and half-life of the BZD. Consider a taper over several weeks or months. Often switching to a long-acting BZD is an effective method in an individual who has serious abuse problems. Tapering is effective in cases of long active benzodiazepines, but not as effective in short-acting benzodiazepines. Example: An individual who has been taking a BZD for 12 weeks, taper for 10- 25% per week (PsychDB, 2021). Common adverse effects of BZDs include respiratory arrest, drowsiness, confusion, headache, syncope, nausea/vomiting, diarrhea, and tremors (Bounds & Nelson, 2022). Central nervous system (CNS) adverse effects include euphoria, diplopia, ataxia, and cognitive impairment with long-term use. BZDs are contraindicated in angle-closure glaucoma and have a black box warning with concomitant use of opioids, which leads to severe
respiratory depression, coma, and death (Bounds & Nelson, 2022). Several groups are at high risk for abuse; caution is essential when prescribing. Individuals who consume large amounts of alcohol often present for treatment of anxiety and insomnia, and there is a high likelihood of abuse (Ciraulo, 2014). Polysubstance use frequently involves benzodiazepines, especially in methadone clinics. Individuals self-medicate for insomnia, anxiety, and withdrawal; additionally, benzodiazepines increase hedonistic effects of methadone (Ciraulo, 2014). Older individuals utilize benzodiazepines more than younger individuals. The greatest concern in this population is risk of falls and cognitive impairment and is not recommended according to Beers’ Criteria (Ciraulo, 2014).
STIMULANT RELATED DISORDERS
Stimulant use disorders include a range of issues related to illicit cocaine, methamphetamine, ecstasy, as well as prescription stimulants, including methylphenidate and amphetamine. Approximately 5 million individuals misused prescription amphetamines ages 12 and older (CDC, 2020). Stimulant use and disorders are associated with physical, psychological, and societal harm. Acute adverse effects can cause acute conditions, including tachycardia, vasoconstriction, and bronchodilation, as well as hyperthermia. Psychological and neurological effects include panic attacks, hostility, paranoia, psychosis, and even violent behavior (SAMSHA, 2020). The highs and lows from these drugs create a binge and crash pattern (NIDA, 2019). Chronic stimulant use can alter brain structures with decreased attention span, confusion, impaired memory, inhibited impulse, and reduced motor skills (SAMSHA, 2020). Stimulant Drugs by Schedules Schedule I Aminorex; methyl-aminorex; methcathinone, animal use only (3,4-Methylenedioxymethamphetamine) commonly known as MDMA. Schedule II Amphetamines, dextroamphetamine; methamphetamine, methylphenidate; phentermine, cocaine.
catecholamines, such as dopamine and norepinephrine, causing hyperstimulation at selected postsynaptic neurons (Richards, 2023). Other non-catecholaminergic central and nervous pathways are hyperstimulated. CNS dopaminergic alterations cause changes in mood, excitation, motor and sensory movements, and appetite. Serotonin contributes to mood changes and psychotic and aggressive behavior (Richards, 2023). This drug is inexpensive and readily synthesized from cheap chemicals, such as pseudoephedrine, anhydrous ammonia, red phosphorus, and hydrochloric acid (Richards, 2023) 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 (SAMSHA, 2020). MDMA is commonly known as ecstasy ( E or X ) and is derived from methamphetamine. MDMA is an indirect sympathomimetic that 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 (Preda, 2018). Adverse effects can include nausea, diaphoresis, anorexia, tremors myoclonus, tics, paresthesia nystagmus, hyperreflexia, hypertension, urinary retention, and ataxia (Preda, 2018). Individuals exposed to these stimulants can develop stimulant use disorder within one week (APA, 2013). Individuals demonstrating a problematic pattern of substance use that leads to significant impairment as manifested by two or more of the following over a 12-month period meet the criteria: ● The stimulant is taken in larger amounts than intended. ● There is a persistent desire or unsuccessful efforts to cut down or control stimulant. ● A great deal of time is spent in activities to obtain the stimulant. ● Craving is an urge to use the stimulant. ● Recurrent stimulant use results in a failure to fulfill work and home obligations. ● Stimulant use continues despite persistent or recurrent interpersonal problems. ● Important social, occupational, or recreational activities are given up or reduced due to stimulant use. ● Recurrent stimulant use occurs in situations when physically hazardous. ● Stimulant use is continued despite the knowledge of having physical or psychological problems that may have been caused or exacerbated by the stimulant. ● Tolerance develops: ○ A need for increased amounts of the stimulant to achieve intoxication. ○ Diminished effect with continued use of the same amount of the stimulant. ● Withdrawal occurs: ○ Characteristic withdrawal syndrome for stimulant. ○ The stimulant is taken to relieve or avoid the withdrawal. (APA, 2013)
Schedule III
Clortermine, not currently in use Phendimetrazine, weight loss; benzphetamine, weight loss.
Schedule IV Schedule V
Diethylpropion, weight loss; Modafinil.
Pyrovalerone. Cocaine is a naturally occurring alkaloid obtained from the Erythroxylon coca shrub (Holstege et al., 2021). After its first use by ancient Peruvians, Freud later proposed cocaine to treat depression, asthma, and cachexia (Holstege et al., 2021). Today, cocaine has limited medical use but is widely used as an illicit drug through inhalation (snorting) and other routes. 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 (Holstege et al., 2021). The drug has numerous adverse health effects on all organ systems (Holstege et al., 2021). Cocaine increases dopamine in the brain, reinforcing drug-taking behaviors that are desensitized over time. Individuals with cocaine use present with many different symptoms. Physical effects of cocaine include constricted blood vessels, dilated pupils, increased body temperature, tachycardia, tremors, or restlessness (NIDA, 2020). Methamphetamine is a highly addictive psychostimulant chemically related to amphetamine. In the central nervous system, amphetamines block presynaptic reuptake of
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