Stimulant Use Disorder Flashcards
What is stimulant use disorder?
inappropriate use of stimulants leading to clinically significant impairment/distress
What are some commonly abused stimulants?
ecstasy
crack
Adderall
Ritalin
cocaine
Describe the diagnostic criteria for stimulant use disorder.
problems with use:
-using more (time or amount)
-repeated attempts to quit/control use
-much time spent using
problems with lifestyle:
-interpersonal/social problems
-physical/psychological problems
-activities given up
-major roles neglected
-hazardous use
problems with physiology:
-craving
-tolerance
-withdrawal
2 or more meet criteria for substance use disorder
Describe some general facts about stimulants.
stimulants are derivatives of amphetamine
referred to as sympathomimetics because they mimic physiological effects of epinephrine
stimulants increase motivation, energy, mood, wakefulness, and concentration
What does the cycle of stimulant use look like?
binge –> crash –> repeat
eventually tolerance and addiction
What are the categories of stimulants?
weak: social use
-caffeine, nicotine
mild: cough and cold preps, diet pills
-ephedrine, PSE, phenylpropanolamine, DM
moderate: ADHD, narcolepsy
-MPH, Vyvanse, Adderall, Dexedrine, bupropion, modafinil
strong: illicit use
-cocaine, methamphetamine
Describe the pharmacology of stimulants.
increase CNS and ANS activity (adrenergic overdrive)
all effect the reward pathway by increasing DA [ ] at synapse
-cocaine prevents reuptake of DA, NE, 5HT
-amphetamines cause release of DA, NE, 5HT from storage sites and to various degrees also inhibit reuptake
regardless of mechanism, outcome is similar although intensity varies
duration:
-cocaine: shorter (<1h)
-amphetamines: up to 12h (6-30h) depending on route + amount
What are the effects of stimulants on the CNS?
intense euphoria
increased alertness
decreased fatigue
increased concentration
decreased appetite
increased talkativeness
increased sexual behavior
What are the effects of stimulants on the ANS?
increased HR
increased BP
increased RR
dilated pupils
increased body temperature
increased vasoconstriction
What can stimulant overdose lead to?
coma
seizures
cardiac toxicity (arrhythmia, MI)
respiratory arrest
brain hemorrhage
death
What are the immediate complications of stimulants?
increased risk of violent or illegal behaviors
increased engagement in risky sexual behavior
pregnancy: poor outcomes for fetus
irritability, anxiety
psychosis
What are the long term complications of stimulants?
dental decay, skin picking, panic attacks, wt. loss
brain changes, memory loss
chronic psychotic disorders
What are some of the symptoms that may be seen in acute stimulant intoxication or overdose?
mania
psychosis
paranoia
delirium
increased BP
chest pain
agitation
sweating
skin picking
Describe some key considerations in the management of stimulant intoxication.
generally do not require tx in an inpatient setting as withdrawal sx are not severe or medically complex
mainly supportive unless delusions or autonomic hyperactivity
pharmacologic agents only if overtly psychotic and agitated or medical crisis
Describe the management of the different situations that may be seen in stimulant intoxication.
agitation:
-lorazepam 2-4 mg IM or po prn
-incomplete response: low dose AAP
psychosis:
-low dose AAP (risp 0.5-2, olz 2.5-7.5)
-delusions often self-remitting without tx
CV complications:
-arrhythmia: anti-arrhythmic
-tachy +/- HTN: BB (labetalol, carvedilol), clonidine
seizures:
-anti seizure med if seizing
-no preventive role
Differentiate the stages of stimulant withdrawal.
stage 1: the crash
-begins within hours and lasts 4-7 days
-sx: hypersomnolence, fatigue, hyperphagia or anorexia, agitation, dysphoria
stage 2:
-begins after 1st week and can last up to 10 weeks
-first wk: normal sleep, euthymia, little anxiety, minimal craving
-subsequent wks: anhedonia, anxiety/depression, fatigue, extreme craving
What is the management of stimulant withdrawal?
primarily supportive; rarely life-threatening
non-pharm
post-acute hyperarousal/anxiety:
-continue benzos a little longer
-mirtazapine (mixed results)
What are the goals of therapy for the long term management of stimulant use disorder?
achieve abstinence
maintain abstinence
treat comorbidities
prevent harm to patient and others
What kind of dependence is greater in stimulant use disorder?
psychological dependence > physical dependence
What is the biggest factor leading to relapse and challenge to manage stimulant use disorder?
craving
What do sustained neurophysiological changes lead to?
depressed mood
loss of pleasure (anhedonia)
cognitive impairment
poor health
What is the rationale behind antidepressant use in stimulant use disorder?
5HT may attenuate reinforcing effects of amphetamine, and 5HT/NE counter withdrawal symptoms as depression
Describe the evidence for antidepressant use in stimulant use disorder.
bupropion has been tried given NE/DA effects
-mixed results
mirtazapine had 1 positive RCT in general pop, and 1 in MSM for amphet abstinence
desipramine and fluoxetine trials have been done
-mixed results
avoid sertraline?? (no efficacy and increased AE)
ALL: most ineffective for abstinence, may have positive mood-related results
What is the rationale behind antipsychotic use in stimulant use disorder?
counterbalance excess DA activity and restore NT pathways
-risk promote cravings??
Describe the evidence for antipsychotic use in stimulant use disorder.
consistently showed no difference in any treatment outcomes
avoid arip (mixed results, some increased craving and use)
several studies reported fewer study dropouts vs placebo
use according to psychosis guidelines if indicated; review need after 6 months
What is the rationale behind prescribed stimulant use for stimulant use disorder?
substitution therapy
Describe the evidence for prescribed stimulants for stimulant use disorder.
mixed results for long term benefit, possible reduction in use or craving
usually no difference in tx outcomes observed
not generally recommended, risk of worsening psychosis/mood lability, establish targets if used
What is the rationale behind dopamine agonists for stimulant use disorder?
chronic stimulant use leads to DA depletion
-amantadine, bromocriptine
Describe the evidence for dopamine agonists for stimulant use disorder.
general results not promising
some possible benefit in severe withdrawal
What is the indication of modafinil?
narcolepsy
What is the rationale behind modafinil for stimulant use disorder?
differs from amphetamines: increased NE/histamine/glutamate and decreased GABA
-has been shown to blunt cocaine euphoria
-no added AE when used with cocaine
Describe the evidence for modafinil in stimulant use disorder.
mixed evidence of benefit
-possibly useful to reduce cocaine use but 2 neg trials and risk of increased effect of concurrent stimulant use
What is the evidence for bupropion + naltrexone ER in stimulant use disorder?
SS difference vs placebo but low response rate for all
What is first line for long term management of stimulant use disorder?
non-pharm
-psychosocial approaches (CBT, contingency management, addictions treatment)
