Psychological and neurological effects include panic attacks, hostility, paranoia, psychosis, and even violent behavior. 41 Stimulant-involved overdoses have risen in the last decade. The psychostimulant- involved death rate increased by over 300%. 42 Stimulant use and disorders are associated with a range of physical, psychological, and societal harms. The highs and lows from these drugs create a binge and crash pattern. Chronic stimulant use can alter brain structures with decreased attention span, confusion, impaired memory, inhibited impulse, and reduced motor skills. Common Stimulants of Abuse Cocaine is a naturally occurring alkaloid obtained from the Erythroxylon coca shrub. It was first used by ancient Peruvians; psychologists such as Freud later proposed cocaine as a treatment for depression, asthma, and cachexia in the early 20th century. Today, cocaine has limited medical use as a treatment for epistaxis but is widely used as an illicit drug through inhalation (snorting), smoking, and other routes, including parenteral use. When snorted, the onset of action is within 5 minutes and typically peaks within 30 minutes. The half-life of cocaine is 30-90 minutes, and it can be absorbed across any mucosal surface including respiratory, gastrointestinal, and genitourinary tracts. 44 Cocaine has a local anesthetic affect by blocking presynaptic reuptake of the neurotransmitters norepinephrine and dopamine. Cocaine also increases the quantity of neurotransmitters at the postsynaptic receptor sites. The resultant activation of the sympathetic nervous system produces an acute rise in arterial pressure, tachycardia, and a predisposition to ventricular arrhythmias and seizures. Sympathetic activation also may result in mydriasis, hyperglycemia, and hyperthermia along with tremors and restlessness. Behavioral side effects include agitation, paranoia, hallucinations, delusions, and violence, as well as suicidal and homicidal thinking. They can be primary to the drug’s effect or secondary to exacerbation of comorbid psychiatric disorders. 45 Methamphetamine is a highly addictive psychostimulant chemically related to amphetamine. In the central nervous system, amphetamines block presynaptic reuptake of catecholamines, such as dopamine and norepinephrine, causing hyperstimulation at selected postsynaptic neurons. Other noncatecholaminergic central nervous pathways are hyperstimulated. CNS dopaminergic alterations cause changes in mood, excitation, motor and sensory movements, and appetite. Serotonin effects are thought to contribute to
mood changes and psychotic and aggressive behavior. Methamphetamine is inexpensive and readily synthesized from cheap chemicals, such as pseudoephedrine, anhydrous ammonia, red phosphorus, and hydrochloric acid. 46 Snorting or smoking methamphetamine causes excessive tooth and gum disease (meth mouth); snorting methamphetamine causes anosmia and deviated septum; smoking this drug causes lung and airway damage. In recent years, methamphetamine- involved overdoses have been increasing in the United States across many demographic groups. 47 MDMA , commonly known as ecstasy ( E or X ), is derived from methamphetamine. MDMA is an indirect sympathomimetic which stimulates the release and inhibits the reuptake of epinephrine, norepinephrine, and dopamine. MDMA can cause tachycardia, elevated blood pressure, mydriasis, increased energy, anorexia, and increased concentration. Adverse effects can include nausea, diaphoresis, anorexia, myoclonus tremors, tics, paresthesia, nystagmus, hyperreflexia, hypertension, urinary retention, and ataxia. 43 Bath salts (synthetic cathinones) are designer drugs derived from naturally occurring amphetamine analogs found in the Catha edulis plant. Cathinones stimulate the release and block the reuptake of norepinephrine, dopamine, and serotonin at synapses in the brain, producing stimulant effects similar to cocaine and amphetamines. Commonly abused substituted cathinones include mephedrone, methylenedioxypyrovalerone, and methylone, although the composition in bath salts sold for use by abusers varies widely. Stimulant Intoxication As in other situations, behavioral and psychological changes occur in stimulant intoxication. Auditory hallucinations or paranoid ideations may be prominent. Signs and symptoms of intoxication develop during or shortly after use, including • Tachycardia or bradycardia • Pupillary dilation • Elevated or lowered blood pressure • Perspiration or chills • Nausea or vomiting • Evidence of weight loss • Psychomotor agitation or retardation • Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias • Confusion, seizures, dyskinesias, dystonias, or coma
Stimulant intoxication is not a criterion for substance use disorder. A specific antidote does not exist, and supportive treatment is recommended in the case of an overdose. The careful use of benzodiazepines is frequently prescribed to counteract the hypervigilance and agitation seen in acute stimulant use/overuse. Stimulant Withdrawal The essential feature of stimulant withdrawal is characterized by the development of dysphoria along with • Fatigue • Vivid, unpleasant dreams • Insomnia or hypersomnia • Increased appetite • Psychomotor retardation or agitation Bradycardia is often present and can be a measure of withdrawal. Additionally, anhedonia and drug craving can also be present. Withdrawal lasts up to 1-3 weeks. Pharmacotherapeutics utilized in withdrawal including trazadone, benzodiazepines, and neuroleptics as part of a comprehensive treatment plan. Cocaine washout syndrome is a clinically recognized syndrome and includes extreme fatigue, sleepiness, and depression thought to be related to depletion of catecholamine reserves. Treatment is supportive in nature. Treatment of Stimulant Use Disorder Evidence is lacking for pharmacological treatment of stimulant use disorder. Interventions with multiple treatments including antidepressants, anticonvulsants, disulfiram, and opioid agonists have been studied and there currently is insufficient evidence to support their routine use. The strongest evidence-based approach for the treatment of stimulant use disorder remains behavioral interventions including contingency management. Contingency management includes the strategy of rewarding positive behavior and reaching a specific achievement such as abstinence, confirmed by a negative urine drug test. Rewards can be monetary in the form of a gift card or voucher. 136 For cocaine use disorder, topiramate, a gamma-aminobutyrate (GABA) modulator, has shown some value when paired with psychosocial treatments such as contingency management. 137 Contraindications to topiratmate include kidney stones and glaucoma. Bupropion and naltrexone administered in combination have shown some promise in the treatment of methamphetamine use disorder. 138 BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 2 ON THE NEXT PAGE. Hallucinogen-Related Disorders A long history of using hallucinogenic plants exists among humans for ceremonial and religious purposes. It is difficult to define psychoactive drugs that are so diverse in chemical structures. Hallucinogens are a group of drugs that alter an individual’s awareness of surroundings, emotions, and thoughts.
Table 4. Stimulant Drugs by Schedules 43
Schedule I
Aminorex; methyl-aminorex; methcathinone, animal use only;3,4- Methylenedioxymethamphetamine, commonly known as MDMA Amphetamines, dextroamphetamine; methamphetamine, methylphenidate; cocaine Clortermine, not currently in use; phendimetrazine, weight loss; benzphetamine, weight loss
Schedule II
Schedule III
Schedule IV Schedule V
Diethylpropion, weight loss; Modafinil, Phentermine
Pyrovalerone
8
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