Stimulant Abuse and Addiction

1
Stimulant Abuse and Addiction

• Martha J Wunsch MD
• Addiction Medicine
• Principles of Primary Care
• March 6, 2006

2
Reading Assignment

• Drug and Alcohol Abuse A Clinical guide to
  Diagnosis and Treatment. Marc A Schuckit. 6th
  edition
• PP 137-163
• Be prepared to discuss in class

3
Learning Objectives

• List the medications and illicit drugs which are
  included in this class of drugs and the how they
  are abused.
• Describe the intoxication state and the
  psychological effects of discontinuation after
  chronic use.
• Describe common medical consequences of abuse of
  stimulants.
• List the important elements of treatment in
  stimulant addiction

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Who uses stimulants?
Past year new initiates for all illicit drug
categories. NHSDUH 2004
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Mean age for past year initiates, illicit drugs
by categories
NHSDUH, 2004
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Stimulants are.

• Prescription Methylphenidate, Dextroamphetamine,
  Amphetamine, Dexamethylphenidate, Pemoline,
  fenfluramine and more
• Made in a home lab Methamphetamine
• Bought on the street Cocaine

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Will work for morphine or cocaine
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Neurobiology of Stimulants

• All cause release or block reuptake of
  neurotransmitters
• Dopamine cocaine in particular
• Mimic NE by direct effect
• Serotonin at high levels
• NMDA, Acetylcholine, substance P, endogenous
  opioids, GABA
• Alter blood flow in prefrontal, frontal,
  temporal, subcortical grey areas
• Dopamine effects
• Increase in activity in mesolimbic and
  mesocortical area
• NO Dopamine TransporterNo activity of stimulants

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An added bonus!

• What is the chemical formed when cocaine and
  alcohol are combined?
• Cocaethylene
• Powerful vasconstrictor and stimulant
• Why is it so reinforcing?
• Longer acting, more intense stimulus, may affect
  development of tolerance for alcohol and cocaine
• Why combine heroin and cocaine? Or oxycodone and
  methamphetamine?
• Stimulant will stave off the sleepiness nodding
  from opiates
• Opiates will decrease the irritability of
  stimulant toxicity

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Craving People, places, things, and feelings
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Neurotransmitter/Modulator Relationships in
Reinforcement
Adapted from Kalivas and Volkow (2005) Am J
Psychiatry 1621403-1413
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How are stimulants used?

• What are the different forms of cocaine?
• Derivative of a plant, leaves may be chewed
• Cocaine hydrochloride powder
• Crack cocaine Combine powder with baking soda
  and you get crack
• Freebase Add a strong base and water and extract
  freebase
• Both crack and freebase have a lower melting
  point. Can be smoked in pipes
• How can stimulants be used?
• Oral dexamphetamine, methylphenidate
• Smoke Crack and freebase
• IV Powder, crack, freebase
• Snort Powder
• Why shift use patterns?
• Tolerance
• Euphoria
• Avoid first pass metabolism in the liver

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Clinical Picture

• Restless, hyperalert state
• Anxiety
• Irritability
• Aggressive
• Paranoia
• Hallucinations
• Depression
• Fatigue
• Tracks, skin abscesses
• Worn down teeth
• Nasal ulcerations

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Signs

• Dilated pupils
• Increased Heart Rate
• Dry Mouth
• Increased reflexes
• Elevated temperature
• Hypertension
• Sweating
• Track marks, skin abscess, scarring

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Evaluation

• Urine Drug Screen
• PCP
• Amphetamines
• Marijuana
• Opiates
• Benzodiazepines
• You may need to add a drug if it is prevalent in
  your area (Methadone and Oxycodone in NRV)
• Hepatitis B and C, HIV, CBC, Liver Function Tests
• Mode of use involves transmission ( IV, snorting)
• Use with alcohol indicates need to evaluate liver
  function
• Workers in sex industry may contract STDs

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Stimulant Intoxication

• Psychiatric Violence, psychosis, anxiety,
  hallucinations
• CNS increased HR, BP, temp, euphoria, irritable,
  decreased need for sleep, food, sexual prowess
• Cardiovascular Effects Arrhythmias (direct and
  catecholamine release)
• Low dose lower HR through vagal nerve
• High dose vasoconstriction and hypertension
• Pulmonary Effects black sputum from hemorrhage
  secondary to vasoconstriction

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Case Methamphetamine Abuse

• 23 year old male who presents with the following
• Restless, hyperalert, anxious
• Dilated pupils, tachycardia, fever
• Sweating, hyperactive reflexes
• Actively hallucinating, auditory
• Paranoid, violent, labile mood
• UDS for amphetamine

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Medical complications Sympathetic overdrive

• Psychiatric Paranoia, Anxiety, depression,
  hallucinations, psychosis
• Cardiac Myocardial infarction, arrhythmias(may
  be fatal), atrial fibrillation
• Pulmonary (if smoking) crack lung with
  necrosis, infarction, pneumothorax
• Infectious disease HIV, Hepatitis, STDs
• Pregnancy Fetal demise, preterm labor, placental
  abruptio
• Dental Gum necrosis, bruxism leading to tooth
  destruction and wear.
• Skin Infection from excoriations due to coke
  bugs with digging at skin

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Cessation of use Inability to experience pleasure

• Physiological Decreased levels of prolactin,
  undetermined results of decreased dopamine,
  changes in EKG
• Psychological Moodiness, irritability,
  anhedonia, depression, agitation
• Chronic Exhaustion, rebound appetite, increased
  need for sleep
• Craving Crash intense with intense craving and
  cocaine seeking behavior ( 9h-weeks)

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Treatment

• Medical Complications of use including cardiac,
  infectious, pulmonary
• Psychiatric Control psychosis, prevent suicide
  during dysphoria of cessation
• Substance Abuse Treatment Extensive. Individual
  and group counseling, medication to stabilize
  psychiatric morbidity, behavioral changes

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Case

• JC is a 35 year old female who is brought to the
  ER by her friends because she is acting crazy
• What history do you want to know from her
  friends? Substance use, time, what, how
• What history will you ask her? Substance use
  history, history of infectious complications,
  history of cardiac problems, hepatitis status,
  HIV status

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Case

• You are preparing for the physical exam
• What is the FIRST thing you will look at on her
  ER sheet? Vital signs
• What will you look for most carefully during the
  physical exam? IE What are the pertinent
  positives? Skin exam, cardiac exam, pulmonary
  exam. Is she hypoxic? If so, order a chest X Ray.
• What laboratory information do you want? UDS,
  LFTs, pregnancy test

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Case

• What is your current diagnosis?
• Stimulant toxicity
• Stimulant withdrawal
• Acute psychosis
• Depression with psychosis
• Bipolar Disease Due to lability of mood
• UDS for cocaine
• Patient is calm and no longer hallucinating so
  you decide that 3 and 4 are less likely
• Bipolar Disease is still a possibility, but you
  will leave that diagnosis for evaluation by her
  primary care doc.

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Case

• What is your treatment plan for this patient?
• Brief intervention
• State your concern Your use of cocaine made you
  hallucinate and thats why you are here
• State the evidence UDS, VS, track marks
• State your diagnosis Cocaine abuse
• State your treatment Referral to Substance Abuse
  Resources in the community
• SA Treatment 12 step group ( Cocaine Anonymous),
  individual counseling, referral to a treatment
  program for cocaine abuse.