Do Not Overlook Bupropion Misuse

See case report by Noe et al

A recent case report by Noe et al¹ described a young man who endorsed bupropion misuse by insufflation and presented with mania following an overdose. This case highlights the need to increase awareness about bupropion misuse.¹ Medications with misuse potential include gabapentinoids, anticholinergics, antipsychotics, and antidepressants.² Bupropion misuse is gaining popularity and is of growing concern.^2,3 Bupropion is approved for the treatment of major depressive disorder, seasonal affective disorder, and smoking cessation.² It is sometimes preferred over selective serotonin reuptake inhibitors due to lack of sexual dysfunction and its weight-neutral profile.⁴ It is also used off label for attention-deficit disorder.⁵ Since most misusers will seek a prescription, prescribers must be aware of its misuse potential and related complications.⁶

Prescribers can suspect bupropion misuse in patients who insist on a bupropion prescription or seek out multiple prescribers.⁴ Red flags of misuse include euphoria, excess energy, insomnia, and previous illicit drug use.⁴ Physical clues manifest as nonhealing skin ulcers, damage to nostrils, and new-onset unexplained seizures.^3,4 In the United States, young males are at particular risk to misuse bupropion.⁷ Street names such as “wellies,” “dubs,” “welbys,” and “barnies” may exhibit regional variations with highest prevalence in California, New England, Utah, and New Mexico.^2,5 Oral bupropion undergoes extensive first-pass hepatic metabolism, which is why recreational users prefer nasal insufflation or injection due to immediate absorption and higher plasma levels, leading to euphoria.⁸ The effect of bupropion when insufflated resembles the effects of cocaine with less intensity,⁸ hence the term poor person’s cocaine as described by Noe and colleagues.¹

Parenteral routes make toxic effects more likely due to increased serum concentration.⁵ These patients are more frequently admitted to critical care compared to other routes.⁵ The main undesirable effects are dose dependent seizures, usually present at a median dose of about 4.4 g.⁹ In terms of cardiovascular effects, bupropion overdose can cause QRS and corrected QT interval prolongation, potentially leading to ventricular dysrhythmias and cardiovascular collapse.⁴

Careful documentation and tracking of bupropion prescriptions is important to identify potential misuse. From a public health perspective, adding bupropion to state prescription monitoring programs could help identify misuse.⁶ In the meantime, prescribers should be aware of the misuse potential of this medication and screen appropriately. Further research is needed to identify the epidemiologic and clinical impact of a poor person’s cocaine in high risk populations.

Article Information

Published Online: April 30, 2024. https://doi.org/10.4088/PCC.23lr03685
© 2024 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2024;26(2):23lr03685
Submitted: December 16, 2023; accepted January 19, 2024.
To Cite: Kaur J, Modesto-Lowe V, León-Barriera R. Do not overlook bupropion misuse. Prim Care Companion CNS Disord. 2024;26(2):23lr03685.
Author Affiliations: Connecticut Valley Hospital, Middletown, Connecticut (Kaur); Hartford Behavioral Health, Hartford, Connecticut (Modesto-Lowe); Department of Psychiatry, University of Connecticut, Farmington, Connecticut (Modesto-Lowe); School of Health Sciences, Quinnipiac University, Hamden, Connecticut (Modesto-Lowe); Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (León-Barriera).
Corresponding Author: Jasleen Kaur, MD, Connecticut Valley Hospital, Middletown, CT (Jasleen.Kaur@ct.gov).
Relevant Financial Relationships: None.
Funding/Support: None.