Although data on the prevalence of anticholinergic misuse is scarce, it has been reported among psychiatric patients. Anticholinergic drugs can act as potent indirect dopamine agonists in the limbic system, a mechanism that has been hypothesized to explain their misuse potential among patients. In psychiatric practice settings, the use of typical antipsychotics in conjunction with anticholinergics is common, with the latter mainly used to manage extrapyramidal side effects of the former. Haloperidol is a first-generation (typical) antipsychotic with weak anticholinergic properties that may sometimes be potentiated when it is used in combination with other anticholinergic medications. This combination can induce significant gastrointestinal hypomotility, constipation, and rarely even paralytic ileus. We present the case of a 67-year-old African American male with a history of schizophrenia, benign prostatic hyperplasia, and essential hypertension, who abruptly started misusing benztropine, without any prior history of a substance use disorder. This case highlights the importance of obtaining a detailed history when previously stable psychiatric patients develop acute physical symptoms. It also illustrates the importance of care coordination among care providers and the central role of the psychiatrist in the care of patients with medical comorbidities.

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Objective: The objective of this study was to identify factors associated with leaving against medical advice (AMA) from inpatient substance use detoxification treatment. Methods: A retrospective study of 832 adult patients discharged AMA from an inpatient substance use detoxification unit. Variables from the following factors were included: demographics, substance type, medical history, psychiatric history, tobacco use, detoxification protocol, legal history, and reason for discharge AMA. The outcome variable was days until discharge AMA. Results: For demographics, only increased age was significantly associated with increased days before leaving AMA (B=0.002, SE=0.001, P< 0.01). For detoxification protocol, lorazepam was significantly associated with increased days before leaving AMA (B=0.06, SE=0.03, P< 0.05). For reasons for discharge AMA, only personal obligation was significantly associated with increased days before leaving AMA (B=0.05, SE=0.02, P< 0.01). Medical history, substance type, psychiatric history, tobacco use, and legal history were each not significantly associated with days before leaving AMA. Conclusions: This study identified factors associated with leaving AMA from substance use detoxification units. Clinicians may find it useful to spend more time counseling younger patients to encourage engagement in the entire spectrum of care, including detoxification completion. Patients who cited personal obligations as a reason for leaving AMA stayed more days than those who did not cite personal obligations as a reason for leaving AMA. Clinicians may thus find it useful to assess the urgency of the patient’s personal obligations before initiating detoxification, highlight ways addiction impacts each patient’s personal obligations, and identify available supports in the community to promote treatment completion.

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