Keywords
Varenicline; Intoxication; Involuntary intoxication; Pathological intoxication; Criminal responsibility; Behavioral toxicity
Abstract
The use of varenicline as an aid to smoking cessation is ordinarily safe and effective. Its mechanism of action includes blockade and partial agonism of central nicotine receptors, thus relieving the user of nicotine withdrawal while providing release of dopamine in the nucleus accumbens. A small fraction of users develop neuropsychiatric effects, which can include changes in mood (including depression and mania), psychosis, hallucinations, paranoia, delusions, homicidal ideation, aggression, hostility, agitation, anxiety, and panic, as well as suicidal ideation, suicide attempt, and completed suicide. When the toxicity includes aggression toward others or dangerous acts that run afoul of the law, the patient may have a defense of involuntary (pathological) intoxication. This article reviews reported cases and scenarios that have utilized a causal relationship between use of varenicline and otherwise unaccountable behaviors. Unlike voluntary intoxication, involuntary intoxication can be used as a defense against criminal charges. The criminal defendant must prove that the drug was used for ordinary medical reasons (not to become intoxicated), that there was a causal relationship between ingestion of the drug and the behavioral effect, and that, at the time of the criminal act, the defendant did not know that his/her actions were wrong. In essence, it is an insanity defense without risk of subsequent civil commitment. Since some physicians and patients with existing mental disorders are afraid of behavioral effects of varenicline, there could be a chilling effect on prescribing. Ethical concerns are addressed.
Citation
Weiss KJ (2020) Varenicline and Involuntary Intoxication: Forensic Implications. SM J Forensic Res Criminol 4: 5. doi: https://dx.doi. org/10.36876/smjfrc945423.