Stimulant use disorder
Stimulant use disorder is a pattern of amphetamine-type stimulant use, covering methamphetamine, misused prescription amphetamines, and MDMA, that meets 2 or more of 11 substance use disorder criteria within 12 months. Intoxication produces a sympathomimetic toxidrome with hyperthermia and agitation; management starts with a benzodiazepine and active cooling, since no pharmacotherapy is approved for the use disorder itself and contingency management is the named behavioral treatment.
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What this article covers
- Overview
Definition: stimulant use disorder is a pattern of use of an amphetamine-type stimulant (methamphetamine, a misused prescription amphetamine or methylphenidate product, or…
- Epidemiology
Prescription stimulant diversion: amphetamine and methylphenidate products for attention-deficit/hyperactivity disorder (ADHD) are schedule II with significant misuse and diversion potential.
- Risk factors
Co-occurring psychiatric illness: an untreated mood, anxiety, or psychotic disorder makes self-medicating with a stimulant more likely, and use can itself trigger or aggravate psychosis.
- Pathophysiology
Transporter-mediated release, not reuptake blockade: amphetamines and methamphetamine act on the vesicular monoamine transporter and the dopamine, norepinephrine, and serotonin reuptake transporters…
- Clinical features
Diagnostic criteria (applies to substance use disorders generally): meeting 2 or more of 11 criteria within the same 12-month period defines a substance use disorder; the criteria include using in…
- Differential diagnosis
Cocaine use disorder: shares the sympathomimetic intoxication picture, but cocaine intoxication lasts about 30 minutes versus about 20 hours for methamphetamine, with a distinct myocardial infarction…
- Diagnosis
Diagnostic basis: stimulant use disorder is diagnosed clinically when a patient meets 2 or more of the 11 substance use disorder criteria within a 12-month period; acute intoxication or a positive…
- Management
First, stabilize the agitated, hyperthermic patient: lorazepam 1 to 2 mg IV or IM every 4 to 6 hours as needed, titrated to effect, plus active cooling with ice packs, cool water sprays, and fans…
- Complications
Hyperthermia: the leading acute cause of death, from sympathetically mediated heat production that outpaces the body's ability to dissipate it; severe hyperthermia is a core temperature above 40°C.
- Prognosis
Acute intoxication and withdrawal are self-limited: intoxication clears within about 20 hours for methamphetamine and sooner for MDMA, and withdrawal, while distressing, is not itself life-threatening.
- Prevention
Screen for the disorder early: ask about each of the 11 substance use disorder criteria whenever 2 or more have accumulated within any 12-month period, since earlier identification opens the window…
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- Hyponatremia
Hyponatremia is a serum sodium below 135 mEq/L, worked up by serum osmolality then volume status and urine osmolality/sodium; treatment is a 3% saline bolus for severe or acute symptomatic cases (chronic correction capped at 8 mEq/L per 24 hours), isotonic saline for hypovolemic disease, and fluid restriction plus tolvaptan or demeclocycline for SIADH.
- Rhabdomyolysis
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