Hydroxyzine

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Hydroxyzine

Common Trade Names: Atarax, Vistaril, Alamon, Aterax, Durrax, Tran-Q, Orgatrax, Quiess, Tranquizine, Equipose, Masmoran, and Paxistil

Other Names: UCB-4492, 2-[2-[4-[(4-chlorophenyl)-phenylmethyl]piperazin-1-yl]ethoxy]ethanol

It can also be used for anxiety and tension. Hydroxyzine comes in tablets or capsules in 10, 25, 50, and 100mg formulations.

Hydroxyzine is not generally considered an addictive substance and many doctors prescribe it for its anxiety-managing properties, but when used in conjunction with other substances, individuals can become psychologically dependent on it. If you know someone who is misusing hydroxyzine, it’s a good idea to take note of the signs and symptoms of substance use disorder. This way, you can readily identify when the drug is being used incorrectly, and seek out the treatment needed to prevent the addictive behavior from escalating.

A Brief History of Hydroxyzine

Hydroxyzine was first synthesized in 1956 by the pharmaceutical company Union Chimique Belge. Soon after, it was approved for sale in the United States. In 2018, hydroxyzine ranked 78th among the most commonly prescribed medications in the country, with more than 10 million documented prescriptions.

How Does Hydroxyzine Work in the Human Body

Hydroxyzine is a derivative of piperazine, an anthelminthic drug used in the treatment of intestinal roundworm infections in humans. Its antihistaminic effects can be attributed to its metabolite cetirizine, a potent histamine receptor antagonist and selective inhibitor of peripheral H1 receptors. Cetirizine binds to H1-receptor sites on the effector cell surface, functionally blocking the binding of histamine. Hydroxyzine also has the ability to suppress certain subcortical regions of the brain which gives it its sedative properties. Lastly, hydroxyzine also functions as an anticholinergic and can thereby act as an antiemetic.

Hydroxyzine is a first-generation antihistamine primarily used to treat nausea and itchiness. Its sedative properties also render it effective against anxiety, tension, and mild sleeping disorders. Because hydroxyzine belongs to the piperazine class of antihistamines, its usefulness is better demonstrated in these conditions rather than those of allergic rhinitis or coryza.

Hydroxyzine is contraindicated in patients with a history of documented hypersensitivity to the medication or to its related products, including other antihistamines like cetirizine and levocetirizine. Caution must be observed when used concomitantly with medications known to prolong QT interval, such as quinidine, amiodarone, and procainamide.

How Is Hydroxyzine Taken or Administered?

Hydroxyzine is available as tablets or capsules which can be bought in 10, 25, 50, and 100mg formulations. It can also come as an oral suspension or syrup with 10mg/5mL dosing, and as a solution with 25 or 50mg/mL formulations for intravenous injection. The recommended adult oral dose of hydroxyzine for symptomatic relief of anxiety associated with psychoneurosis is 50-100mg orally every 6 hours or 50-100mg intramuscularly every 4-6 hours. Recommended doses for itching are generally lower than those recommended in the treatment of anxiety and tension, with most physicians prescribing 25mg orally or intramuscularly to be taken every 6-8 hours. Most hydroxyzine formulations require a prescription and are not available over the counter.

What Are the Immediate and Long-Term Effects of Hydroxyzine Abuse?

Hydroxyzine has anticholinergic properties, and overdose of hydroxyzine can lead to several adverse effects related to its anticholinergic actions, including:

  • Difficulty in urination (dysuria)
  • Difficulty swallowing (dysphagia)
  • Constipation
  • Double vision (diplopia)

As an antihistamine, common side effects of hydroxyzine intoxication include:

  • Sedation
  • Confusion or dizziness
  • Blurred vision
  • Increased heart rate and palpitations
  • Abdominal disturbances, such as constipation
  • Headache

Hydroxyzine can also worsen glaucoma as it increases the risk for angle closure. Use of hydroxyzine among patients with glaucoma must therefore be closely supervised. Rarely, hydroxyzine can also cause acute generalized exanthematous pustulosis (AGEP), a drug-related skin reaction characterized by an acute onset of small and superficial pustules. AGEP generally resolves spontaneously within two weeks.

Signs of Hydroxyzine Use Disorder

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) Criteria for Substance Use Disorders (SUD) lists four main categories of pathological set of behaviors related to drug abuse, including abuse of hydroxyzine:

  1. Impaired control
  2. Social impairment
  3. Risky use
  4. Pharmacological indicators (tolerance and withdrawal)

These categories cover all 11 criteria for the diagnosis of SUDs:

Impaired control

  1. Taking the substance in larger amounts or for longer than intended
  2. Wanting to reduce or stop using the substance, yet being unsuccessful
  3. Spending excessive amount of time getting, using, or recovering from use of the substance
  4. Intense cravings and urges to use the substance

Social impairment

  1. Drug use causing problems with work, school, or family obligations including absenteeism, poor school performance, or failure to meet household responsibilities
  2. Continued use despite having interpersonal or relationship problems
  3. Giving up important social, occupational, or recreational activities because of substance use

Risky Use

  1. Repeated use of substances in physically dangerous situations, such as while driving a vehicle
  2. Continuing to use, despite causing or worsening physical and psychological problems

Physical tolerance

  1. Needing more of the substance to achieve the desired effect (tolerance)
  2. Development of withdrawal symptoms, which can be relieved by taking more of the substance (withdrawal)

Unlike other anxiolytics, hydroxyzine is generally not dependence-forming and is largely considered nonaddictive. However, it could be taken to potentiate other substances, making it potentially addictive from a psychological standpoint. Any attempts to take hydroxyzine that go beyond the prescriptive bounds set by a medical professional could constitute a symptom of substance use disorder.

Rehab and Treatment for Hydroxyzine Use Disorder

Detoxification. The detox process for hydroxyzine abuse is generally similar to that of other substances. The most important step of the detox process is a complete assessment of the individual’s condition in order to determine the most appropriate treatment setting and programs to initiate. It includes the examination of the patient’s blood to confirm the presence and concentration of the substance of interest, in this case hydroxyzine. It also involves a series of interviews that aims to screen coexisting medical and psychiatric conditions to help guide the treatment approach.

The stabilization phase of the detox process involves the use of various pharmacological, psychosocial, and behavioral interventions to assist the patient through acute intoxication and withdrawal to achieve a substance-free state. As of now, there is no FDA-approved medication indicated in the treatment of hydroxyzine abuse. A pharmacologic approach more relevant to hydroxyzine would be to start tapering off doses or replace hydroxyzine with a drug that has similar efficacy and safety profile, but with less risk for addiction. Many psychosocial interventions may also be initiated in this stage to jumpstart the withdrawal process. In addition, milieu therapy is also introduced in this stage. Milieu therapy is a form of group therapy that focuses on developing healthy coping skills and correcting maladaptive behaviors through active participation in a safe and structured community.

The last step in the detox process is fostering entry into treatment. Here, patients are being mentally and emotionally prepared before entry into an addiction treatment program. It is important to emphasize the value of completing or finishing the program, especially to patients who have a history of failing to follow up. A written treatment contract is commonly provided at this time, to encourage adequate follow up in the continuum of care. This contract is not legally binding and is voluntarily signed by patients at the beginning of treatment.

The detoxification process is a general approach to hydroxyzine abuse treatment. There are several treatment options that may be incorporated in the detox process, and these are available in either an inpatient or outpatient setting. Some of these will be discussed below.

Counselling. Counselling is a form of psychotherapy where either a trained counsellor or a recovered substance abuse victim helps uncover and address possible difficulties in the rehab process, which may include a client’s personal feelings and circumstances. In substance abuse rehab, counselling can promote compliance to the treatment program and reduce relapse rates by providing or teaching healthier options to cope with relapse triggers. Counselling has long been established as a vital part of the rehab process, and effective counselling leads to significant reductions in drug use.

Psychotherapy. Psychotherapy comes in various forms, each of which uses a different and specialized approach that aims to provide resolutions to certain problem areas. For example, cognitive-behavioral therapy (CBT) is a form of psychotherapy that helps people identify and change maladaptive and destructive behavioral patterns and come up with more appropriate coping mechanisms. CBT includes treatment strategies such as relapse prevention, aversion therapy, and contingency contracting. In contrast, psychodynamic therapy emphasizes the importance of self-awareness and how a deep sense of self-awareness can positively contribute to a person’s desire to change negative behaviors.

Outpatient treatment. There is also an outpatient treatment option available for people who want to receive treatment on a part-time basis. Outpatient treatment allows clients to carry out their daily activities while undergoing rehab. Outpatient treatment involves the use of combination therapies such as the ones mentioned above. The advantage of having outpatient treatment is that clients will be able to continue to uphold personal and social responsibilities while maintaining compliance to their treatment program. Outpatient treatment may be more appropriate for individuals with less severe withdrawal symptoms and whose adherence to the program can be guaranteed.

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