Stimulant Use Disorder

Question 1

Ddx for substance of abuse in apparent stimulant use disorder

Answer 1

Cocaine

Methamphetamine

Other amphetamines (less than meth, usually perscription)

Question 2

Long-term effects of amphetamine use disorder

Answer 2

• Psychosis
  
  • Paranoia
  • Hallucinations
• Cognitive dysfunction
  
  • Memory loss
• Motor manifestations
  
  • Repetitive motor activity
• Mood disruptions
  
  • Anxiety, lability, depression
  • Aggressive behavior
• Physical symptoms
  
  • Weight loss
  • Dental problems (“Meth mouth”)

Question 3

Diagnostic criteria for stimulant intoxication

Answer 3

• Recent use of stimulant
• Clinically significant maladaptive behavioral or psychological changes after use
• Two or more of:
  
  • Change in heart rate
  • Dilation of pupils (mydriasis)
  • Change in BP
  • Perspiration or chills
  • N/V
  • Weight loss
  • Muscular weaknes, respiratory depression, chest pain, arrhythmia
  • Confusion, seizure, dyskinesia, dystonia, coma

Question 4

Stimulant-associated behavioral changes

Answer 4

Euphoria OR blunting of feelings

Hypervigilance or hypersensitivity

Heightened anxiety or irritability/anger

Stereotyped behaviors

Impaired judgement

Question 5

Stimulant-associated physical changes

Answer 5

• Dilated pupils (mydriasis)
• Autonomic instability
• Chills
• N/V
• Psychomotor agitation OR retardation
• Muscle weakness
• Chest pain/arrhythmia
• Weight loss

Question 6

Stimulant withdrawal

Answer 6

Usually lasts 2-4 days, but may be longer in heavy users

The “crash” is commonly accompanied by dysphoria, irritability, fatigue, increased appetite, psychomotor agitation/retardation, vivid and unpleasant dreams, insomnia/hypersomnia.

These patients may become profoundly depressed and suicidal, and can require hospitalization.

Question 7

Diagnosing a psychiatric comorbidity in a patient with a stimulant use disorder

Answer 7

This is tricky. While many of these patients do really have comorbidities, the diagnosis can be blurred by the effects of chronic stimulant use on mood and cognition.

Therefore, a period of abstinence lasting up to several months may be required before an accurate diagnosis of comorbidities may be made.

Question 8

Treatment of stimulant use disorder

Answer 8

• Acute:
  
  • Supportive during the intoxication (first ~48 hours) and withdrawal (next ~48-96 hours) periods
  • An antidepressant may be considered if depressive symptoms do not clear after a few weeks of withdrawal
  • Emergency treatment of amphetamine intoxication an include use of antipsychotics and/or restraints if the patient is violent, and section 12 may be invoked
• Long-term:
  
  • Multimodal treatment (medical, psychological, social)
  • Craving may be so strong that residential treatment is necessary in early stages of recovery
  • Frequent, routine urine tox screenings
  • Family therapy and 12 step programs are useful

Question 9

After a patient with cocaine use disorder uses, cocaine will be detected in their urine for. . .

Answer 9

. . . the next ~72 hours

It takes that much time for the kidneys to completely clear it

Question 10

What medications are contraindicated in the setting of cocaine-induced coronary vasospasm?

Answer 10

Nonselective beta blockers!!! Specifically, propranolol.

Beta blockers can result in unopposed alpha-1 activation in the setting of cocaine-induced vasospasm.

Nonselective adrenergic blockers with both alpha and beta activity, like labetalol, are okay in this setting.

Question 11

Treatment of stimulant intoxication/stimulant overdose

Answer 11

Benzos

Cooling may be necessary

If evidence of cardiac ischemia, antihypertensives (nitroprusside, phentolamine)