Stimulant Use Disorder

Question 1

what are the categories of stimulants and examples?

Answer 1

weak: caffeine, nicotine
mild: ephedrine, pseudoephedrine, phenylpropanolamine, dextromethorphan
moderate: methylphenidate, dextroamphetamine, lisdexamphetamine, mixed amphetamine salts, modafinil, bupropion
strong: cocaine, methamphetamine (crystal meth), MDA, MDEA, MDMA

Question 2

what is MOA of stimulants?

Answer 2

increase CNS and ANS activity
all effect the reward pathway by increasing DA concentrations at the synapse

Question 3

what is the most common way that meth is used?

Answer 3

smoking

Question 4

what effects do stimulants have on the CNS?

Answer 4

intense euphoria
increase alertness
increase concentration
increase talkativeness
decrease fatigue
decrease appetite
decrease sexual behaviour
also: nausea, tremors, tics/twitches, anxiety, agitation

Question 5

what effects do stimulants have on the ANS?

Answer 5

increase body temp
increase HR
increase BP
increase RR
increase constriction of blood vessels
dilated pupils

Question 6

what are the complications of stimulant OD?

Answer 6

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

Question 7

what are the immediate complications of stimulant use?

Answer 7

increase risk of violent or illegal behaviours
increase engagement in risky sexual behaviour and HIV
psychosis: paranoia, visual and tactile hallucinations
irritability, anxiety
pregnancy; poor outcome for fetus

Question 8

what are long term complications of stimulant use?

Answer 8

dental decay, weight loss, picking at skin with scabs, panic attacks
brain changes, memory loss
chronic psychotic disorders

Question 9

what are the symptoms of acute stimulant intoxication or OD?

Answer 9

mania
psychosis
paranoia
severe delirium
increase BP
chest pain
agitation
sweating
skin-picking

Question 10

what the management of acute stimulant intoxication?

Answer 10

generally do not require treatment as withdrawal symptoms are not severe or medically complex
mostly supportive unless delusions or autonomic hyperactivity
pharmacological agents only if overtly psychotic and agitated or medical crisis

Question 11

what is used for agitation in stimulant intoxication?

Answer 11

lorazepam 2-4 mg IM or PO PRN (q30min t0 6h)
incomplete response: may add low dose AP

Question 12

what is used for psychotic symptoms of stimulant intoxication?

Answer 12

low dose antipsychotic such as risperidone 0.5-2 mg/d, olanzapine 2.5-7.5 mg/d
delusions often self-remitting without treatment

Question 13

what is used to treat cardiac complications associated with stimulant intoxication?

Answer 13

arrhythmia: anti-arrhythmic agents
tachycardia (+/- HTN): beta blockers (esp. labetalol/carvediolol), clonidine

Question 14

when are anti-seizure meds given in stimulant intoxication?

Answer 14

if seizing
no role as a preventative

Question 15

when does stage 1 of stimulant withdrawal start and how long does it last

Answer 15

crash
begins within hours and lasts 4-7 days

Question 16

what are s/sx of stimulant crash?

Answer 16

agitation
marked dysphoria
fatigue
hypersomnolence
hyperphagia or anorexia

Question 17

when does stage II of stimulant withdrawal start and how long does it last?

Answer 17

begins after the first week and can last up to 10 weeks

Question 18

what are the s/sx of stage II of stimulant withdrawal

Answer 18

first week:
- normal sleep
- euthymia
- little anxiety
- minimal craving
subsequent weeks
- anhedonia
- increase anxiety and depression
- fatigue
- extreme craving

Question 19

what can be used for post-acute hyperarousal/anxiety in stimulant withdrawal?

Answer 19

continue benzos a little longer
mirtazepine

Question 20

what is the management of stimulant withdrawal

Answer 20

primarily supportive; rarely life threatening
non pharm: addictions counselling support, community supports, rehab options, housing needs

Question 21

what is the rationale behind using antidepressants in stimulant withdrawal?

Answer 21

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

Question 22

what is the consensus with antidepressant use in stimulant withdrawal?

Answer 22

mostly ineffective with regard to abstinence; may have mood related results
avoid sertraline?
use according to guidelines if indicated

Question 22

what is the rationale behind antipsychotics in stimulant withdrawal?

Answer 22

counterbalance excess DA activity and restore NT pathways

Question 23

what is the consensus on antipsychotics in stimulant withdrawal?

Answer 23

no different in any treatment outcomes
avoid aripiprazole?
use according to psychosis guidelines if indicated; review need after 6 months

Question 24

what is the consensus on prescribed stimulants in stimulant wtihdrawal?

Answer 24

not generally recommended
risks: worsening psychosis, mood lability

Question 25

what is the rationale behind DA agonists in stimulant withdrawal?

Answer 25

chronic stimulant use leads to DA depletion

Question 26

what is the consensus on DA agonists in stimulant withdrawal?

Answer 26

general results not promising
some possible benefit in severe withdrawal

Question 27

what is the consensus on modafinil use for stimulant use in stimulant withdrawal?

Answer 27

mixed evidence of benefit: possibly useful to reduce cocaine use, but 2 neg trials and risk of increase effect of concurrent stimulant use