Stimulant Use Disorder

Question 1

What is stimulant use disorder?

Answer 1

inappropriate use of stimulants leading to clinically significant impairment/distress

Question 2

What are some commonly abused stimulants?

Answer 2

ecstasy
crack
Adderall
Ritalin
cocaine

Question 3

Describe the diagnostic criteria for stimulant use disorder.

Answer 3

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

Question 4

Describe some general facts about stimulants.

Answer 4

stimulants are derivatives of amphetamine
referred to as sympathomimetics because they mimic physiological effects of epinephrine
stimulants increase motivation, energy, mood, wakefulness, and concentration

Question 5

What does the cycle of stimulant use look like?

Answer 5

binge –> crash –> repeat
eventually tolerance and addiction

Question 6

What are the categories of stimulants?

Answer 6

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

Question 7

Describe the pharmacology of stimulants.

Answer 7

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

Question 8

What are the effects of stimulants on the CNS?

Answer 8

intense euphoria
increased alertness
decreased fatigue
increased concentration
decreased appetite
increased talkativeness
increased sexual behavior

Question 9

What are the effects of stimulants on the ANS?

Answer 9

increased HR
increased BP
increased RR
dilated pupils
increased body temperature
increased vasoconstriction

Question 10

What can stimulant overdose lead to?

Answer 10

coma
seizures
cardiac toxicity (arrhythmia, MI)
respiratory arrest
brain hemorrhage
death

Question 11

What are the immediate complications of stimulants?

Answer 11

increased risk of violent or illegal behaviors
increased engagement in risky sexual behavior
pregnancy: poor outcomes for fetus
irritability, anxiety
psychosis

Question 12

What are the long term complications of stimulants?

Answer 12

dental decay, skin picking, panic attacks, wt. loss
brain changes, memory loss
chronic psychotic disorders

Question 13

What are some of the symptoms that may be seen in acute stimulant intoxication or overdose?

Answer 13

mania
psychosis
paranoia
delirium
increased BP
chest pain
agitation
sweating
skin picking

Question 14

Describe some key considerations in the management of stimulant intoxication.

Answer 14

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

Question 15

Describe the management of the different situations that may be seen in stimulant intoxication.

Answer 15

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

Question 16

Differentiate the stages of stimulant withdrawal.

Answer 16

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

Question 17

What is the management of stimulant withdrawal?

Answer 17

primarily supportive; rarely life-threatening
non-pharm
post-acute hyperarousal/anxiety:
-continue benzos a little longer
-mirtazapine (mixed results)

Question 18

What are the goals of therapy for the long term management of stimulant use disorder?

Answer 18

achieve abstinence
maintain abstinence
treat comorbidities
prevent harm to patient and others

Question 19

What kind of dependence is greater in stimulant use disorder?

Answer 19

psychological dependence > physical dependence

Question 20

What is the biggest factor leading to relapse and challenge to manage stimulant use disorder?

Answer 20

craving

Question 21

What do sustained neurophysiological changes lead to?

Answer 21

depressed mood
loss of pleasure (anhedonia)
cognitive impairment
poor health

Question 22

What is the rationale behind antidepressant use in stimulant use disorder?

Answer 22

5HT may attenuate reinforcing effects of amphetamine, and 5HT/NE counter withdrawal symptoms as depression

Question 23

Describe the evidence for antidepressant use in stimulant use disorder.

Answer 23

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

Question 24

What is the rationale behind antipsychotic use in stimulant use disorder?

Answer 24

counterbalance excess DA activity and restore NT pathways
-risk promote cravings??

Question 25

Describe the evidence for antipsychotic use in stimulant use disorder.

Answer 25

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

Question 26

What is the rationale behind prescribed stimulant use for stimulant use disorder?

Answer 26

substitution therapy

Question 27

Describe the evidence for prescribed stimulants for stimulant use disorder.

Answer 27

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

Question 28

What is the rationale behind dopamine agonists for stimulant use disorder?

Answer 28

chronic stimulant use leads to DA depletion
-amantadine, bromocriptine

Question 29

Describe the evidence for dopamine agonists for stimulant use disorder.

Answer 29

general results not promising
some possible benefit in severe withdrawal

Question 30

What is the indication of modafinil?

Answer 30

narcolepsy

Question 31

What is the rationale behind modafinil for stimulant use disorder?

Answer 31

differs from amphetamines: increased NE/histamine/glutamate and decreased GABA
-has been shown to blunt cocaine euphoria
-no added AE when used with cocaine

Question 32

Describe the evidence for modafinil in stimulant use disorder.

Answer 32

mixed evidence of benefit
-possibly useful to reduce cocaine use but 2 neg trials and risk of increased effect of concurrent stimulant use

Question 33

What is the evidence for bupropion + naltrexone ER in stimulant use disorder?

Answer 33

SS difference vs placebo but low response rate for all

Question 34

What is first line for long term management of stimulant use disorder?

Answer 34

non-pharm
-psychosocial approaches (CBT, contingency management, addictions treatment)