|Year : 2012 | Volume
| Issue : 1 | Page : 43-45
Addiction to vitamin D: Unusual, unexpected substance abuse
Bharti Kalra1, Yatan Pal Singh Balhara2, Sanjay Kalra1
1 Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, Haryana, India
2 Department of Psychiatry, Lady Hardinge Medical College, New Delhi, India
|Date of Web Publication||3-Dec-2012|
Bharti Hospital, BRIDE, Wazir Chand Colony, Kunjpura Road, Karnal, Haryana
Source of Support: None, Conflict of Interest: None
This case reviews the history and findings of a young patient with vitamin D deficiency, successfully treated with vitamin D, who became addicted to injectable calcitriol. To the best of our knowledge, this is the first report of such an occurrence in the world literature.
Keywords: Addiction, calcitriol, vitamin D
|How to cite this article:|
Kalra B, Balhara YP, Kalra S. Addiction to vitamin D: Unusual, unexpected substance abuse. J Acad Med Sci 2012;2:43-5
| Case Report|| |
History and Investigations
AG, a 32-year-old lady, presented to the metabolic outpatient department with complaints of generalized weakness, aches and pains, and difficulty in squatting/getting up from squatting position. She had just recovered from her second abortion, which followed three full-term pregnancies. She was a pure vegetarian and would wear traditional whole-body wrap around Indian costume (sari) everyday. Owing to her dressing and lifestyle, sunlight exposure would be less than 5 minutes a day; limited to the face, hands, and forearms. She was fair complexioned and did not volunteer history of using sunscreens, anticonvulsants, antitubercular drugs, calcium, or vitamin D supplement. Menstrual history did not reveal any abnormality.
Investigations revealed normal hematological and biochemical parameters, including renal, hepatic, and thyroid tests. X-rays of the pelvis and lumbar sacral spine were unremarkable.
A serum 25-hydroxy vitamin D test revealed severe vitamin D deficiency (<2.6 ng/ml, by EIA/ELISA; normal range >30 ng/ml).
AG was treated with oral calcium 1 g twice daily and oral cholecalciferol 60,000 U twice weekly. Relatively high doses were used because of the severity of her symptoms and the extremely low serum vitamin D levels. The patient did not respond well to the treatment as her symptoms continued to persist despite a month's therapy. A month later she was switched to intravenous calcitriol, administered once weekly. This preparation of vitamin D is approved for use in renal osteodystrophy  and is not used as the usual therapy to correct vitamin D deficiency in renally competent patients. In this case, it was prescribed by the treating endocrinologist in view of refractoriness of clinical symptoms and dissatisfaction of the patient in spite of having received an adequate trial (8×60,000 U) of oral cholecalciferol and the extremely low serum 25 (OH) vitamin D level. A once-weekly dose of 0.25 μg was chosen on empirical basis. Although the main aim of treatment is to suppress high parathormone level, serum parathormone could not be done before starting this therapy due to logistic reasons. 
AG responded dramatically to this treatment. Within 2 weeks, her muscle pains and weakness had disappeared, her mobility improved, and she was able to perform routine household and personal care activities.
The same treatment (once-weekly injectable calcitriol) and oral calcium were continued for 3 more months. Because of the symptomatic recovery, numerous attempts were made by the treating doctor to shift the patient to oral vitamin D from intravenous calcitriol. To our surprise, she would vehemently refuse to accept our advice as she felt very satisfied with the current therapy. This reluctance to shift to oral medication would persist in spite of the repeated attempts to explain the rationale behind such a change. She would argue that she would be asymptomatic only if she continues to get the injection. Evidence of normalization of biochemical parameters in form of serum calcium, phosphorus, and alkaline phosphatase levels would also be of no help in this regard. Even delay of a few days to the scheduled dose of injection calciriol would lead to emergence of irritability, sleeplessness, and unexplained bodily symptoms such as bone pains. Consequently, she would try her best to be very regular with the calcitriol injection. While introduction of injectable therapy was a challenging decision in itself, we were facing even a bigger challenge now-to stop inappropriate and unjustified use of a therapy. Such use was beyond clinical justification and could potentially lead to adverse effects. Serum calcium, phosphorus, and alkaline phosphatase were monitored at irregular intervals and remained within normal limits.
AG continued to receive the injections. Six months into therapy, she developed recurrence of generalized bone pains, without any objective signs of myopathy. A repeat serum vitamin D estimation revealed a 25 (OH) vitamin D level of 123 ng/ml (toxic level > 100 ng/ml).This was not accompanied by hypercalcemia (serum calcium 9.8 mg%) or hypophosphatemia (serum phosphorus 3.9 mg%). None of the classic symptoms of vitamin D intoxication (nausea, headache, thirst, and polyuria)  were reported by AG even on detailed questioning. Her sensorium was normal.
Serum paratharmone and 1,25 dihydroxy Vitamin D could not be measured because of resource limitations.
| Management|| |
The subject was counselled regarding the clinical situation and potential adverse effects of overtreatment with vitamin D. She agreed to stop injectable calcitriol and oral calcium for few weeks.
However, her husband reported a few months later that she has continued to take the drugs on her own, fearing that she would become worse if she stopped vitamin D.
She was able to buy the injection from chemists, based on her old prescriptions. She continued to take the injection in spite of repeated counselling. Psychiatric intervention was refused by both the patient and her husband-a result of stigma toward psychiatric care in population at large.
The self-medication carried on until (mercifully) the drug was withdrawn from the local market by the manufacturer, for unknown reasons. She tried her best to search for the drug in neighboring cities but was unable to procure it.
She gradually came to terms with the situation. However, she continues to take oral cholecalciferol 60,000 U once a month. Serum biochemistry, including 25 (OH) vitamin D, is performed at irregular intervals and are normal as of writing this report.
| Discussion|| |
Vitamin D deficiency is endemic in India  and is usually treated with oral cholecalciferol. The active metabolites of vitamin D are used in patients with renal or hepatic impairment or in clinical situations where a quick response to therapy is necessary. 
As awareness grows regarding the extraskeletal manifestations of vitamin D deficiency and its role in metabolic syndrome,  the use of this drug is bound to grow. Use of any drug, however, may also associate with misuse. Patients often get addicted to various medicinal products for various reasons.
An addiction is defined by the American Society of Addiction Medicine as follows:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in the individual pursuing reward and/or relief by substance use and other behaviors. The addiction is characterized by impairment in behavioral control, craving, inability to consistently abstain, and diminished recognition of significant problems with one's behaviors and interpersonal relationships. Like other chronic diseases, addiction involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. 
Diagnostic and Statistical Manual of Mental Disorders (DSM) IV defines drug dependence as a syndrome of physiological, cognitive, and behavioral features associated with use of a psychoactive substance leading on to development of clinically significant distress and dysfunction. 
Interestingly, psychoactive drugs are not the only drugs that are known to be abused. Drugs that do not act primarily at the central nervous system are also known to lead to abuse and dependence. In fact, abuse of such formulations finds a special mention in the International Statistical Classification of Diseases (ICD)-10. Such conditions are listed in chapter F55 under the rubric "abuse of non-dependence-producing substances." It includes medications such as antidepressants, laxatives, and analgesics that can be purchased without medical prescription, such as aspirin and paracetamol. 
To begin with, the medication might have been medically prescribed. However, prolonged, unnecessary, and often excessive dosage develops. The persistent and unjustified use of these substances is usually associated with unnecessary expense and is sometimes marked by the harmful physical effects of the substances. The abuse is facilitated by the free availability of the substances without medical prescription. Attempts to discourage or forbid the use of the substances are often met with resistance on part of the patient.
The case of AG fits the typical description given in ICD-10. Her injection calciriol use stared as a medical prescription for a valid medical condition. The use continued beyond the point of clinical relevance. She would not agree to the recommendations to stop the medication in spite of evidence of clinical and biochemical recovery and later on emergence of adverse effects as well. Substance seeking was evident by frantic efforts to procure the substance without prescription-a behavior put to an end by the logistic factors only.
There is no biological explanation for this case of vitamin D abuse observed in the current case. It is not associated with feelings of euphoria or relief of the negative affective states-a feature of the psychoactive substances of abuse. Yet the patient continued its abuse and ended up having adverse effects.
This case serves as a cautionary tale for endocrinologists and patient alike, especially in an era when vitamin D supplementation is becoming more and more popular. The endocrinologists should consider the possibility of abuse of the prescribed medications if the patient resists attempts to modify the regimen for non-clinical reasons. Such patients could be helped by comprehensive psychiatric evaluation and care.
| References|| |
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