mg $40–$50 $3–$8AntidepressantsMirtazapine 15 mg $30–$43 $3–$5Citalopram 10 mg $20–$30Fluoxetine 20 mg $22–$29HypnoticsClonazepam 1 mg $50–$80 $5–$11Diazepam 5 mg $35–$60 $5–$7Zolpidem 5 mg $20–$28 $3–$6Alprazolam 0.5 mg $12–$22Am J Psychiatry 164:2, February 2007 351LETTERS TO THE EDITORajp.psychiatryonline.org0.86) to after (M=4.77, SD=1.48) exercise (t=7.56, df=50,p<0.001). When Ms. A exercised in direct response to self-injurious thoughts, exercise acutely reduced her urge toself-injure, from before (M=3.00, SD=1.87) to after (M=0.15, SD=0.38) exercise in every single instance (t=5.38,df=24, p<0.001). An 8-week follow-up interview revealedsustained improvement in Ms. A’s mental and physicalwell-being

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