Stimulant use disorder - Revision history

Aidan: /* Chronic treatment */ updated based on recent systematic review

2020-07-15T00:36:41Z

Chronic treatment: updated based on recent systematic review

← Older revision		Revision as of 00:36, 15 July 2020
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	===Chronic treatment===		===Chronic treatment===

	*There is no good evidence in favour of any pharmacologic treatment, and medication-based treatment is generally not recommended		*There is no good evidence in favour of any pharmacologic treatment, and medication-based treatment is generally not recommended[[CiteRef::siefried2020ph]]
	**Stimulants may be helpful[[CiteRef::tardelli2020pr]]~~. Lisdexamfetamine (Vyvanse) is currently under investigation at doses of 150 mg to 250 mg daily~~[[CiteRef::~~ezard2018li~~]] ~~(compared~~ to a ~~usual maximum of 70 mg)~~		**Stimulants may be helpful[[CiteRef::tardelli2020pr]][[CiteRef::siefried2020ph]], including [[dexamphetamine]] and [[methylphenidate]]
			***[[Lisdexamfetamine]] (Vyvanse) is currently under investigation at doses of 150 mg to 250 mg daily[[CiteRef::ezard2018li]] (compared to a usual maximum of 70 mg)
⚫	**[[N-acetylcysteine]] ~~may~~ ~~prevent~~ ~~relapse~~[[CiteRef::nocito echevarria2017n-]]
			**Other promising medications include [[naltrexone]] and [[topiramate]]
⚫	**[[Disulfiram]] may treat cocaine use disorders[[CiteRef::2010di]]
			**Other medications that may eventually prove useful include:
	**[[Modafinil]] may be useful[[CiteRef::sangroula2017mo]]
			***[[Buproprion]]
⚫	**~~The~~ ~~following~~ have ~~not~~ been ~~found to be~~ ~~helpful~~: anticonvulsants[[CiteRef::minozzi2015an]][[CiteRef::alvarez2010an]] including topiramate[[CiteRef::singh2016to]], many stimulants[[CiteRef::2013ef]][[CiteRef::2016ps]][[CiteRef::bhatt2016ef]], dopamine agonists[[CiteRef::2015do]], antidepressants[[CiteRef::2011an]][[CiteRef::torrens2005ef]], and antipsychotics[[CiteRef::2016an]]
			***[[Riluzole]]
			***[[Mirtazapine]]
		⚫	***[[N-acetylcysteine]]: unclear if it reduces cravings[[CiteRef::nocito echevarria2017n-]]
		⚫	***[[Disulfiram]]: may treat cocaine use disorders[[CiteRef::2010di]]
		⚫	**Others that have been studied include: anticonvulsants[[CiteRef::minozzi2015an]][[CiteRef::alvarez2010an]] including topiramate[[CiteRef::singh2016to]], many stimulants[[CiteRef::2013ef]][[CiteRef::2016ps]][[CiteRef::bhatt2016ef]] including modafinil, dopamine agonists[[CiteRef::2015do]], antidepressants[[CiteRef::2011an]][[CiteRef::torrens2005ef]], and antipsychotics[[CiteRef::2016an]]
	*The main focus is on psychosocial treatments, including [[contingency management]], [[cognitive behavioural therapy]], [[motivational interviewing]], [[relapse prevention]], and [[psychodynamic therapy]]		*The main focus is on psychosocial treatments, including [[contingency management]], [[cognitive behavioural therapy]], [[motivational interviewing]], [[relapse prevention]], and [[psychodynamic therapy]]
	**Long-term abstinence is around 30 to 50% for people in treatment, with 40-50% dropout rate		**Long-term abstinence is around 30 to 50% for people in treatment, with 40-50% dropout rate

Aidan: /* Chronic treatment */

2020-07-15T00:23:15Z

Chronic treatment

← Older revision		Revision as of 00:23, 15 July 2020
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	*There is no good evidence in favour of any pharmacologic treatment, and medication-based treatment is generally not recommended		*There is no good evidence in favour of any pharmacologic treatment, and medication-based treatment is generally not recommended
	**Stimulants may be helpful[[CiteRef::tardelli2020pr]]		**Stimulants may be helpful[[CiteRef::tardelli2020pr]]. Lisdexamfetamine (Vyvanse) is currently under investigation at doses of 150 mg to 250 mg daily[[CiteRef::ezard2018li]] (compared to a usual maximum of 70 mg)
	**[[N-acetylcysteine]] may prevent relapse[[CiteRef::nocito echevarria2017n-]]		**[[N-acetylcysteine]] may prevent relapse[[CiteRef::nocito echevarria2017n-]]
	**[[Disulfiram]] may treat cocaine use disorders[[CiteRef::2010di]]		**[[Disulfiram]] may treat cocaine use disorders[[CiteRef::2010di]]

Aidan: /* Chronic treatment */

2020-07-14T23:54:25Z

Chronic treatment

← Older revision		Revision as of 23:54, 14 July 2020
Line 90:		Line 90:

	*There is no good evidence in favour of any pharmacologic treatment, and medication-based treatment is generally not recommended		*There is no good evidence in favour of any pharmacologic treatment, and medication-based treatment is generally not recommended
			**Stimulants may be helpful[[CiteRef::tardelli2020pr]]
	**[[N-acetylcysteine]] may prevent relapse[[CiteRef::nocito echevarria2017n-]]		**[[N-acetylcysteine]] may prevent relapse[[CiteRef::nocito echevarria2017n-]]
	**[[Disulfiram]] may treat cocaine use disorders[[CiteRef::2010di]]		**[[Disulfiram]] may treat cocaine use disorders[[CiteRef::2010di]]

Aidan: /* Chronic treatment */ added citations, and treatments that don't work

2020-07-14T23:18:36Z

Chronic treatment: added citations, and treatments that don't work

← Older revision		Revision as of 23:18, 14 July 2020
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	*There is no good evidence in favour of any pharmacologic treatment, and medication-based treatment is generally not recommended		*There is no good evidence in favour of any pharmacologic treatment, and medication-based treatment is generally not recommended
	**[[N-acetylcysteine]] may prevent relapse		**[[N-acetylcysteine]] may prevent relapse[[CiteRef::nocito echevarria2017n-]]
	**[[Disulfiram]] may treat cocaine use disorders		**[[Disulfiram]] may treat cocaine use disorders[[CiteRef::2010di]]
	**[[Modafinil]] may be useful		**[[Modafinil]] may be useful[[CiteRef::sangroula2017mo]]
			**The following have not been found to be helpful: anticonvulsants[[CiteRef::minozzi2015an]][[CiteRef::alvarez2010an]] including topiramate[[CiteRef::singh2016to]], many stimulants[[CiteRef::2013ef]][[CiteRef::2016ps]][[CiteRef::bhatt2016ef]], dopamine agonists[[CiteRef::2015do]], antidepressants[[CiteRef::2011an]][[CiteRef::torrens2005ef]], and antipsychotics[[CiteRef::2016an]]
	*The main focus is on psychosocial treatments, including [[contingency management]], [[cognitive behavioural therapy]], [[motivational interviewing]], [[relapse prevention]], and [[psychodynamic therapy]]		*The main focus is on psychosocial treatments, including [[contingency management]], [[cognitive behavioural therapy]], [[motivational interviewing]], [[relapse prevention]], and [[psychodynamic therapy]]
	**Long-term abstinence is around 30 to 50% for people in treatment, with 40-50% dropout rate		**Long-term abstinence is around 30 to 50% for people in treatment, with 40-50% dropout rate

Aidan: /* Epidemiology */ edited for clarity

2020-07-14T23:02:06Z

Epidemiology: edited for clarity

← Older revision		Revision as of 23:02, 14 July 2020
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	===Epidemiology===		===Epidemiology===

	*~~Second~~-most commonly used illicit ~~substance~~ after marijuana		*Stimulants are the second-most commonly used illicit substances after marijuana

	===Pathophysiology===		===Pathophysiology===

Aidan: /* Background */ formatting

2020-07-10T18:46:36Z

Background: formatting

← Older revision		Revision as of 18:46, 10 July 2020
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	!Routes of administration		!Routes of administration
	\|-		\|-
	\| colspan="4" \|Cocaine		! colspan="4" \|Cocaine
	\|-		\|-
	\|~~&emsp;~~Powder cocaine		\|Powder cocaine
	\| rowspan="3" \|dopamine reuptake inhibitor		\| rowspan="3" \|dopamine reuptake inhibitor
	\| rowspan="3" \|30 to 120 minutes		\| rowspan="3" \|30 to 120 minutes
	\|snorted, but can be mixed with water and injected		\|snorted, but can be mixed with water and injected
	\|-		\|-
	\|~~&emsp;~~Crack cocaine		\|Crack cocaine
	\|smoked, but can be mixed with an acid and injected		\|smoked, but can be mixed with an acid and injected
	\|-		\|-
	\|~~&emsp;~~Freebase		\|Freebase
	\|similar to crack, but may explode when smoked		\|similar to crack, but may explode when smoked
	\|-		\|-
	\| colspan="4" \|Methamphetamine		! colspan="4" \|Methamphetamine
	\|-		\|-
	\|~~&emsp;~~Powder		\|Powder
	\| rowspan="3" \|dopamine reuptake inhibitor, also increases dopamine release		\| rowspan="3" \|dopamine reuptake inhibitor, also increases dopamine release
	\| rowspan="3" \|wide variability, about 10 to 30 hours		\| rowspan="3" \|wide variability, about 10 to 30 hours
	\|snorted or pressed into a pill and taken orally		\|snorted or pressed into a pill and taken orally
	\|-		\|-
	\|~~&emsp;~~Base		\|Base
	\|swallowed or injected		\|swallowed or injected
	\|-		\|-
	\|~~&emsp;~~Crystal		\|Crystal
	\|smoked, dissolved and injected, or snorted		\|smoked, dissolved and injected, or snorted
	\|}		\|}

Aidan: /* Background */

2020-07-10T18:45:49Z

Background

← Older revision		Revision as of 18:45, 10 July 2020
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	==Background==		==Background==

	* A [[substance use disorder]] that includes cocaine (freebase, crack, rock), methamphetamine (crystal meth, meth, crystal, jib, speed, ice, tina, side), and other amphetamine-like substances (including prescription stimulants)		*A [[substance use disorder]] that includes cocaine (freebase, crack, rock), methamphetamine (crystal meth, meth, crystal, jib, speed, ice, tina, side), and other amphetamine-like substances (including prescription stimulants)

	{\| class="wikitable"		{\| class="wikitable"
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	!Routes of administration		!Routes of administration
	\|-		\|-
	\|Cocaine		\| colspan="4" \|Cocaine
	\|decreased dopamine re-uptake
⚫	\|30 to 120 minutes
	\|depends on the form
	\|-		\|-
	\|&emsp;Powder cocaine		\|&emsp;Powder cocaine
			\| rowspan="3" \|dopamine reuptake inhibitor
⚫	\|
		⚫	\| rowspan="3" \|30 to 120 minutes
⚫	\|
	\|snorted, but can be mixed with water and injected		\|snorted, but can be mixed with water and injected
	\|-		\|-
	\|&emsp;Crack cocaine		\|&emsp;Crack cocaine
⚫	\|
	\|
	\|smoked, but can be mixed with an acid and injected		\|smoked, but can be mixed with an acid and injected
	\|-		\|-
	\|&emsp;Freebase		\|&emsp;Freebase
	\|
	\|
	\|similar to crack, but may explode when smoked		\|similar to crack, but may explode when smoked
	\|-		\|-
	\|Methamphetamine		\| colspan="4" \|Methamphetamine
		⚫	\|-
	\|reverses dopamine reuptake, leading to increased excretion
			\|&emsp;Powder
⚫	\|wide variability, about 10 to 30 hours
			\| rowspan="3" \|dopamine reuptake inhibitor, also increases dopamine release
	\|powder can be snorted or pressed into a pill; base can be swallowed or injected; crystal meth can be smoked, dissolved and injected, or snorted
		⚫	\| rowspan="3" \|wide variability, about 10 to 30 hours
			\|snorted or pressed into a pill and taken orally
		⚫	\|-
			\|&emsp;Base
			\|swallowed or injected
		⚫	\|-
			\|&emsp;Crystal
			\|smoked, dissolved and injected, or snorted
	\|}		\|}

	===Epidemiology===		===Epidemiology===

	* Second-most commonly used illicit substance after marijuana		*Second-most commonly used illicit substance after marijuana

	===Pathophysiology===		===Pathophysiology===

	* All stimulants ~~work~~ on the dopamine system		*All stimulants act mainly on the dopamine system

	==Clinical Manifestations==		==Clinical Manifestations==

Aidan at 18:40, 10 July 2020

2020-07-10T18:40:15Z

@@ Line 1: / Line 1: @@
 ==Background==
-*A [[substance use disorder]] that includes cocaine (freebase, crack, rock), methamphetamine (crystal meth, meth, crystal, jib, speed, ice, tina, side), and other amphetamine-like substances (including prescription stimulants)
+* A [[substance use disorder]] that includes cocaine (freebase, crack, rock), methamphetamine (crystal meth, meth, crystal, jib, speed, ice, tina, side), and other amphetamine-like substances (including prescription stimulants)
 {| class="wikitable"
@@ Line 42: / Line 34: @@
 |powder can be snorted or pressed into a pill; base can be swallowed or injected; crystal meth can be smoked, dissolved and injected, or snorted
 |}
 ==Clinical Manifestations==

Aidan: added a bit more background info on cocaine

2020-07-10T18:39:27Z

added a bit more background info on cocaine

← Older revision		Revision as of 18:39, 10 July 2020
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	== Background ==		==Background==

	* A [[substance use disorder]] that includes cocaine (freebase, crack rock), methamphetamine (crystal meth, meth, crystal, jib, speed, ice, tina, side), and other amphetamine-like substances		*A [[substance use disorder]] that includes cocaine (freebase, crack, rock), methamphetamine (crystal meth, meth, crystal, jib, speed, ice, tina, side), and other amphetamine-like substances (including prescription stimulants)

	=== Epidemiology ===		===Epidemiology===

	* Second-most commonly used illicit substance after marijuana		*Second-most commonly used illicit substance after marijuana

	=== Pathophysiology ===		===Pathophysiology===

	* All stimulants work on the dopamine system		*All stimulants work on the dopamine system

	{\| class="wikitable"		{\| class="wikitable"
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	\|decreased dopamine re-uptake		\|decreased dopamine re-uptake
	\|30 to 120 minutes		\|30 to 120 minutes
			\|depends on the form
	\|smoking, snorting, or injecting
			\|-
			\|&emsp;Powder cocaine
			\|
			\|
			\|snorted, but can be mixed with water and injected
	\|-		\|-
	\|&emsp;Crack cocaine		\|&emsp;Crack cocaine
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	\|		\|
	\|		\|
	\|may explode when smoked		\|similar to crack, but may explode when smoked
	\|-		\|-
	\|Methamphetamine		\|Methamphetamine
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	\|}		\|}

	== Clinical Manifestations ==		==Clinical Manifestations==

	=== Acute intoxication ===		===Acute intoxication===

	* Common symptoms include tachycardia or bradycardia, pupillary dilatation, high or low blood pressure, sweating, chills, nausea or vomiting, weight loss, psychomotor agitation or retardation, muscular weakness, respiratory depression, chest pain, arrhythmias, confusion, seizures, dyskinesia, dystonia, and coma		*Common symptoms include tachycardia or bradycardia, pupillary dilatation, high or low blood pressure, sweating, chills, nausea or vomiting, weight loss, psychomotor agitation or retardation, muscular weakness, respiratory depression, chest pain, arrhythmias, confusion, seizures, dyskinesia, dystonia, and coma
	* Severe intoxication may cause mania, paranoia, severe delirium, hypertension, agitation, sweating, formication and skin picking, choreoathetosis, and ataxia		*Severe intoxication may cause mania, paranoia, severe delirium, hypertension, agitation, sweating, formication and skin picking, choreoathetosis, and ataxia

	=== Stimulant-induced psychosis ===		===Stimulant-induced psychosis===

	* [[Schizophrenia]] complicates about 15 to 25% of chronic stimulant use within 2 to 5 years		*[[Schizophrenia]] complicates about 15 to 25% of chronic stimulant use within 2 to 5 years
	* Unclear what the causal relationship is between stimulants and [[schizophrenia]]		*Unclear what the causal relationship is between stimulants and [[schizophrenia]]

	=== Other sequelae ===		===Other sequelae===

	* Cardiovascular or cerebrovascular disease, including [[myocardial infarction]], [[stroke]], and [[acute kidney injury]]		*Cardiovascular or cerebrovascular disease, including [[myocardial infarction]], [[stroke]], and [[acute kidney injury]]
	* Psychiatric diseases including [[psychosis]], [[depression]], and suicidal ideation		*Psychiatric diseases including [[psychosis]], [[depression]], and suicidal ideation
	* Increased risk of [[HIV]] and [[hepatitis C]]		*Increased risk of [[HIV]] and [[hepatitis C]]
	* Death		*Death

	=== Withdrawal ===		===Withdrawal===

	* Symptoms include depressed mood, vivid dreams, fatigue, insomnia, hypersomnia, cravings, psychomotor agitation or impairment, increased appetite, agitation, irritability, and cognitive impairment		*Symptoms include depressed mood, vivid dreams, fatigue, insomnia, hypersomnia, cravings, psychomotor agitation or impairment, increased appetite, agitation, irritability, and cognitive impairment

	== Investigations ==		==Investigations==

	=== Urine drug screen ===		===Urine drug screen===

	* Cocaine metabolites are detectable for about 3 to 5 days		*Cocaine metabolites are detectable for about 3 to 5 days
	** False positives: none		**False positives: none
	* Methamphetamines may be detectable for 3 to 5 days, with some variability		*Methamphetamines may be detectable for 3 to 5 days, with some variability
	** False positives: nasal inhalers, ADHD medications, [[bupropion]], [[trazodone]], [[chlorpromazine]], [[promethazine]], [[ranitidine]]		**False positives: nasal inhalers, ADHD medications, [[bupropion]], [[trazodone]], [[chlorpromazine]], [[promethazine]], [[ranitidine]]

	== Management ==		==Management==

	=== Intoxication ===		===Intoxication===

	* Generally focussed on supportive care		*Generally focussed on supportive care

	=== Withdrawal ===		===Withdrawal===

	* Generally focussed on supportive care, including good nutrition		*Generally focussed on supportive care, including good nutrition
	* [[Cognitive behavioural therapy]] and [[sleep hygiene]] may be helpful		*[[Cognitive behavioural therapy]] and [[sleep hygiene]] may be helpful

	=== Chronic treatment ===		===Chronic treatment===

	* There is no good evidence in favour of any pharmacologic treatment, and medication-based treatment is generally not recommended		*There is no good evidence in favour of any pharmacologic treatment, and medication-based treatment is generally not recommended
	** [[N-acetylcysteine]] may prevent relapse		**[[N-acetylcysteine]] may prevent relapse
	** [[Disulfiram]] may treat cocaine use disorders		**[[Disulfiram]] may treat cocaine use disorders
	** [[Modafinil]] may be useful		**[[Modafinil]] may be useful
	* The main focus is on psychosocial treatments, including [[contingency management]], [[cognitive behavioural therapy]], [[motivational interviewing]], [[relapse prevention]], and [[psychodynamic therapy]]		*The main focus is on psychosocial treatments, including [[contingency management]], [[cognitive behavioural therapy]], [[motivational interviewing]], [[relapse prevention]], and [[psychodynamic therapy]]
	** Long-term abstinence is around 30 to 50% for people in treatment, with 40-50% dropout rate		**Long-term abstinence is around 30 to 50% for people in treatment, with 40-50% dropout rate
	** [[Contingency planning]] with or without [[cognitive behavioural therapy]] seems to be the most promising		**[[Contingency planning]] with or without [[cognitive behavioural therapy]] seems to be the most promising

	[[Category:Addiction medicine]]		[[Category:Addiction medicine]]

Aidan: /* Pathophysiology */ formatting of table

2020-07-10T16:55:54Z

Pathophysiology: formatting of table

← Older revision		Revision as of 16:55, 10 July 2020
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	\|smoking, snorting, or injecting		\|smoking, snorting, or injecting
	\|-		\|-
	\|Crack cocaine		\|&emsp;Crack cocaine
	\|		\|
	\|		\|
	\|smoked, but can be mixed with an acid and injected		\|smoked, but can be mixed with an acid and injected
	\|-		\|-
	\|Freebase		\|&emsp;Freebase
	\|		\|
	\|		\|