Stimulants speed up communication between the brain and the central nervous system. They are a "feel good" staple for the club and party scene. The American Psychiatric Association has merged the past diagnoses of stimulant abuse and stimulant dependence into one diagnosis: stimulant use disorder. The severity of stimulant use disorder can range from mild to moderate or severe. Some examples of stimulants include amphetamines, meth, and cocaine.
The use of stimulants is often an exercise in polysubstance use. While the stimulant-using person will often have their favorite substance, many use whatever is at hand to achieve the goal of renewed energy, a mood boost, or simply to help them keep a feeling of control. Stimulants range from licit items such as over-the-counter (OTC) decongestants to illicit and illegal substances such as cocaine or methamphetamines.
Stimulants can be either synthetic, as many amphetamine-like substances are, or naturally occurring plant-derived compounds, such as cocaine. Legitimate stimulant uses do exist, including treatments for ADHD, obesity, and sleep disorders.
Amphetamine-type stimulants go by the most recognized names in the street slang pharmacopeia. Speed, ice, ecstasy, base, meth, and Crystal, to name a few. They have a longer active duration than cocaine and thus need fewer uses each day to support the desired effects. Clinical manifestations of amphetamine-type drugs tend to revolve around sympathetic activation, e.g., increased energy, alertness, euphoria, decreased need for sleep, and weight loss. The typical downside is mood and cognitive changes, rapid tooth decay due to chronic dry mouth, and problems with executive functioning and decision-making.
Users who prefer the amphetamine types tend to go on binges with periods of non-use, often due to the lack of available substance. During binges, users tend to stack doses in a sometimes purposeful, though often unplanned, manner achieving dangerously elevated levels of a psychoactive substance in their systems. Paranoia, delusions, anxiety attacks, hallucinations, and panic disorders are all possible outcomes of the high quantities of stimulants in one's circulation.
Cocaine is a tropane alkaloid extracted from the South American Erythoxylon coca plant leaves. Each stop in its processing, from harvesting the leaves of this hardy plant to the final street market form, has found a fan base amongst users. Processing ranges from coca leaves, coca paste, and powdered cocaine hydrochloride to rock crystal cocaine alkaloids. The two most common available cocaine forms are more processed, and therefore more concentrated, forms:
- Hydrochloride salt (a white crystalline powdered form of cocaine)- dissolves in water and can be taken intravenously, snorted up the nose, smoked, or rubbed onto the gums. The peak duration may last from 15 to 30 minutes, depending on the purity of the substance. Street names are blow, coke, flake, and snow.
- Cocaine alkaloids, aka freebase or crack (a rock crystal form of cocaine) -the cocaine extract has been processed with ammonia or baking soda and now requires heating to remove the active hydrochloride. Because it is difficult to dissolve in water, crack is smoked and, when taken, has a peak duration of less than 5 to 10 minutes. The term crack comes from a crackling sound that occurs when the rock crystal is heated. Crack's chief appeal is the low cost to make and buy.
Cocaine has a legitimate legal use as a Schedule II local or topical anesthetic, although synthetic topicals have made heavy inroads into its medicinal use in recent years. It has a substantial following and is considered the second most-used illicit drug worldwide and ranks as the third most-used illicit substance in the United States (Foy, 2022).
Cocaine is almost exclusively smuggled into the country and tends to be expensive. A heavy user can buy a gram daily and easily spend around $50,000 a year. Around 1.3 million Americans currently struggle with cocaine use disorder. Three hundred fifty thousand hospital visits are due to cocaine annually, and 54% of those in jail and prisons due to drug-related charges are due to cocaine (Foy, 2022). Perhaps most worrisome is the 16,000 overdose deaths linked to cocaine annually.
Cocaine effects come from the enhancement of monoamine neurotransmitters such as dopamine, norepinephrine, and serotonin. The positive effects are attributed to dopamine enhancement of the brain reward system, including alertness, energy, elation, and euphoria. Users describe the feeling of cocaine peaking as a "total body orgasm." Unwanted adverse effects of cocaine use include irritability, anxiety, suspiciousness, paranoia, panic attacks, impaired judgment, grandiosity, delusions, and hallucinations. Sleep disturbances, weight loss, tremors, and stereotyped behaviors like picking at the skin accompany cocaine use.
Like amphetamine-type substances, cocaine users often binge, displaying short periods of heavy use separated by longer periods of drug abstinence until the next binge. Often these times without their substance of choice are dictated by external factors such as lack of finances or unavailability of cocaine. Be aware that many cocaine users do not use it often and tend to fly under the radar without notice. It tends to be heavy or impulse use that gains enough attention to be noticed and included in research demographics.
Feelings of alertness and energy make stimulants a substance of choice among young people in dance clubs or festivals. Euphoric feelings add to the energy boost these drugs give and become a feeling that users fight to keep, often at the cost of cognitive functioning and physical health. Stimulants are one of the quickest substances to form a chemical dependence in our bodies.
Stimulants dilate pupils, constrict blood vessels, and increase heart rate, body temperature, and blood pressure. Use can cause nausea, abdominal pain, and headaches, and because stimulants decrease appetite simultaneously, increasing metabolism can cause serious malnutrition effects.
Heart attack and stroke are familiar accompaniments to stimulant use. Cocaine is well known for sudden cardiac arrest followed by respiratory collapse.
Laboratory testing for suspected stimulant use disorder should include finger stick glucose, salicylate and acetaminophen levels, electrocardiogram (ECG), and pregnancy testing due to the substantial risk of potential effects of stimulant use on the unborn. While urine toxicology screens may be useful for documentation purposes, they have little clinical use when dealing with acute intoxication.
Acute stimulant intoxication may present with grandiose statements or actions and continue to restlessness, sudden jerky movements, rambling speech, headache, and ringing in the ears. The person may show ideas of reference, paranoid thinking, auditory hallucinations, and the client may even report the sensation of being touched or other tactile hallucinations. Sexual acting out, threats or actions of aggression, depression, suicidal feelings, and mood fluctuations may also be present.
Diagnostic criteria for stimulant intoxication include the following (American Psychiatric Association, 2022):
A. Recent use of an amphetamine-type substance, cocaine, or other stimulant.
B. Clinically significant problematic behavioral or psychological changes (e.g., euphoria or affective blunting, changes in sociability, hypervigilance, interpersonal sensitivity with anxiety/tension/anger, stereotypical behaviors, impaired judgment) developed during or shortly after use.
C. One (or more) of the following signs or symptoms that develop during or shortly after use:
- Tachycardia or bradycardia
- Pupil dilation
- Elevated or lowered blood pressure
- Perspiration or chills
- Nausea or vomiting
- Evidence of weight loss
- Psychomotor agitation or retardation
- Muscular weakness, respiratory depression, chest pain, cardiac arrhythmias
- Confusion, seizures, dyskinesia, dystonia, or coma
The cycle of intoxication and withdrawal tends to be familiar to users of any stimulant. Binge usage means that withdrawal is only a few "hits" away, leading to the desperation that the desired feelings may end. Legal consequences of actions provoked by user desperation to keep the positive effects of stimulant use can shatter social or work relationships.
Withdrawal from amphetamine-type substances can occur within hours of stopping use. Withdrawal symptoms peak within one or two days and diminish around two weeks after substance use ceases. The acute withdrawal or "crash" includes anhedonia (the inability to experience pleasure from activities usually found enjoyable), dysphoria, fatigue, insomnia, increased need for sleep, vivid dreams, anxiety, agitation, increased appetite, and drug cravings. Following acute withdrawal, many users face a month-long phase of continued insomnia/hypersomnia, appetite fluctuations, depression, and a tendency toward suicidal thinking.
Cocaine cessation, on the other hand, while having profound psychological symptoms, is rarely medically life-threatening. Common findings are anxiety, depression, fatigue, increased sleep, increased dreaming, difficulty concentrating, anhedonia, increased appetite, and cocaine cravings. Some cocaine users experience an intensity of feelings in the hours after ceasing cocaine use that may include severe depression and suicidal thinking. Most have milder symptoms that resolve within one to two weeks without medical intervention. Physical aspects of cocaine withdrawal include generalized musculoskeletal pain, tremors, chills, and involuntary motor movements. Myocardial ischemia has been noted during the first week of cocaine withdrawal, possibly due to coronary vasospasms.
Long-term effects of stimulant use include an increased risk for brain disorders and various body organ systems. Cognitive and psychiatric disorders such as schizophrenia, major depression, stimulant-induced bipolar disorder, sleep disorder, sexual dysfunction, or anxiety disorders all have a heightened frequency in long-term stimulant users.
