LETTERS
Use of Aripiprazole in
Treatment of Cannabis
Dependence in a Patient
Presenting With Borderline
Personality Disorder
To the Editor: Aripiprazole is the first
partial-agonist dopaminergic anti-
psychotic, with activity on dopamine
D2/D3 receptors and a low side-
effect profile. As defined in the
DSM-IV-TR,1 Borderline Personality
Disorder (BPD) is a persistent and
highly disabling mental disorder that
is characterized by patterns of un-
stable relationships, self-image, and
affect; and marked impulsiveness;
often complicated by co-occurring
Substance Use Disorders (SUD), in-
cluding abuse of cannabis.
We report the case of a 32-year-old
Caucasian woman with a BPD (first
diagnosed 8 years ago) and a canna-
bis abuse disorder (for 10 years; 6–8
cigarettes daily). She suffered from
spastic paraparesia caused by a con-
genital medullar dysplasia, and
explained her cannabis abuse as
caused by pain related to her
medullar disease and anxiety due to
her BPD. During her last hospitali-
zation in our psychiatric unit, for
depression and suicidal behavior,
she wanted to stop the cannabis use,
which was increasing and becoming
problematic in her daily life.
Therapeutic modification was
necessary, but not easy because of
her heavy pain treatment, involving
a combination of gabapentin
1,200 mg/day, baclofen 30 mg/day,
tramadol 37.5 mg/day, paracetamol
975 mg/day, and tetrazepam 50 mg
on demand, and her BDP treatment,
marked by a combination of
J Neuropsychiatry Clin Neurosci 24:2, Spring 2012
oxazepam 100 mg/day, fluoxetine
40 mg/day, valpromide 600 mg/day,
and zopiclone 7.5 mg at night. Urine
screen for tetrahydrocannabinol was
initially positive, and we then mea-
sured responsiveness to aripiprazole
for abstinence from cannabis by this
test and clinic examination. The
patient was started on aripiprazole at
a dose of 10 mg/day; and valpromide
was decreased and stopped after
5 days.
The aim of our treatment was to
obtain a significant improvement of
affective symptoms, impulsivity, and
cannabis dependence, without
somatic pain increase. Affective
symptoms and impulsivity improved
after the first week of hospitalization,
and the patient had no more craving
for cannabis after 13 days.
A 9-month follow-up of our pa-
tient showed that she has wholly
stopped cannabis consumption, and
presently shows better functional
status. She has not consumed alcohol
or other drugs since, and has not
developed affective or other BPD
symptoms. Her impulsivity and af-
fective instability have significantly
decreased.
In this case, gabapentin and
baclofen have been administered for
years. Both are thought to be
effective against SUD, through
their GABAergic action.2 However,
they appeared to be inefficient in
this case before the addition of
aripiprazole.
The pharmacological action of
aripiprazole is as a partial agonist
effect on dopamine D2 receptors in
the nucleus accumbens (NA). These
receptors are also involved in
addictive behavior when stimulated
by dopamine.3 Moreover, BPD
showed greater m-opioid receptor
concentration in NA and
endogenous opioid system
deactivation in the left NA.4 A recent
Cochrane review indicates some
beneficial effects with second-
generation antipsychotics in the BPD
treatment.5
We think that aripiprazole has
helped to treat our patient’s
addictive and psychiatric symptoms
of affective and behavioral
dyscontrol marked by impulsivity
and craving. New research need to
be conducted, and we may expect
promising results with aripiprazole,
especially on BPD patients with SUD,
and this maybe a new treatment for
cannabis addiction.
Pierre Alexis Geoffroy
Benjamin Rolland
Dewi Guardia
Frederique Warembourg
Olivier Cottencin
Lille, France
References
1. American Psychiatric Association:
Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition. Washington, DC,
American Psychiatric Association, 1994
2. Leggio L, Kenna GA, Swift RM: New
developments for the pharmacological
treatment of alcohol withdrawal syndrome:
a focus on non-benzodiazepine GABAergic
medications. Prog Neuropsychopharmacol
Biol Psychiatry 2008; 32:1106–1117
3. Pilla M, Perachon S, Sautel F, et al: Selective
inhibition of cocaine-seeking behaviour by
a partial dopamine D3 receptor agonist.
Nature 1999; 400:371–375
4. Prossin AR, Love TM, Koeppe RA, et al:
Dysregulation of regional endogenous
opioid function in borderline personality
disorder. Am J Psychiatry 2010; 167:925–933
5. Stoffers J, Völlm BA, Rücker G, et al:
Pharmacological interventions for
borderline personality disorder. Cochrane
Database Syst Rev 2010; CD005653:CD005653
http://neuro.psychiatryonline.org E37