Stimulant use disorder: Difference between revisions

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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
|-
| Powder cocaine
|
|
|snorted, but can be mixed with water and injected
|-
|-
| Crack cocaine
| 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]]

Revision as of 18:39, 10 July 2020

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)

Epidemiology

  • Second-most commonly used illicit substance after marijuana

Pathophysiology

  • All stimulants work on the dopamine system
Stimulant Mechanism Half-life Routes of administration
Cocaine decreased dopamine re-uptake 30 to 120 minutes depends on the form
 Powder cocaine snorted, but can be mixed with water and injected
 Crack cocaine smoked, but can be mixed with an acid and injected
 Freebase similar to crack, but may explode when smoked
Methamphetamine reverses dopamine reuptake, leading to increased excretion wide variability, about 10 to 30 hours 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

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
  • Severe intoxication may cause mania, paranoia, severe delirium, hypertension, agitation, sweating, formication and skin picking, choreoathetosis, and ataxia

Stimulant-induced psychosis

  • 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

Other sequelae

Withdrawal

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

Investigations

Urine drug screen

Management

Intoxication

  • Generally focussed on supportive care

Withdrawal

Chronic treatment

References

  1. a b  Krista J. Siefried, Liam S. Acheson, Nicholas Lintzeris, Nadine Ezard. Pharmacological Treatment of Methamphetamine/Amphetamine Dependence: A Systematic Review. CNS Drugs. 2020;34(4):337-365. doi:10.1007/s40263-020-00711-x.
  2. ^  Vitor S. Tardelli, Adam Bisaga, Felipe B. Arcadepani, Gilberto Gerra, Frances R. Levin, Thiago M. Fidalgo. Prescription psychostimulants for the treatment of stimulant use disorder: a systematic review and meta-analysis. Psychopharmacology. 2020;237(8):2233-2255. doi:10.1007/s00213-020-05563-3.
  3. ^  Nadine Ezard, Adrian Dunlop, Michelle Hall, Robert Ali, Rebecca McKetin, Raimondo Bruno, Nghi Phung, Andrew Carr, Jason White, Brendan Clifford, Zhixin Liu, Marian Shanahan, Kate Dolan, Amanda L Baker, Nicholas Lintzeris. LiMA: a study protocol for a randomised, double-blind, placebo controlled trial of lisdexamfetamine for the treatment of methamphetamine dependence. BMJ Open. 2018;8(7):e020723. doi:10.1136/bmjopen-2017-020723.
  4. ^  Marco Antonio Nocito Echevarria, Tassio Andrade Reis, Giulianno Ruffo Capatti, Victor Siciliano Soares, Dartiu Xavier da Silveira, Thiago Marques Fidalgo. N-acetylcysteine for treating cocaine addiction – A systematic review. Psychiatry Research. 2017;251:197-203. doi:10.1016/j.psychres.2017.02.024.
  5. ^  Pier Paolo Pani, Emanuela Trogu, Rosangela Vacca, Laura Amato, Simona Vecchi, Marina Davoli. Disulfiram for the treatment of cocaine dependence. Cochrane Database of Systematic Reviews. 2010. doi:10.1002/14651858.cd007024.pub2.
  6. ^ minozzi2015an 
  7. ^  Yolanda Alvarez, Magí Farré, Francina Fonseca, Marta Torrens. Anticonvulsant drugs in cocaine dependence: A systematic review and meta-analysis. Journal of Substance Abuse Treatment. 2010;38(1):66-73. doi:10.1016/j.jsat.2009.07.001.
  8. ^  Mohit Singh, Dipinder Keer, Jan Klimas, Evan Wood, Dan Werb. Topiramate for cocaine dependence: a systematic review and meta-analysis of randomized controlled trials. Addiction. 2016;111(8):1337-1346. doi:10.1111/add.13328.
  9. ^  Clara Pérez-Mañá, Xavier Castells, Marta Torrens, Dolors Capellà, Magi Farre. Efficacy of psychostimulant drugs for amphetamine abuse or dependence. Cochrane Database of Systematic Reviews. 2013. doi:10.1002/14651858.cd009695.pub2.
  10. ^  Xavier Castells, Ruth Cunill, Clara Pérez-Mañá, Xavier Vidal, Dolors Capellà. Psychostimulant drugs for cocaine dependence. Cochrane Database of Systematic Reviews. 2016. doi:10.1002/14651858.cd007380.pub4.
  11. ^  Meha Bhatt, Laura Zielinski, Lola Baker-Beal, Neera Bhatnagar, Natalia Mouravska, Phillip Laplante, Andrew Worster, Lehana Thabane, Zainab Samaan. Efficacy and safety of psychostimulants for amphetamine and methamphetamine use disorders: a systematic review and meta-analysis. Systematic Reviews. 2016;5(1). doi:10.1186/s13643-016-0370-x.
  12. ^  Silvia Minozzi, Laura Amato, Pier Paolo Pani, Renata Solimini, Simona Vecchi, Franco De Crescenzo, Piergiorgio Zuccaro, Marina Davoli. Dopamine agonists for the treatment of cocaine dependence. Cochrane Database of Systematic Reviews. 2015. doi:10.1002/14651858.cd003352.pub4.
  13. ^  Pier Paolo Pani, Emanuela Trogu, Simona Vecchi, Laura Amato. Antidepressants for cocaine dependence and problematic cocaine use. Cochrane Database of Systematic Reviews. 2011. doi:10.1002/14651858.cd002950.pub3.
  14. ^  Marta Torrens, Francina Fonseca, Gerard Mateu, Magí Farré. Efficacy of antidepressants in substance use disorders with and without comorbid depression. Drug and Alcohol Dependence. 2005;78(1):1-22. doi:10.1016/j.drugalcdep.2004.09.004.
  15. ^  Blanca I Indave, Silvia Minozzi, Pier Paolo Pani, Laura Amato. Antipsychotic medications for cocaine dependence. Cochrane Database of Systematic Reviews. 2016. doi:10.1002/14651858.cd006306.pub3.

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