Case study: cerebrovascular parkinsonism with levodopa addiction

Levodopa (L-dopa), the mainstay of treatment for idiopathic Parkinson’s disease (IPD), has a mild stimulant effect and may cause agitation, restlessness, and euphoria even in normal subjects. It is associated with a well documented withdrawal syndrome consisting of confusion, muscular pain, and rigidity. This can progress to involve symptoms comparable with neuroleptic malignant syndrome, including pyrexia and increased creatine kinase.1 There is now good evidence that L-dopa is addictive, and there are many case reports of patients with IPD who seek to increase their L-dopa dose to high levels because of psychological dependence rather than therapeutic benefit.2 The largest series of such patients3 suggested that L-dopa dependence results in paranoia, hypomania, hypersexuality, and euphoria associated with weight loss and severe dyskinesias. Many of the behavioural changes are similar to those seen in amphetamine or cocaine abusers and have been termed “hedonistic homeostatic dysregulation”.

CASE REPORT

An 81 year old woman had been diagnosed with Parkinson’s disease 10 years before. She reported a five year history of extremely frequent but intermittent severe pain and stiffness in all her muscles, resulting in severe disability and distress. Her general practitioner had tried amitriptyline and baclofen with no effect. The only effective treatment was Madopar, a combination levodopa …