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 past diagnoses of Stimulant Abuse and Stimulant Dependence have been merged by the American Psychiatric Association into one diagnosis, that of Stimulant Use Disorder.3 The severity of Stimulant Use Disorder can range from mild, to moderate, or severe and encompasses all of the areas previously utilized when attempting a clear diagnostic portrait of the individual with the unhealthy use of stimulant-related substances.
The use of stimulants is often an exercise in polysubstance use. While the stimulant using person will often have their favorite substance, many imbibe whatever is at hand that can be utilized to achieve the goal of renewed energy, a mood boost, or simply to help them maintain 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 most of the amphetamine-like substances are, or naturally occurring plant-derived compounds such as cocaine. Legitimate uses for stimulants abound, including treatments for ADHD, obesity, sleep disorders, etc.
Amphetamine-type stimulants go by some of the most recognized names in the street slang pharmacopeia; Speed, Ice, Ecstasy, Base, Meth, and Chrystal just to name a few. They possess a longer active duration than cocaine and thus need fewer uses each day to maintain 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. With the typical downside being mood and cognitive changes, rapid tooth decay due to chronic dry mouth, problems with executive functioning and decision making.
Users who prefer the amphetamine-types tend to go on binges with periods of non-use between, 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 high levels of psychoactive substance in their systems. Paranoia, delusions, anxiety attacks, hallucinations, panic disorders are all possible outcomes of the high quantities of stimulants in one’s circulation.
Cocaine is a tropane ester alkaloid extracted from the leaves of the South American Erythroxylum coca plant, and each stop in its processing from the leaves of this hardy plant to the final street market form has found a fan base amongst users; coca leaves, coca paste, powdered cocaine hydrochloride, and rock crystal cocaine alkaloids. The two most common street available cocaine forms are the 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. Other street names are Blow, Coke, Flake, Snow.
- Cocaine alkaloids, aka Freebase or Crack (a rock crystal form of cocaine), have been processed with ammonia or baking soda and require 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 purchase.
Cocaine has a legitimate legal use as a Schedule II local or topical anesthetic; although in recent years synthetic topicals have made heavy inroads into its medicinal use. Around 0.7% of adult Americans or 1.9 million people have used cocaine within the past thirty days. Some 867,000 U.S. adults or 0.3% of the population meet the criteria for cocaine abuse disorder. Most healthcare providers are familiar with cocaine as it is the illegal drug most often associated with hospital emergency room visits.26 In the year 2011, the Drug Abuse Awareness Network (DAWN), estimated 40.3% of all illicit drug-related emergency visits involved cocaine.26
Cocaine effects come from enhancement of monoamine neurotransmitters such as dopamine, norepinephrine, and serotonin. The positive effects are attributed to dopamine enhancement of the brain reward system and include alertness, energy, elation, and euphoria. Users describe the feeling of cocaine peaking as a “total body orgasm.” Unwanted negative effects of cocaine use include irritability, anxiety, suspiciousness, paranoia, panic attacks, impaired judgment, grandiosity, delusions, and hallucinations.26 Sleep disturbances, weight loss, tremors, and stereotyped behaviors such as picking at the skin also accompany cocaine use.27
Similar to the amphetamine-type substances, cocaine users frequently 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 the majority of cocaine users do not use frequently and tend to fly under the radar without notice by legal or health professionals. 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 given by these drugs and become a feeling that users fight to maintain, often at the cost of cognitive functioning and their physical health. Stimulants are one of the quickest substances to form a chemical dependence in our bodies.
Stimulants dilate pupils, constrict blood vessels, increase heart rate, body temperature and blood pressure. Use can cause nausea, abdominal pain, headaches, and because stimulants decrease appetite at the same time as increasing metabolism can cause serious malnutrition effects.
Heart attack and stroke are familiar company for stimulant use. Cocaine, in particular, 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 high risk of potential effects of stimulant use to 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 proceed to restlessness, sudden jerky movements, rambling speech, headache, ringing in the ears. The person may exhibit ideas of reference, paranoid thinking, auditory hallucinations, and 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.
Stimulant Intoxication, Diagnostic Criteria3, 27
- Recent use of an amphetamine-type substance, cocaine, or other stimulant.
- 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.
- One (or more) of the following signs or symptoms developing 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 very familiar to users of any form of stimulant. Binge usage means that withdrawal is only a few “hits” away, and leads to desperation that the desired feelings never end. Legal consequences of actions provoked by user desperation to maintain the positive effects of stimulant use while avoiding the inevitable crash into withdrawal can be shattering to social or work relationships.
Withdrawal from amphetamine-type substances can occur within hours of stopping use. Withdrawal symptoms tend to 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 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 these 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 while minor tend to 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.
Stimulant Withdrawal, Diagnostic Criteria3, 27
- Cessation of (or reduction in) prolonged amphetamine-type substance, cocaine, or other stimulant use.
- Dysphoric mood and two (or more) of the following physiological changes, developing within a few hours to several days after Criterion A:
- Vivid, unpleasant dreams
- Insomnia or hypersomnia
- Increase in appetite
- Agitation or psychomotor retardation
Long-term effects of stimulant use include an increased risk of several disorders in the brain and various organ systems throughout the body. Cognitive and psychiatric disorders such as schizophrenia, major depression, stimulant-induced bipolar, sleep disorder, sexual dysfunction, or anxiety disorder all have a heightened frequency in long-term stimulant users.