Stimulant Use Disorder can develop very quickly, in just a few weeks, especially with smoking and intravenous use, and drastic personality changes occur just as fast. Heavy stimulant users are hard to miss. To an observer, they appear restless, talkative, euphoric, grandiose, anxious, and may have bizarre behaviors or violent outbursts. Stimulant users tend to go on binges, using frequently for several days in a row while relinquishing food and sleep. These are followed by a few days of abstinence, characterized by increased sleep and appetite, and after, the cycle begins again.
The new edition of the DSM consolidates all stimulant use disorders (such as cocaine, methamphetamine, and prescription drugs) into one category because of their similar effects and diagnostic profiles. In the short term, stimulants increase heart rate, blood pressure, body temperature, and can cause chest pain similar to a heart attack. Stimulant use also leads to a short-term increased risk of heart attack, heart arrhythmia, and respiratory difficulties, even in otherwise healthy individuals. It can also cause placental abnormalities and miscarriage in pregnant women. Chronic stimulant users become psychotic and experience paranoid delusions and hallucinations. These disturbances can last for years even after drug use has stopped.
Signs of methamphetamine use include scattered scabs (from picking in response to hallucinations of things under the skin) and poor dentition (“meth mouth”) from dry mouth and lack of oral hygiene. Long term methamphetamine use impairs attention and working memory. It blunts the sensation of pleasure so that chronic users derive joy from nothing but the drug.
Cocaine has it’s own set of hallmarks. Users get frequent nosebleeds and chronic runny nose from snorting and respiratory tract irritation from smoking. Long term use of cocaine increases the risk of stroke (as does methamphetamine) and seizures, and damages and weakens heart muscle. All stimulants lead to weight loss, and intravenous use can lead to infection and risk of HIV and viral hepatitis.
Causes and Risk Factors
People tend to begin using stimulants and have higher risk for developing dependence in their early to mid 20s, later than with other drugs. About 1.5 million Americans currently use cocaine, and 1.6 million use amphetamine-type stimulants, of which methamphetamine accounts for a third. In both cases, the age group with the highest percentages of users was 18-25 years old.
People are twice as likely to develop a use disorder with cocaine one year after the first use compared to alcohol and marijuana. Similarly with methamphetamine, the lag time between initial use and first admission to a treatment program is 6 years less than for other illicit drugs. This rapid onset of dependence is because of how powerfully stimulants activate the brain reward system. They work by rapidly increasing levels of dopamine, the neurotransmitter that mediates feelings of pleasure and motivation. Though all drugs of abuse activate this same system to some extent, this is in addition to their other neurochemical effects. In contrast, this is the primary effect of stimulants.
Pressure to perform
The desire to excel can rapidly lead to Stimulant Use Disorder. People frequently start using prescribed stimulants to help them stay awake to study or do work. In fact, prescription stimulant abuse is especially popular in college students, specifically in those with concurrent marijuana use and binge drinking disorders. However, because the effects come and go quickly, there is a propensity for rapid escalation of doses. Of note, individuals with ADHD treated with prescription stimulants are not at increased risk of Stimulant Use Disorder.
Risk in the gay community
Homosexual and bisexual men are also at increased risk of initiating use of methamphetamine, especially in urban nightlife settings. Methamphetamine is a popular aphrodisiac in these settings because the rapid euphoria removes sexual inhibitions. This combination leads to increased risk of unsafe sexual behaviors, such as lack of condom use, anonymous intercourse, and intercourse with HIV-positive individuals.
Diagnosing Stimulant Use Disorder
Many different types
Stimulants include illegal substances like methamphetamine and cocaine, as well as prescription and over-the-counter medications. Legal variants are intended for treatment of ADHD, narcolepsy, rhinitis, and weight control. These are medications like Adderall (amphetamine/dextroamphetamine), Ritalin (methylphenidate), ephedrine (multiple brand names, no longer sold), and pseudoephedrine (multiple brand names, most common is Sudafed). Ephedrine was banned by the FDA in 2004 and sales of pseudoephedrine have been restricted since 2005 pursuant to the Combat Methamphetamine Epidemic Act because both can be used to make methamphetamine.
How are they used?
Prescription stimulants can be taken orally or ‘snorted’, as can methamphetamine and cocaine. Cocaine and methamphetamine can also be smoked (crack is the smokeable form of cocaine) or dissolved in liquid and injected intravenously.
Diagnosis requires at least two of the following symptoms over the course of one year:
- Patients take larger doses of stimulants or use for longer than they intended
- They want or try to cut down, but can’t
- Finding, using and recovering from stimulants consumes their time
- Patients crave stimulants or fight strong impulses to use them
- They avoid responsibilities at home, work or school
- Social and intimate relationships suffer because of their stimulant use
- Once-important social, career, or leisure activities are abandoned
- Patients risk life and limb under the influence of stimulants
- They don’t care that their stimulant use is harming their physical or mental health
- They need increasingly larger doses to achieve the same desired effect
- These people undergo withdrawal (fatigue, disturbing dreams, low mood, increased or decreased sleep, increased appetite, psychomotor agitation or retardation) when they stop using stimulants, or they use just to avoid the symptoms
Increasing numbers of symptoms determines the severity of the disorder. Four or five symptoms qualify as a moderate case; it’s a severe case if there’s six symptoms or more. Patients are in early remission if they have had none of those criteria for at least three months and not more than one year. Late remission extends beyond one year.
Treating Stimulant Use Disorder
The Matrix Model
The only treatment designed specifically to address stimulant use is the Matrix Model. This was originally designed to treat cocaine and methamphetamine use, but is also successful in treating other stimulant use. This reproducible, manualized program takes place in a 16-week intensive outpatient setting, where patients spend day time at the treatment center but go home at night. It combines 12-Step groups, family meetings, regular drug testing, group and individual therapy, and Cognitive-Behavior Therapy (CBT) based skills training.
The 12-Step model of sobriety through individualized spiritual reflection, peer support, and the sponsorship process has been used independently for decades for various substances. Two groups, Cocaine Anonymous and Narcotics Anonymous, are available for cocaine, methamphetamine, and other stimulant users. These types of group programs are especially helpful in maintaining sobriety because of their long-term structure. They also emphasize giving back to others by becoming a sponsor who helps guide newly sober people through the program.
CBT alone is useful for both cocaine and methamphetamine. It is at least as effective as 12-step programs and has similar long-term efficacy. CBT requires significant motivation on the part of the patient to learn skills to avoid tempting situations and deal with triggers. CBT can be combined with Contingency Management (CM), in which patients receive vouchers redeemable for money or goods as rewards for clean urine drug screens. A study examining CM and CBT showed that adding CM to CBT nearly doubled the probability of patients completing the full course of CBT.
There are no FDA-approved medications for treating methamphetamine or cocaine use disorders. Replacement therapy with dexamphetamine in place of methamphetamine has reduced abuse-related side effects (such as injection site infections and psychotic episodes) in the U.K., and similar results appear with methylphenidate replacement for cocaine, especially when combined with CBT. Topiramate, an anticonvulsant, and disulfiram, which produces nausea and headache when combined with alcohol, both show promise in treating cocaine use, with the former more than doubling sobriety rates compared to placebo.
Managing Stimulant Use Disorder
Put in the work
If you want to get sober, be ready to commit to self-work. Because there are no medications to support abstinence from stimulants, the chances of maintaining sobriety largely depend on your own effort, especially in programs involving CBT. If money is an issue, remember that Cocaine Anonymous and Narcotics Anonymous are both free resources and are great starting points.
Even if you are an active user of stimulants, you can still take steps to protect your body from their detrimental side effects.
If you use stimulants intravenously or have frequent unprotected intercourse, be aware of the multitude of infections this can lead to and take measures to prevent them (condoms and clean needle exchanges). Regularly get yourself tested for sexually and blood-borne pathogens like HIV and hepatitis. Although some of the causes of poor dentition in methamphetamine users are unavoidable in the setting of ongoing drug use (teeth grinding, dry mouth), poor oral hygiene does play a part, and patients can slow the progression of ‘meth mouth’ by regular care and fluoride use as much as possible. However, know that these attempts to mitigate damage to your body are ultimately useless in the face of continuing drug use.
Expect to feel depressed for the first few months of sobriety. Stimulants cause lasting damage to the areas of the brain dealing with memory and emotions. Researchers have identified a “protracted withdrawal” syndrome with similar symptoms to a major depressive episode: low mood and energy, irritability, poor memory and concentration, and anhedonia (lack of enjoyment in previously enjoyable hobbies). This emotional state is a risk for relapse and needs to be addressed as part of treatment.
Find new pastimes
Because Stimulant Use Disorder patients have spent such a large percentage of their daily lives pursuing and using stimulants, powerful feelings of boredom emerge early in treatment. Patients should seek out treatment settings that offer recreational therapy and job placement services.