The Use of Prazosin in Treatment of Drug Dreams in Adolescents with Substance Use Disorder: Two Case Reports

Abstract

~ Nightmares are psychologically distressing events that may cause significant effects on mental health, physical well-being and overall quality of life, in addition to their negative impact on quality and duration of sleep. Drug dreams are a variant of nightmares and a known phenomenon in addiction medicine, and have been studied as a potential causative factor in relapse of substance use. Recent studies have noted that addictive behaviors and drug dreams share a similar neurobiological pathway, and that certain neurotransmitters, most notably those of the noradrenergic system, may underlie these complex processes. This has led to the theory that alleviation of drug dreams and suppression of involved neurocircuits may potentially reduce subsequent craving and relapse in the treatment of substance use disorders, with an important potential agent being the alpha-1 antagonist, prazosin.

Nightmares are psychologically distressing events that may cause significant effects on mental health, physical well-being and overall quality of life, in addition to their negative impact on quality and duration of sleep. Drug dreams (DD) are a variant of nightmares and a known phenomenon in addiction medicine, and have been studied as a potential causative factor in relapse of substance abuse. Yee, et al. (2004)¹ found that DD were a negative prognostic indicator due to their association with increased craving and subsequent relapse, a finding that was parallel to that of Christo and Franey (1996).² Furthermore, DD have been found to be associated with higher levels of negative affect and craving, particularly in cases of “active” drug use (Tanguay, et al. 2015).³ Prazosin was first approved in the 1970s by the United States Food and Drug Administration for treatment of hypertension, and later recognized as having therapeutic effects in alleviating nightmares in posttraumatic stress disorder (PTSD). While this agent has been well-studied in the literature for PTSD-associated nightmares, there is limited data on its efficacy and suitability in treating “drug dreams”, particularly in the adolescent population.

Prazosin is a lipid-soluble, alpha-1 antagonist that easily crosses the blood-brain barrier and blocks noradrenergic activity in the central nervous system. It is hypothesized that this counteraction of noradrenergic activity is responsible for amelioration of nightmares by way of reducing startle response and disrupting reconsolidation of fear memories (Berardis, et al. 2015).⁴ A systemic review of 12 studies conducted by Kung, et al.⁵ (n = 259) found that prazosin use in PTSD-associated nightmares was associated with a small but positive effect in nightmare reduction, but found insufficient data to recommend use of prazosin for non-PTSD-related nightmares. Gopalakrishna, et al.⁶ published a case report of 2 adult patients treated with prazosin during acute psychiatric hospitalization for DD involving substance use, and observed an immediate lack of symptoms upon treatment initiation. This case report presents 2 scenarios in which administration of prazosin to adolescent patients with DD was associated with positive treatment response.

Case 1 - Patient T is a 16-year-old Caucasian male who was seen in the outpatient psychiatry clinic for drug dreams. He was recently admitted to a residential treatment program at a juvenile correctional facility and was diagnosed with conduct disorder, adolescent-onset type, moderate; cannabis use disorder, mild and stimulant (cocaine) use disorder, moderate. He denied any previous psychiatric history and reported that the last use of cocaine was about 3 weeks before the appointment. He reported daily distressing dreams about using cocaine for the last 2 weeks and increasingly feeling anxious about these dreams. He was started on Prazosin 1 mg at bedtime and demonstrated good response and tolerability to this medication. He was seen for monthly follow ups for 3 months and reported having no distressing drug dreams.

Case 2- Patient A is a 15-year-old African American male who was recently admitted to a residential treatment facility at a juvenile correctional facility and was seen in the outpatient psychiatry clinic. He was diagnosed with Major depressive disorder, single episode, moderate; conduct disorder, onset in childhood, severe; cannabis use disorder, moderate and stimulant (amphetamine type) use disorder, moderate. He reported that his last use of methamphetamine was about 4 weeks before the clinic appointment and he was having distressing dreams about injecting methamphetamine 4–5 nights per week for the last 2 weeks. He was started on sertraline 25 mg daily for depression and prazosin 1 mg at bedtime for drug dreams. At the 1 month follow up he reported that the frequency of drug dreams had decreased to 1–2 nights per week and dose of Prazosin was increased to 2 mg at bedtime at that visit. He was then seen 3 more times for monthly follow up visits and reported a complete resolution of drug dreams.

Based on these 2 cases Prazosin demonstrated good response and tolerability for the treatment of drug dreams. More research is needed to validate these findings.