Stimulants vary in their chemical structure, but they are all “sympathomimetics.” Meaning that they mimic the actions of the sympathetic (fight or flight) nervous system. These include the physiological changes that prepare an organism for rapid action. Such as increased heart rate and blood pressure, pupillary dilation, and decreased appetite. Unfortunately, there is both a psychological and physiological crash after the effects of stimulants wear off. And the crash leads to most of the negative effects, including cravings and depression. This needs a proper treatment.
Overview of stimulants Cocaine
Cocaine is a psychoactive compound that is derived from the leaves of the coca plant. Chewing coca leaves has been a part of South American culture for millennia. Historically done to overcome fatigue, hunger, and thirst.
FUN FACT: Walking a Cocada
In South America, a “cocada” was used as a measure of distance, defined as how far a man could walk in a day while chewing coca leaves. Villages were said to be a certain number of cocadas apart.
Cocaine is rendered by placing the leaves in various solvents to produce cocaine hydrochloride. Which is purified to a white powder. This powder can then be snorted or injected when dissolved in water. Another commonly used version of cocaine is called crack. Crack is created by mixing cocaine hydrochloride powder with baking soda. (to create the “freebase” form). Microwaving it to make it hard, then breaking it into small chunks called rocks. This process removes the hydrochloride and lowers the substance’s melting point. That allows the crack to be smoked.
Smoking creates a quicker and more intense high than snorting. In the U.S., cocaine became popular among the wealthy in the 1970s. But late in that decade, Colombian drug cartels developed crack as a less expensive alternative to cocaine powder. A rock of crack could be purchased for $10. And since it was smoked, it was easier to consume and titrate to the desired effect.
NOT-SO-FUN FACT: Crack and the Open Flame
Since cocaine is expensive, users don’t keep it lit like a tobacco pipe. Rather, they only heat it when they’re ready to inhale a hit. So they are periodically applying a flame from a cigarette lighter or gas stove to the crack pipe. This can result in burns to the hands or face.
Because of the impurities in crack, users can inhale soot that is vaporized along with the cocaine. That can burn the mouth or the back of the throat. Often a filter is used, which can be a piece of cloth, a fine wire mesh. Or anything that will serve as a strainer.
Unfortunately, the burst of hot air that comes out of the pipe can blow the filter into the back of the throat. I had a patient who accidentally inhaled the steel wool filter she used for her crack pipe. The hot metal caused her throat to swell up. Requiring endotracheal intubation to allow her to breathe. What surprised me is that she did this more than once. Means endangering her life and ending up in the ICU twice. The famous comedian Richard Pryor suffered a severe burn injury in 1980 related to smoking crack.
Methamphetamine is simply the amphetamine molecule with a methyl group attached. It allows for easier entry to the brain via the blood-brain barrier. Its effects are similar to cocaine. But longer-lasting (4–8 hours, as opposed to about 30 minutes for cocaine).
Amphetamines block dopamine reuptake and are MAO inhibitors, enhancing the actions of the catecholamines, epinephrine, and norepinephrine. ADHD stimulants Stimulants approved for treating ADHD are also drugs of abuse. While amphetamines (Adderall and others) and methylphenidate (Ritalin) are both addictive. Adderall has emerged as a favorite and is especially popular with younger people.
Among high school and college students, Adderall and other stimulants are viewed as “smart pills,” though they don’t improve mastery or memory. The drugs enable students to stay awake longer to cram before exams. But most users report that taking them doesn’t improve their grades. Caffeine and energy drinks Caffeine is different from stimulants. Since it works on adenosine receptors as opposed to dopamine and is therefore not as potent.
While caffeine is not problematic for most users. A subset will use larger amounts and go through a cycle of heightened energy and attention followed by withdrawal. That includes symptoms such as tiredness, headache, and irritability.
In substance users, caffeine withdrawal may increase the risk of relapse to other drugs. Consuming energy drinks such as Red Bull and Monster increases the risk of caffeine problems.
Because caffeine can be a source of irritability and contribute to anxiety. That reduces caffeine consumption is a relatively easy fix to improve people’s moods. I’ll suggest things like having smaller cups, mixing half caffeinated and half decaffeinated. Or even substituting other beverages like water as ways to start cutting down on coffee, tea, or soda consumption.
When assessing caffeine use, I ask patients, “How many cups of coffee do you have a day? And how many cups of tea or sweet tea? How many sodas? How often do you have energy drinks?” If patients report that they use caffeine to counteract tiredness or “to get going” in the morning, I’ll advise them to exercise to increase their energy level.
I’ll also teach them basic sleep hygiene tips. And I will remind them that they’ll sleep better if they don’t have caffeine after dinner. Although people may say they can fall asleep fine after drinking a cup of coffee. The sleep they get is more likely to be the non-restorative type. Many people don’t know caffeine has two effects on sleep. An awakening effect early on, and a sleep-depressing effect up to 12 hours later.
This means if they drink coffee at 3 p.m., it could still be keeping them awake at 3 a.m. Patients will sometimes cut down on their afternoon or evening caffeine after this is explained to them.
Both cocaine and meth lead to an immediate rush of euphoria, energy, and enhanced concentration. At high doses, the drugs lead to such heightened alertness that it borders on paranoia.
Regular use can cause psychotic features. That including auditory hallucinations and delusions of thought insertion or extraction. Although these symptoms can be clinically indistinguishable from schizophrenia, they usually subside when the drug wears off. Cocaine and other stimulants can also cause various perceptual effects. For example, “snow lights” are flashes and colors in the periphery of a user’s vision, and “coke bugs” (or “crank bugs”) are a tactile hallucination of bugs crawling on the skin.
The sensation caused by coke bugs is also known clinically as formication (the word is derived from the formic acid excreted by ants in the subfamily Formicinae). The skin lesions seen in cocaine and meth users are partially caused by this hallucination, since people will scratch and pick at their skin to get at the imagined bugs.
Heavy stimulant users often use sedatives to take the edge off the stimulant effects. Sometimes they will combine opioids with stimulants (speedballs), either by combining cocaine and heroin into one needle, or more commonly by smoking crack and snorting heroin. Combining alcohol with cocaine also takes the edge off, but it has another popular effect: It prolongs the cocaine high.
When alcohol and cocaine coexist in the bloodstream, the liver combines them to create an active metabolite called cocaethylene. Because about 40% of cocaethylene is metabolized back into cocaine, the combination effectively lengthens cocaine’s half-life.
SAD FACT: Famous Victims of Speedball Overdoses
- John Belushi, 33, comedian (cocaine and heroin); died 1982
- River Phoenix, 23, actor (cocaine and heroin); died 1993
- Chris Farley, 33, comedian (cocaine and morphine); died 1997
- Philip Seymour Hoffman, 46, actor (cocaine, heroin, benzodiazepines, and amphetamines); died 2014
Unlike drugs such as sedatives and opioids, people don’t use stimulants at a constant level; instead, they use intensely for a short period of time, called a run or spree. This can last for several hours or several days, sometimes ending only when users run out of money, drug, or dopamine. Then they crash, and after a period of not wanting to use, they start to have cravings.
Psychiatric syndromes, such as depression and psychosis, can persist between periods of stimulant use. A Parkinson-like syndrome can occur, and is likely due to dopamine depletion. You may see symptoms such as choroid movements (wiggling or writhing), twitchiness, muscular contractions, restlessness, wiggling of hands and feet, or constant motion. They look a bit different from nervous movements since they have more of a fluid character.= Users can experience cardiac issues due to the constant excess of catecholamine release during stimulant use.
Tachycardia may eventually cause cardiac muscle hypertrophy, leading to cardiomyopathy. Hypertension can occur, and there is an increased risk for myocardial infarction and stroke. Lastly, “crack lung” is a sort of pulmonary allergic reaction to cocaine.
It leads to shortness of breath, pleuritic chest pain, and infiltrates on a chest x-ray. Withdrawal syndrome Stimulants do not cause any obvious physical withdrawal syndromes, but they do cause fatigue, depression, irritability, and increased appetite, as well as suicidal behavior at times. There is no specific treatment for cocaine or other stimulant withdrawal. After several days, the symptoms go away on their own. These will be followed by cravings, which can be intense.
As with all substance use assessments, ask your patients about the quantity and frequency of their stimulant use. Most people use stimulants in a binge pattern, and cravings are more prominent with stimulants than for many other drugs. Ask about associated symptoms, such as psychotic symptoms, paranoia, or depression. For help with subsequent behavioral treatment, ask about how the drug is used.
Often, environmental cues will trigger cravings. Since stimulants enhance alertness, everything that occurs around users while they are getting high is associated with that high. Triggers can be olfactory, such as the smell of fellow users’ perfume or cologne, or tactile, such as the feeling of money in a pant or coat pocket. To help motivate patients to make a behavior change, I ask about the consequences of their stimulant use.
I may use the “good things/less-good things” technique or ask about a typical day. Consequences due to stimulant use may include interpersonal, financial, or legal effects. Stimulants are hard on the body and the mind, so there can be physical and mental health consequences. Because of the binge pattern of use, patients may spend a lot of money at a time on drugs, leading to significant financial difficulties.
There is no pharmacotherapy for stimulant addiction, but frequently patients will have chronic depressive symptoms interrupted only by drug use. In these cases, antidepressants can be very helpful.
There’s a saying in substance use treatment circles: “When you are trying to treat stimulants, the thing that works best is money.” This refers to contingency management, which is essentially paying patients to quit. While contingency management has been shown to be effective for most substance use disorders, I have found it particularly useful for stimulant use disorder.
Contingency management programs
Contingency management programs work in various ways. But their key element is identifying a group of behaviors that are likely to lead to lasting recovery. Then rewarding people for these behaviors. Patients can be rewarded for negative urine drug tests. By showing up to group or individual sessions, and completing therapy homework assignments. They can also be rewarded for consistency.
For example, after several successive negative urine drug screens, their reward could increase. The rewards themselves are usually not actual cash. In fact, things like gift cards or lottery tickets. Research has shown that the chance of getting a big reward tends to be just as motivating as actually getting the reward. And hence the common use of lottery tickets in programs.
It is a way to enhance the outcomes of substance use treatment. But it can be expensive to implement. However, lottery tickets or small denomination gift cards are less expensive. They still work as motivational incentives. So contingency management can add value when used with other elements of a treatment program.
Most early contingency management programs were funded as research programs but now they are often subsidized by government grants or private donations. Even though the rewards are not very large. They are more tangible than an abstract goal. such as abstinence, and they give people an external motivation and keep them engaged in treatment.
People will apply cognitive behavioral therapy skills in day-to-day life so they can accumulate skills to stay clean and get prizes. Eventually, the prizes become less important than the achievement of abstinence, and patients see the other benefits—their life rewards—take center stage.